BOARD OF DIRECTORS 11 July 2018 - University College Hospital meeting... · undertaking an end of life care project focusing on the care provided by UCLH for those patients at the

BOARD OF DIRECTORS

11 July 2018

BOARD OF DIRECTORS PUBLIC MEETING

Wednesday 11 July 2018 2:00pm

Venue: Education Centre, 1st

Floor West Wing, 250 Euston Road, London NW1 2PG

AGENDA

Agenda item Lead Attachment

1. Welcome and apologies for absence David Prior Oral

2. Minutes of the last meeting David Prior A

3. Action tracker David Prior B

4. Matters arising David Prior Oral

5. New declarations of Interest David Prior Oral

6. Presentation Human Factors in Safety Cathy Mooney

7. Chairman’s overview David Prior Oral

8. Chief Executive and Senior Director Team report including: Month 2 Performance pack (attachment D)

Quarterly report on Safe Working Hours for Doctors and Dentists in Training (attachment E)

Guidance for Boards on Freedom to Speak Up (attachment F) Freedom to Speak Up self-review tool (attachment G) Freedom to Speak Up Guardian Annual Report (attachment H) CQC Registration documentation (attachment I) Standards of Business Conduct Policy (attachment J) Board Assurance Framework (attachment K)

Marcel Levi C

9. Finance Directors report Tim Jaggard L

10. Electronic Health Records System report Gill Gaskin M

11. Quality and Safety Committee report

11.1 Mortality Surveillance Report

Tony Mundy N

N1

12. Research report Bryan Williams O

13. Audit Committee report

Audit Committee Annual report

Rima Makarem P

P1

14. Audit Committee minutes – for information Q

15. Any other business Oral

16. Questions from the public – limited to 10 minutes

17. Date and time of next meeting in public: Wednesday 12 September 2018

A

Agenda Item 2

Minutes of the last meeting

Board of Directors Minutes of the meeting held in Public on Wednesday 9 May 2018

Present Geoff Bellingan, Medical Director, Surgery & Cancer Board Harry Bush, Non-Executive Director, Vice-Chairman Gill Gaskin, Medical Director, Specialist Hospitals Board Charles House, Medical Director, Medicine Board Tim Jaggard, Finance Director Marcel Levi, Chief Executive David Lomas, Non-Executive Director Rima Makarem, Non-Executive Director Tony Mundy, Corporate Medical Director (items 1 - 9) Kieran Murphy, Non-Executive Director Flo Panel-Coates, Corporate Medical Director David Prior, Chairman Caspar Woolley, Non-Executive Director

In attendance

Simon Knight, Director of Planning and Performance Kate Price, Deputy Director of Workforce Liz O’Hara, Deputy Director of Workforce Tonia Ramsden, Director of Corporate Services Dr Caroline Stirling, Lead Consultant in Palliative Care (item 6) Rachel Stoukas, Trust Administrator Uma Metha, NHSI NExT Programme

Item Matters covered BoD/37/18 Welcome and apologies for absence 37.1 The Chairman welcomed Board Members and members of the public to the

meeting. Apologies had been received from Althea Efunshile. BoD/38/18 Minutes of the last meeting 38.1 The minutes of the last meeting held on Wednesday 14 March 2018 were agreed

as an accurate record. BoD/39/18 Action tracker 39.1 There was one item on the action tracker which was complete. BoD/40/18 Matters arising 40.1 There were no matters arising. BoD/41/18 Presentation – End of Care Life

41.1 The Board welcomed Caroline Stirling. Her presentation focused on the Trust response to the National Palliative and End of Life Care Partnership’s strategy to improve the quality and accessibility of end of life care for all people and for the healthcare professionals delivering the care. Caroline explained the six ambitions of the strategy and how the Trust’s end of life care team was implementing the guidance. With the support of the Trust and with funding from the Charity the team had been able to implement a transforming end of life care programme which included many new aspects such as a new training tool for staff on how to care for dying patients, ward based training sessions, treatment escalation plans, applying learning from the Bereaved carer’s survey, review of complaints and incidents and improving the information on the Trust’s website.

41.2 The Chairman highlighted that patient governor; Christine Mackenzie was undertaking an end of life care project focusing on the care provided by UCLH for those patients at the end of their life. The palliative care team had been involved in the planning stages of the study and the Board were supportive that the project would benefit both patients and staff.

41.3 Kieran Murphy asked about the vision of the transformation programme, Caroline explained the ambition was to teach UCLH staff and embed the six core principles of the national strategy. She recognised that clinicians were being asked to take on specific skills which they did not choose, but she stressed, to provide outstanding patient care it was important for the principles to become business as usual. The Chief Executive supported this adding this approach needed to be embedded and incorporated within the foundations of teaching for junior doctors.

41.4 The Board thanked Caroline for attending to update them on the excellent work of the end of life care team.

BoD/42/18 Quality and Safety Committee report 42.1 Tony Mundy introduced the report which provided a comprehensive summary of

the Quality and Safety Committee meetings held in March and April 2018. He highlighted to the Board that the next Care Quality Commission (CQC) inspection was likely to take place between July – September 2018. This would include a Well Led review and interviews with Board members. The CQC Executive Steering Group was meeting regularly in preparation.

42.2 The Patient Experience Committee (PEC) had reviewed the CQC maternity survey report published in February. Overall the Trust was not statistically different from England as a whole. UCLH was ‘about the same’ for each of the three subsections of the survey: labour and birth, staff during labour and birth and care in hospital after birth, which was an improvement on 2015 when the results were worse than expected for labour and birth. The division was preparing an action plan in response to the survey results.

42.3 In the April meeting the committee had finalised and agreed the 2018/19 Quality Account priorities.

42.4 The Board noted the Quality and Safety Committee report BoD/43/18 Research report 43.1 The quarterly research report included updates on the Biomedical Research

Centre (BRC), the Clinical Research Facility, recruitment and performance of research studies and preparations by the Joint Research Office to meet the guidance for the implementation of the General Data Protection Regulation (GDPR).

43.2 Tony Mundy highlighted progress of the Research Hospital. A launch date had been set for 21 May to outline the UCLH Research Hospital vision. A digital strategy in support of the Research Hospital was in progress and the principles of the UCLH-Turing partnership had been agreed and a partnership agreement was under negotiation.

43.3 Harry Bush asked about research performance and recruitment to studies. T Mundy highlighted that although the total recruitment to all studies had decreased in 2017/18, the total number of new studies approved remained consistent but almost twice the number of studies closed in 2016/17 (144 studies) than in 2017/18 (76 studies).

43.4 The Research report was noted. BoD/44/18 Chief Executive and Senior Director report 44.1 Month 12 operational performance The Board discussed the month 12 performance report, the cancer wait remedial

action plan, the emergency department (ED) remedial action plan, and the longer term performance trends analysis report.

44.2 ED Performance – during March the Trust reported 85.9% performance against a revised trajectory of 95.1% for the four hour standard. Overall performance in quarter 4 was not met therefore the Trust would not receive sustainability and transformation funding (STF). The Chief Executive explained the department was full to capacity during March. The Trust had tried to manage non urgent cases in the urgent care centre (UTC), which saw stable waiting times with performance between 90 – 95%. Unfortunately the UTC also became an overspill area for the patients who were waiting in ED majors to be admitted. He went on to report that during April there had been an improvement, with more work being done to ensure patients were being seen by specialists in the ED sooner. There had also been an improvement in discharges in the Tower meaning patients could be transferred sooner from the ED to the ward.

44.3 The Chairman noted the update but explained he remained concerned that the Trust would find itself in a similar position next winter and he felt the Trust needed to act early to avoid a recurrence. The Chief Executive agreed however confirmed there was a good, robust winter plan in place for 2017/18 however the numbers of patient visits could not be anticipated. However there was broad agreement by the Board that extra steps would need to be taken to manage capacity and operational performance ahead of winter 2018/19.

44.4 Charles House added that the Trust compared favourably to its peers in North Central London in terms of performance and had a higher number of patient attendances. He went on to explain the immediate actions that had been agreed and introduced by the Senior Directors Team (SDT) including an Operational Clinical Excellence Group focussing on length of stay, ward discharges and improving overall performance on the wards to improve the flow of patients from ED.

44.5 Caspar Woolley asked why there was no target set for ‘Tower bed occupancy’ which would help move ED patients on to the wards. Charles House explained that suggested modelling for ideal bed occupancy levels is 85%. There was a discussion about what the Trust could do to achieve this. The Chief Executive explained it could mean undertaking less elective work which the SDT were not in favour of. Other options were being explored including shortening the length of stay of patients, creating more space in the Tower, moving services and improving utilisation reviews.

44.6 The Chairman stressed the importance of the Trust meeting the needs of the local population and achieving the 95% target. He went on to urge the SDT to have a clear plan for hitting the 95% target particularly a robust plan for winter 2018/19 and if there was a risk, the Board should be informed as soon as possible. The Chief Executive acknowledged this but asked the Board to recognise that in the past week only four other NHS Trusts across the country had reached the 95% ED 4 hour wait target.

44.7 David Lomas suggested UCLH explore working with other Trusts with more capacity which the Chief Executive confirmed was an option being explored particularly through the sustainability and transformation partnership (STP).

44.8 Cancer waits – in March the Trust performance of the 62-day wait for first treatment for urgent GP referral to treatment was at 76.6%, only 0.4% below the trajectory. Geoff Bellingan reported internal performance had improved with the backlog of patients waiting decreasing. Inter Trust referral performance had also improved meaning patients were able to be seen and treated sooner. The two specialities which continued to have breaches were kidney and prostate. In particular there had been an influx of prostate referrals owing to a national advertisement campaign. The Board noted the actions being taken to improve performance which were monitored via the cancer remedial action plan.

44.9 Kieran Murphy acknowledged the improvement in cancer waiting times however he queried if this was sustainable given the difference between successes was only one or two patients. He asked how the Trust could reach its overall trajectory as planned by if it had an increase in complex referrals. Geoff Bellingan explained there was ongoing work with the Cancer Vanguard Board and Primary Care to improve referral pathways and patient choice.

44.10 Referral to treatment targets –performance in March was reported as 91.1% against the 92% target. The Board noted the non-compliant divisions and the actions being taken to improve performance.

44.11 Pressure ulcers – there was a slight increase in March with nine grade 2 and one grade 4. Flo Panel-Coates explained the 72 hour review into the grade 4 ulcer had found no serious failings in care. The increase in grade 2 ulcers was partially contributed to complex cases in the emergency services division with two patients wearing spinal collars on the acute medical unit. Learning has been shared with staff and there would be more training taking place around management of patients who are required to wear a spinal collar for longer than usual.

44.12 Quarterly review of Commissioning for Quality and Innovation (CQUIN) – Harry Bush was disappointed to see the Trust had lost the opportunity for funding for not reaching the target for improving the uptake of flu vaccinations for frontline clinical staff. The Chief Executive agreed it was disappointing and confirmed the campaign in 2018/19 would need to be planned early with more input from staff particularly to understand why uptake was low.

44.13 The Board noted the month 12 performance report.

44.14 The Chief Executive continued to highlight areas in his report including the patient feedback update, the Voluntary Services annual report, UCLH plans for the NHS 70th celebrations, the final position of the 2017/18 corporate objectives, use of the Trust seal and an update on the non-emergency patient transport service. The Board joined the Chief Executive in commending the hard work of all UCLH volunteers and thanked them immensely for the help they provided to patients and staff.

44.15 The Board formally noted the changes to the process for the Fit and Proper Persons Test which ensures compliance with the latest Care Quality Commission (CQC) requirements.

44.16 The Board formally approved: 1. The final 2018/19 corporate objectives and metrics 2. The changes to the Standing Financial Instructions and Scheme of

Delegation.

BoD/45/18 Finance Directors report 45.1 The Board discussed the 2017/18 full year financial position and the financial

plan that was submitted to NHS Improvement on the 30 April 2018. Tim Jaggard explained shortfalls throughout the year included an increase in bank and agency spend and non-achievement of sustainability funding. He went on to explain that the overall 2017/18 year end position was helped with two major one-off transactions; the sale of UCLH shares in radiology reporting online and the disposal of Eastman Dental Hospital to University College London (first tranche). UCLH had also received some match funding from NHS Improvement at the end of the year.

45.2 For 2018/19 the Trust had formally accepted its control total of £6.2m deficit before provider sustainability funding. The Trust therefore had a very high cost improvement programme with a £45m target. The plan submitted to NHSI contained £42.5m of identified schemes but Tim Jaggard stressed the importance of the Trust achieving its four hour wait ED targets to achieve STF funding as well.

45.3 Casper Woolley asked about the correlation between the high agency spend and the vacancy rate and how the Trust was planning to manage this going in to 2018/19. Tim Jaggard explained this was a big financial issue linked to recruitment and retention which would be covered later on the agenda. Whilst the Trust tried not to budget for agency at all, in 2018/19 it would need to make allowances to accommodate the EHRS programme.

45.4 The Finance Director’s report was noted. BoD/46/16 Staffing report 46.1 Kate Price introduced the report which set out the current recruitment and

retention position at UCLH and the refreshed approach and actions to improve the position. In addition the report covered the results of the 2017 Staff Survey and the Trust response.

46.2 The Board discussed the report and noted the impact of Brexit and visa rulings had had a negative impact on recruitment of staff, particularly in the nursing field. In 2018/19 recruitment efforts would target sources which had been used successfully before, particularly to employ newly qualified nurses, international nurses, nurses working in the private sector and nurses already in the NHS. The Head of Medical Workforce Intelligence was leading new initiatives to drive workforce planning for the following staff groups; health professionals, nursing and midwifery and medical and dental workforce. The Board looked forward to receiving updates on this in the future. With regards to retention, Flo Panel Coates noted that the cost of living in London was a major issue and one of the main reasons staff gave for leaving the Trust. Actions defined as a result of the staff survey would form part of the retention strategy.

46.3 Staff Survey 2017 The Board reviewed the key findings from the survey and noted the SDT had considered and endorsed seven new initiatives to tackle the themes and issues raised in the survey. The Chairman highlighted he was supportive of the initiatives however he felt there was more the Trust needed to do and there should be a more dynamic approach to ensure UCLH could go against the trend. He highlighted that generally engagement scores across the NHS were low and he suggested SDT could benchmark against private sector organisations for ideas. He recommended the Board re-discuss the staff survey action plan in September.

Action BoD /4/18 (Ben Morrin)

46.4 The Board noted the staffing report and the actions being taking to improve recruitment and retention and to address issues raised in the staff survey.

BoD/47/16 Health and Safety Annual report 47.1 Liz O’Hara introduced the report and assured the Board that UCLH has

appropriate processes in place to manage the risks associated with health and safety.

47.2 The Board approved: The annual Health and Safety report and noted the commitment to refresh the approach to reducing violence, aggression and abuse towards staff and improve the support offered to staff.

BoD/48/18 Annual Equality Report 48.1 The Board reviewed the report. Harry Bush queried the grading assessment for

the Equality Delivery System (EDS2) goal 3 outcome 3.2 (The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their requirements) and asked why the Trust grading was ‘Developing’. The Trust lead for development of the equality report would be asked to provide an explanation.

Action BoD/5/18 (Karin Roberts)

48.2 48.3

The Board approved: The Annual Equality Report. The Chairman reported that he had set aside the October seminar for a dedicated equality and diversity discussion.

BoD/49/18 Electronic Health Records System update

49.1 Gill Gaskin introduced the update reporting overall good progress. She highlighted the challenges in the current build configuration which was slightly behind schedule. She explained that the build team have complex jobs with competing demands however over the past weeks most build teams had stabilised their build rate at the required recovery rate. She encouraged colleagues to visit the team currently located in 250 Euston Road to offer support and encouragement. The other aspect slightly behind plan was the closure of interface contracts. The team were receiving support from the Trust’s Commercial Director.

49.2 The Board discussed the report. David Lomas asked if delivery of the hardware was on track. Gill Gaskin provided assurance that this was on track with good progress in place. Her main concern was the quality of the Wi-Fi connection. This was being addressed.

49.3 Caspar Woolley asked how the project team were coping with the enormity of the work. Gill Gaskin confirmed the build team in particular had been particular stretched and feeling the strain two to three weeks ago. The situation had improved now with organisational development input and plans for annual leave being made.

49.4 The EHRS updated was noted. The Chairman thanked Gill Gaskin and the entire EHRS team for all their hard work and good progress to date.

BoD/50/18 Proposed changes to the UCLH Constitution 50.1 50.2

The Board considered the proposed changes to the UCLH Constitution. The most notable changes involved the Governor’s term in office and the number of Non-Executive Directors on the Board. Governor’s term in office - The current terms of office for Governors is for three years, following which Governors are eligible for re-election at the end of that period. Governors cannot hold office for more than six continuous years without having an interval of up to two years before holding office again for a further term or terms. The proposed change would see an amendment to the total term Governors can hold office to nine years (three terms of three years). The terms could be consecutive or interrupted.

50.3 Number of Non-Executive Directors – the proposal was to increase the number of NEDs to nine in total including the Chairman (currently seven including the Chairman).

50.4 50.5

The Board noted the rationale for the proposed changes to the Board composition and understood these were in line with good governance practices and a healthy, balanced Board of Directors. Regarding the number of years the Governors could hold office the Board did not support the recommendation that a Governor could serve three consecutive terms in office and proposed that a Governor could serve three terms in aggregate but that a two year break be introduced at the end of two consecutive terms. This amendment was agreed.

50.6 50.7

The Board approved: The proposed changes to the Constitution subject to the change highlighted above. The Board understood that the proposed changes could not be implemented until the Council of Governors had also approved the amendments.

BoD/51/18 Audit Committee report 51.1 The Board reviewed the key outcomes following the Audit Committee meetings

held in March and April. Of note the committee had focused on the Trust’s readiness for the new General Data Protection Regulations.

51.2 The Audit Committee report was noted. The Board would receive a GDPR update at its June Seminar.

BoD/52/18 Audit Committee minutes 52.1 The minutes of the Audit Committee meetings held on 30 January 2018 and 20

March 2018 were noted. BoD/53/18 Any other business 53.1 None raised. BoD/54/18 Questions from members of the public 54.1 In response to a question about what business rates the Trust pays, T Jaggard

explained the complex nature for NHS Trusts owing to multiple registered sites. He explained there was ongoing work with the commercial team to re-assess legal requirements and ensure the Trust was being charged the fair going rates.

54.2 In response to a question about whether the breast symptomatic performance data (80%) was a good outcome, Geoff Bellingan and Simon Knight confirmed this was an internal pathway and performance was largely determined by patient choice.

Signed___________________________________________ David Prior, Chairman Date:

B

Agenda Item 3

Action tracker

Board of Directors Action Tracker - Public

Action

Number

Date of

Meeting

Subject Action Responsible

Director

Due date Comments Status

BoD/4/18 09.05.18 Staff survey The Board reviewed the key findings from the

survey and noted the SDT had considered and

endorsed seven new initiatives to tackle the

themes and issues raised in the survey. The

Chairman highlighted he was supportive of the

initiatives however he felt there was more the

Trust needed to do and there should be a

more dynamic approach to ensure UCLH could

go against the trend. He highlighted that

generally engagement scores across the NHS

were low and he suggested SDT could

benchmark against private sector

organisations for ideas. He recommended the

Board re-discuss the staff survey action plan in

September.

B Morrin Sep-18 Open

BoD/5/18 09.05.18 Annual Equality report The Board reviewed the report. Harry Bush

queried the grading assessment for the

Equality Delivery System (EDS2) goal 3

outcome 3.2 (The NHS is committed to equal

pay for work of equal value and expects

employers to use equal pay audits to help fulfil

their requirements) and asked why the Trust

grading was ‘Developing’. The Trust lead for

development of the equality report would be

asked to provide an explanation.

K Roberts 30.05.2018 Equal pay audits had not

yet commenced therefore

in development. An

explanation has been

added to the report.

Complete

C

Agenda item 8

Chief Executive and Senior Director Team Report

Chief Executive and Senior Director Report to the Board of Directors

11 July 2018

FOREWORD

The past few weeks have been very busy for the Trust and as you will see in the various paragraphs

below a large number of successful milestones have been reached. From a strategic point of view our new

buildings on the UCH campus are well on track and we were happy to celebrate the arrival and positioning

of the cyclotron in our Proton Beam Centre as well as the topping out of the Royal National ENT and

Eastman Dental Hospital. Also in June, the extensive refurbishment in Queen Square, including new

wards, operating theatres and ITU space was completed and will be fully used in the next few weeks. Our

strategic alliances with other providers in North-Central/North-East London are developing and it is good

to hear positive feedback on the prominent role of UCLH and many of our staff in these various

partnerships.

We are preparing ourselves for the upcoming Care Quality Commission visit in July (onsite inspection),

August (use of resources review), and September (well-led review) and will do everything we can to pass

these inspections successfully. A lot of focus is given to quality and safety issues and operational

readiness in the various wards and outpatient clinics, to achieve satisfactory levels of completeness of

mandatory training of all staff, and to having our estate in a perfect condition to deliver safe healthcare to

our patients.

Performance remains one of our large points of attention, in particular meeting the 95% A&E 4 hour

waiting target. Since mid-June the occupancy in the hospital has finally reached acceptable post-winter

levels and this, in combination with an increasingly better performance of our Coordination Centre team

has led to a much more acceptable flow of acute patients from A&E who need admission into the hospital.

The appointment of Alison Clements as Head of Operations for Patient Flow, directly reporting to two

medical directors and myself, has been a helpful step achieving this. However, recent performance is

negatively affected to difficulty filling medical rotas in the ED, particularly twilight shifts. This has been

exacerbated by some trusts not sticking to the London-wide agreement on locum pay rates. This has a

particular impact on urgent treatment centre (UTC) performance. In response, we are changing the UTC

model to be staffed by GPs and emergency nurse practitioners. We have successfully recruited a number

of GPs who will start to work with us soon.

Cancer performance is improving but still behind its trajectory, in particular related to our external

performance (patients referred late, often without a treatment plan). I am happy to say that our internal

performance is going well and our internal backlog is at a low point. We are continuing working with

partners to improve referral pathways and trying to support them through our Cancer Alliance. RTT

performance is on track and above 91%. We are still expecting to achieve 92% compliance in the next few

months.

Staffing is one of our greatest concerns and as we are expecting even larger shortages in clinical

workforce in the next months and years we are paying a lot of attention to (new ways to) recruit and retain

staff. We are closely communicating with our junior doctor staff to hear from them how we can improve

their training and working experience at UCLH. I would like to point your attention to the report of Dr

Prasad Kolipara and his questionnaire seeking an answer to the question why we have less exception

reports than other Trusts. We will discuss this in one of the next Board meetings but preliminary results

indicate there may be

Under-reporting of working time exceptions, not so much driven by discouragement of supervisors but

rather by factors coming from the junior doctors themselves. When we have the final results of this survey,

we will discuss with our junior staff how we can facilitate them to report working hours exceptions.

Lastly, the EHRS project is largely on track with ongoing good engagement of our staff in this important

program. We have completed the third adoption cycle and will soon proceed to the next phase. Our IT

partner ATOS has started their refresh of our printers, computers and hardware this month.

1. PERFORMANCE

Enclosed with this month’s performance report are the monthly updates from the Trust’s remedial action plans (RAPS) for Cancer 62 day wait and A&E four hour wait. Emergency Department In May we reported 86.3% performance against a trajectory of 91% for the Accident & Emergency (A&E) four hour standard. Performance for the end of June is slightly less than 84%.This means that we do not meet the Q1 trajectory for the STF funding. June forecast : Performance for the end of June is likely to be less than 83.5%. Referral to Treatment (RTT) incomplete pathways Our agreed 2018/19 plan is to deliver the 92% RTT standard from July but to maintain above 91% performance in April, May and June. We met our plan for May (91.16%, up 0.05% from April). The total number of patients waiting over 18 weeks (backlog) decreased slightly by 16 to 3,826. We reported four 52 week breaches overall, down four from the eight in April: three in neurosurgery and one in paediatric dentistry. The paediatric dentistry patient was also reported last month, and harm review identified the potential for clinical deterioration, which has been attributed to the parents not bringing the patient for a number of appointments and pre-assessments. However, safeguarding processes were correctly followed. No harm is expected for the other patients. We did not meet the diagnostics standard. This was driven by a higher number than normal breaches amongst the imaging modalities. Extra breaches had been caused by patient track list visibility issues as a result of the switch to the Soliton RIS upgrade. Solutions are now in place to reduce these breach numbers. June forecast : RTT performance is forecasted to remain above 91% as per our plan. Diagnostics will remain non-compliant in June, with a forecast of 139 breaches. We are expecting to recover compliance by August. Cancer waits We have agreed a trajectory to deliver overall compliance for June 2018. May's provisional position (69.3%) is 12.9% below our trajectory. We expect to report 13 internal and 14 shared breaches (27 pathways). Provisional internal performance (77.2%) is non-compliant and 6.8% below trajectory (84%). We are assessing each breach for avoid ability to understand any learning to prevent future recurrence. We have increased our focus on managing shared pathways, including delivering treatment in 24 days where referrals reach us after day 38. Applying the future breach reallocation rules would deliver a 2.4% uplift in performance to 71.7%. There is particular pressure in urology due to an increase in the number of

shared pathways referred for robotic surgery. Patients are currently being booked beyond day 24. The service has increased capacity to maximise all opportunities including weekend lists, increasing lists from 2 to 3 patients and using private sector We expect to narrowly miss compliance with the two week wait standard and the breast symptomatic standard. This is due to patient choice. June forecast: Our trajectory is to deliver 82% overall. Our current best known position is approximately 7% below this. We are expecting 11 internal breaches. However, we do not yet know the full extent of shared pathways. Geoff Bellingan has written to all clinical directors, multidisciplinary teams and managerial leads to remind them of the importance of tight monitoring and early escalation of issues to improve performance through June and July. Pressure ulcers During the month of May there were no grade 3 or grade 4 hospital acquired pressure ulcers (HAPU). There were six grade 2 HAPU which was a slight improvement on April's figure of 7, and better than the Trust threshold of 7. There were two suspected deep tissue injuries, but no unstageable ulcers. No omissions of care were identified but patient compliance and engagement remains a factor. However the clinical teams continue to invest energy in exploring avenues to improve this. Complaints responded to within target time We were worse than threshold for patient complaint response times in May at 67.1%. Medicine Board was slightly worse than threshold at 77.8%. This was driven by clinical support reporting three of the seven complaints in target time. This includes transport complaints. All other medicine divisions were 100% compliant. Specialist Hospitals Board was better than target. All divisions were compliant with the exception of women's health with seven of the ten complaints done in target time. Staff within the division has been reminded of the importance of timely complaints management. The Surgery and Cancer Board was worse than threshold. In the cancer division only one of seven complaints was completed in time which was due to multiple complex cases. The division is reviewing resources allocated to complaints.

2. WORKFORCE

Quarterly report from Guardian for doctors and dentists in training

The Guardian for safe working hours, Dr Prasad Kolipara, shared his report for January to March, as

attached (Attachment E), at the SDT in June. Dr Kolipara is on annual leave at the time of our July

Board, so shall not be in attendance. We devoted the main discussion time of our June leadership forum

of our most senior leaders, to review his report and learn from the perspectives of our Chief Registrar,

education and postgraduate education directors and clinical directors. Though our process of

implementation of the contract has been praised locally, I am convinced it is vital to sustain action to

further support trainees working in a demanding national and local context.

The Guardian’s report details a slight increase in the number of exception reports submitted during this

quarter and no serious safety breach. There was a clustering of exception reports in medical/clinical

oncology, gastroenterology and care of the elderly which are detailed in his report.

Given the number of exception reports we have is relatively low compared to peers, Dr Kolipara is

surveying this summer to further probe reasons why that may be the case and any further action we can

take to support trainees. Along with the imminent sharing of the GMC survey results we expect very

shortly, his local survey’s results should allow for a helpful stock take.

Guidance for boards on Freedom to Speak Up

In May, NHS Improvement and the Office of the National Guardian published new guidance for Boards, on

freedom to speak up. I have attached this for Board Members only (Attachment F). Each NHS Trust

Board has since been encouraged to review the guidance and complete its self-review tool, by the end of

August. Responsible managers in the Trust and colleagues involved in supporting staff who raise

concerns have informed a draft self-review. I attach for Board Members only (Attachment G).

The lead director for the independent guardian service, Simon Macrory, shall attend July's Board to speak

to the service's annual report for 2017/18 (Attachment H).

The Board are invited to comment and endorse the self-assure framework with a view to us

reviewing progress on following action, within the quarterly cycle of workforce reports we shall

receive from September.

Since the template is a long one, I hope the following summary of the proposed actions against each of its

nine principles, proves helpful.

1. Leaders are knowledgeable about Freedom to Speak Up

The Guardians' reports and our staff surveys suggest a growing understanding across the trust of the both

roles and the emphasis we place on speaking up, from the multidisciplinary inductions for all staff. I and

the Chairman shall now assume the lead executive and non-executive lead roles for the Guardian for

freedom to speak up.

2. Leaders have a structured approach to freedom to speak up

Our current freedom to speak up policy is due for renewal this autumn. The national guidance allow us a

timely opportunity to inform our next policy by assuring we openly reflect on learning from individual cases

and to evaluate the first two years of the Guardian functions. The Audit Committee shall receive its full

annual speaking up report at its meeting later this month.

3. Leaders actively shape the speaking up culture

4. Leaders receive assurance in a variety of forms

5. Leaders are focused on learning and continual improvement

The Guardians have ready access to senior leaders to enable them to escalate staff and patient safety

issues rapidly, preserving confidence as appropriate. The Workforce Director shall convene an integrated

session this autumn to allow guardians, trade union representatives, our occupational health and staff

psychology consultants, chief registrars (for doctors in training) and key responsible directors for

education and training, to triangulate the themes from their reports, findings and investigations. This shall

directly inform a fresh policy and vision statement for speaking up.

6. Leaders are clear about their role and responsibilities

The Guardian for freedom to speak up’s report offers a guide to their first full year, in establishing the

service and interacting directly with over ten percent of our workforce. Our October Board seminar will

devote focus to barriers that may mean black, Asian and minority ethnic staff are less likely to speak up

and/or to be assured about the interest of the organisation to act on their feedback.

7. Leaders are confident that wider concerns are identified and managed

This principle is at the core of the way I expect us to encourage a more open culture where staff feel safe

to raise a concern and confident it will be well addressed. The Guardian reports and trade union

representatives’ feedback suggests that staff in some areas of the trust may feel reluctant to raise

concerns. On the basis of the quarterly report from the guardian for safe working hours making this

observation, I have asked corporate medical director to support him, so we directly encourage proactive

action to encourage exception reporting in any area of concern.

8. Leaders engage with all relevant stakeholders

Reports from our guardians and supporting staff data including our annual raising concerns report,

equality report and plan are shared with commissioners, regulators and local stakeholders in our

community and shall devote greater attention this year to the experience of staff who raise concerns,

through any means. Our annual report for 2018/19 should allow transparently detail more on actions the

trust is taking to support a positive speaking up culture.

9. Leaders are focused on learning and continual improvement

As well as the actions detailed above, I and the Chairman, and the FTSU Guardian, shall review all

guidance and case review reports from the National Guardian to identify potential learning for the Trust.

3. NATIONAL INPATIENT SURVEY RESULTS 2017 - CQC

UCLH has continued to achieve excellent results in the National Inpatient Survey, with patients rating their overall care as 8.3 out of 10 – the top score amongst our London peers for the second consecutive year. Almost 500 people who were inpatients in July 2017 completed the questionnaire. Their answers were analysed by the Care Quality Commission and the results were published in June. Using the Inpatient CQC data the experience of UCLH is great; we have maintained our good performance in a number of areas and seen particular improvements in questions around bringing medication from home. Taking into consideration the earlier Picker results and ongoing feedback from patients and staff, we remain focused on the following areas for 2018/19: help with meals, planned admission dates changed by hospital, waiting a long time to get a bed on a ward and improvements to discharge including patients knowing what was happening after leaving hospital. Nationally it has been reported that certain groups of patients consistently report poorer experiences of their time in hospital, including patients with mental health conditions, younger patients (16-35yrs) and patients with Alzheimer’s or dementia. This year we will also be looking at ways to better understand the experience of these groups. Patients will be invited to complete the 2018 survey when they have been an inpatient this July.

4. CARE QUALITY COMMISSION (CQC) REGISTRATION

The Paediatric and Adolescent Division have been commissioned by NHS England to lead a pilot to

create a Child House in North Central London. UCLH will work with the NSPCC and The Tavistock and

Portman NHS Trust to bring together services for children and young people who have been victims of

sexual abuse under one roof, including some services that are currently provided by UCLH. The service

will officially be named The LightHouse.

The Board are asked to approve the attached CQC registration documentation.

5. STRATEGIC DEVELOPMENTS

The refreshed strategy for UCLH was published in March 2018 and our objectives for 2018/19 were set in

line with this, which increases UCLH’s focus on working with local partner organisations and operational

excellence in our hospital. We also had an event to launch the UCLH Research Hospital in May, part of

our ambition to ensure as many patients as possible are given the opportunity to take part in a clinical trial,

regardless of whether they are seen in a specialist service or a more local service.

We continue to work with the Wellbeing Partnership across Haringey and Islington, supported by our

partnership with Whittington Health where we continue to work together to improve a number of clinical

services for patients. A Wellbeing Partnership event was held in May 2018, at which the excellent work

that is being delivered locally was presented. UCLH remains committed to working towards more

integrated care across the south of the North Central London sustainability and transformation partnership

(STP) and beyond, working closely with our partner organisations.

The redevelopment of the National Hospital for Neurology and Neurosurgery is now complete and will

provide much better facilities for patients and staff. The university completed their purchase of the

Eastman Dental Site in March, to enable the creation of a world-class academic facility. We are pleased

that this transaction went smoothly and are currently in the process of finessing our understanding of what

is a necessary clinical co-location on this site.

Our new PBT, haematology and short stay surgery centre continues to develop, with the Proton Beam

Therapy (PBT) cyclotron delivered in June. Meanwhile our new clinical facility for ENT and dental services

held its “topping out” ceremony in early July. These were both significant milestones that bring us closer to

the buildings opening in 2020 and 2019 respectively. Staff engagement on both projects is positive and

we were delighted to be joined by patients who have received Proton Beam Therapy at the cyclotron

event and by some alumni staff at the topping out as well as the teams both within UCLH and across our

partner organisations who are involved in making these world class new clinical facilities a reality.

6. NHS 70TH CELEBRATIONS

The NHS turned 70 on Thursday 5 July 2018. Many activities took place around the Trust to celebrate this

monumental event. You will recall the events I informed you about in May, most recently there has been a

‘Great UCLH Bake Off’ event which saw a very high standard of cake entries. I was delighted to be

amongst the judging panel! There have also been ‘NHS70tea’ tea parties held across the Trust and the

Board still have the opportunity to attend a tea party on Wednesday 18 July in Westmoreland Street and

Friday 20 July at NHNN.

7. STANDARDS OF BUSINESS CONDUCT POLICY

The attached Standards of Business Conduct Policy implements NHS England guidance and model policy

on managing conflicts of interest. It will replace the current Code of Conduct and Conflicts of Interest

Policy. This new policy will ask staff to declare additional declarations including:

- Outside Employment - this includes speaking at conferences and lectures for which a fee is paid directly to them, even if they donate this fee to charity

- Clinical private practice – including details of what - speciality and major procedures undertaken - where and when staff practice, sessional activity/hours worked and relevant dates.

- Patents and other intellectual property rights held

- Loyalty interests - in addition to a position of authority in a voluntary body in the field of health or social care, the policy now includes:

- position of authority in another NHS organisation or commercial, charity , voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role;

- Seat on advisory groups or other paid or unpaid decision making forums that can influence how UCLH or other NHS organisations spend taxpayers’ money;

- involvement in the recruitment or management of close family members and relatives, close friends and associates, and business partners.

- Sponsored events - any interests arising as a result of their association with the sponsor of an event held at UCLH. This is not to be confused with offers to pay for travel and accommodation made for attend conferences and lectures. This is now covered under Hospitality and should be declared as such.

- Sponsored research – the nature of their involvement in sponsored research other than that managed by the Joint Research Office. JRO maintains its own records.

- Sponsored posts - interests arising as a result of their association with the sponsor

The Director of Corporate Services and the Policy Compliance Officer have introduced new guidance that

will be circulated to existing and new staff. The NHSE guidance requires that for health organisations

publish somewhere prominent on their public website a register of all interests declared at least annually.

We plan to do this every 6 months.

The Board are asked to approve the Standards of Business Conduct Policy.

8. BOARD ASSURANCE FRAMEWORK

The latest version of the Board Assurance Framework is attached for the Board to review (attachment K).

The Senior Director Team receives regular risk reports and are assured of the Trust’s risk management

processes.

9. MEETINGS OF INTEREST TO THE BOARD

On 10 May I gave a key-note lecture to the UCL Medicine Research Retreat entitled: “The golden

age of Medicine at UCL(H).

On 17 May I gave a presentation on ‘End of Life Care’ at the annual meeting of the Association of

UK university hospitals in Bishop Stortford.

On 18 May I attended with Tim Jaggard the extended Islington and Haringey Wellbeing

Partnership Sponsor Board with inspiring presentations of integrated care throughout this part of

North-Central London

On 25 May I was invited to present a lecture at the European Health Forum in Venice on

‘Transformation of academic medicine in the 21st century.

In June and July I had a series of 5 meetings with staff at various locations in our trust (Meet the

CEO sessions) introducing our renewed strategy and having lively discussions on a variety of

topics.

On 15 June I co-hosted a two-day symposium of 35 European Chief-executives of university

hospitals in London and presented a session on ‘ Alliances, partnerships and mergers in academic

medicine’.

On 25 June I gave a talk and participated in a forum discussion on ‘Women in Medicine’ during

the annual conference of the Royal College of Physicians in the Excel centre in London.

On 27 June I gave a key note lecture on Health Care Leadership at the Congress of the

International Association of Academic Hospitals in Amsterdam.

10. USE OF THE TRUST SEAL

The Trust Seal was used 10 times since the last Board meeting.

Seal Number Date of Entry Entry Details

952/953 13 June 2018 Framework Agreement, Parent Company Guarantee, between

Pulse Healthcare Limited trading as Bank Partners and University

College London Hospitals NHS Foundation Trust.

954/955 13 June 2018 Call off Terms and Conditions of Parent Company Guarantee

between Pulse Staffing Limited and University College London

Hospitals NHS Foundation Trust.

956 18 June 2018 Variation and Extension Agreement for provision of services

between University College London Hospitals NHS Foundation

Trust and HCA International Ltd, Leaders in Oncology Care

Limited and LOC Partnership LLP.

957 18 June 2018 Supplemental Lease of part of Floor 15, Floor 2 and the sub-

basement of UCH, NW1 2BG between University College London

Hospitals NHS foundation Trust and HCA International Ltd.

958 18 June 2018 Supplemental Lease of Room P2 (control room bunker A) and

Bunker A between University College London Hospitals and HCA

International Ltd

959/960 18 June 2018 Deed of Variation to S108 Agreement relating to the former

Odeon site and Rosenheim Building, Grafton Way, TCR, Huntley

Street and University Street between University College London

Hospitals NHS Foundation Trust and The Mayor and The

Burgesses of the London Borough of Camden.

961 18 June 2018 Supplemental Lease of premises forming part of Floor 5 of UCLH

Cancer Centre (Phase 3) located at Huntley Street WC1E 6DH

between University College London Hospitals NHS Foundation

Trust and HCA International Limited.

962 18 June 2018 Agreement for works relating to part of ground floor, level four,

level five and roof garden at TCR between University College

London Hospital NHS Foundation Trust and HCA International

Ltd.

963 27 June 2018 Supplemental Agreement (No. 2) design and construction of

Phase 4 at TCR BETWEEN University College London Hospitals

NHS Foundation Trust and HCA International Ltd.

964/965 27 June 2018 Lease of part of UCH Macmillan Cancer Centre, Huntley Street,

WC1E 6AG between University College London Hospitals NHS

Foundation Trust and Lloyds Pharmacy Ltd for the provision of

Pharmacy Outpatient Dispensing Services.

PROFESSOR MARCEL LEVI

JULY 2018

D

Month 2 Performance report

May 2018

Month 2 - May

Board of Directors Performance Report

Month 2 - May

1. Executive summaries

2. Financial Performance3. Operational Productivity

4. Access

5. Patient Safety and Quality metrics

6. Workforce

7. Externally Reported Frameworks

Page Con

Board of Directors Performance ReportContents

Month 2 - May

Board of Directors Performance Report

LY to date LY to date

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% Elective variance -7.7% 0.0% -12.6% -10.7% -3.7% -10.6% -5.2% -14.2% -6.2% -6.2% Number of MRSA bacteraemias 0 0 0 0 0 0 0 0 0 1

% Daycase variance 2.8% 0.0% -2.8% 10.2% -7.3% 0.8% -9.8% 9.3% -5.6% -2.4%Number of clostridium difficile cases

reported (excluding successful appeals)6 8 3 2 1 17 5 7 5

6

% Non-elective variance -7.0% 0.0% -6.7% -3.8% -9.8% -4.6% -3.0% -9.6% -5.6% 0.0%

Outpatient variance 0.7% 0.0% -1.6% 4.5% -0.6% 0.8% -2.5% 4.8% -0.3% -2.4%

All pressure ulcers acquired at UCLH 6 7 4 2 0 13 7 6 0 8

Inpatient falls with serious harm 1 0 0 1 0 2 8 8 0 0

Theatre touchtime utilisation 82.0% 90.0% 80.8% 81.7% % eVTE risk assessments completed 96.7% 95.0% 95.1% 97.6% 96.3% 96.6% 94.6% 97.7% 96.0% 95.9%

Length of stay - elective 2.9 2.5 0.4 4.4 2.3 3.0Complaints responded to within target

time67.1% 85.0% 77.8% 48.0% 85.7% 72.8% 68.6% 65.8% 84.2% 79.1%

Length of stay - non elective 4.3 3.9 3.1 7.8 4.2 4.0 Friends & Family Test (IP survey) 94.3% 96.5% 95.0% 93.5% 95.9% 94.6% 96.1% 94.2% 95.7% 95.8%

% incomplete pathways < 18 weeks 91.2% 92.0% 95.5% 93.3% 89.5% 91.1% 95.5% 93.3% 89.5% 93.2% % mandated training compliance 85.9% 90.0% 86.0% 84.7% 85.5%

% Diagnostic waiting list within 6 weeks 98.1% 99.0% 100.0% 98.5% 96.9% 98.1% 100.0% 98.6% 97.0% 99.4% All appraisals completed (Tier 1) 45.7%95% (by the

end of May

2018)

36.2% 47.9% 54.0%

Patients waiting longer than 52 weeks 4 0 4 12 2 10 1 Vacancy rate 10.9% 8.0% 13.9% 12.7% 10.4%

A&E attendances within 4 hours 86.3% 95.0% 86.3% 85.0% 85.0% 90.6% Stability Rate (12m Rolling) 83.7% 85.0% 81.7% 84.0% 85.7%

% Temporary as part of the Total

Workforce 11.0% 16.3% 9.5% 8.9%

Cancer 62 day GP referral to treatment 69.3% 85.0% 72.7% 55.9% 87.5% 70.2% 80.0% 64.6% 83.3% 62.1%

Cancer 31-day wait from diagnosis to

first treatment95.5% 96.0% 100.0% 96.1% 92.9% 95.9% 100.0% 96.1% 94.8% 89.6%

Cancer 14 day referral to appointment 92.6% 93.0% 91.1% 92.9% 92.7% 92.6% 91.9% 93.6% 91.3% 93.8%

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

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D ED Trajectory91.0% 90.3% 92.2% 91.4% 91.7% 90.9% 90.5% 90.4% 90.5% 90.1% 92.1% 95.0%

Overall financial rating 3 ED Actual83.6% 86.3%

Operational Performance (Debt Service

Cover) 4

Cash and Balance Sheet Performance

(Liquidity) 1Cancer 62 day trajectory

80.6% 81.8% 86.2% 86.2% 85.0% 86.2% 85.8% 85.8% 85.8% 85.0% 85.8% 85.8%

Income and expenditure plan and CIP

deliveryCancer 62 day actual (Provisional)

70.9% 69.3%

RTT trajectory 91.0% 91.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0%

RTT actual 91.1% 91.2%

Month 2 - May

This month Year to date

Finance

Page 2

Workforce

ED, RTT, and

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waits

Externally

agreed

trajectories

1.2 Executive summary: board performance

This month Year to date

Quality and

safety

Pages 12 - 15

Cancer waits

Infection

Activity

Efficiency and

productivity

2. Financial Performance2.1 Use of Resources Rating Summary

Month 2 - May

Area of review

(metric)Key Highlights

NHS Improvement Use of

Resources Finance Rating

M2

actual

M2

plan

M1

actual

HEADLINE

FINANCIAL

PERFORMANCE

(Overall Rating)

The Trust’s M2 YTD I&E position, excluding exceptional items, is £0.3m behind plan (-£6.2m actual vs. -£5.9m

plan) .

The Trust’s overall use of resources finance rating is a score of 3 (where 1 is the highest rating & 4 the

lowest rating) . This score has been achieved because the Trust’s I&E margin & capital service cover metrics

have individual ratings of 4. Any individual rating of 4 triggers an overall score that can be no better than 3.

3 3 3

1. Operational

Performance

a. Capital service

cover

The Trust’s year-to-date revenue available for capital service (with the inclusion of EHRS costs & PSF income)

is £0.8m behind plan (+£4.7m actual vs. +£5.5m plan) .

Revenue of £4.7m is able to cover 0.42 times the Trust’s capital service (rating = 4).4 4 4

b. I&E margin

The Trust’s YTD performance against the control total is £0.2m ahead of plan (-£8.5m actual vs. -£8.7m plan).

As the Trust has delivered the control total, finance-related provider sustainability funding (PSF) of £1.5m has

been accrued at M2. The YTD ED-related element of PSF (£0.6m) has not been recognised.

The Trust’s adjusted M2 YTD I&E performance (i.e. with the inclusion of PSF) is a deficit of £7.1m, which

produces an I&E margin (on a control total basis) of -4.0% (rating = 4).

4 4 4

c. Distance from

financial plan

The M2 YTD I&E margin (on a control total basis) of -4.0% is 0.2% behind the planned YTD I&E margin of

-3.8% (rating = 2). 2 1 3

d. Agency The Trust’s M2 YTD spend on agency staff is £1.5m (in-month costs of £0.9m). This results in the Trust being

16% over its agency ceiling (£1.3m) (rating = 2). 2 4 1

2. Cash & Balance

Sheet

Performance

(Liquidity)

Working capital (cash + debtors - creditors) is able to cover 34 days of the Trust’s operating expenses

(rating = 1).

At 31st May 2018 the Trust’s cash balance was £156.9m, £3.3m higher than the planned cash position of

£153.6m.

The June month-end cash balance is £148m (£30m lower than plan).

M2 YTD capital expenditure of £19.5m is £5.2m less than plan (of £24.7m).

1 1 1

2. Financial Performance2.2 Income & Expenditure Summary

Month 2 - May

Month 2 - May

2. Financial Performance2.3 Cash flow summary

Month 2 - May

2. Financial performance2.4 Statement of Financial Position and Capital Programme Summary

2. Financial performance2.5 Monthly Financial Performance Summary

Month 2 - May

2. Financial performance2.6 Trust Wide - Financial Performance & Agency Reporting

Month 2 - May

2. Financial performance2.6 Medicine board - Financial Performance & Agency Reporting

Month 2 - May

2. Financial performance2.6 Specialist hospital board - Financial Performance & Agency Reporting

Month 2 - May

2. Financial performance2.6 Specialist hospital board - Financial Performance & Agency Reporting

Month 2 - May

2. Financial performance2.7 Activity trends

Month 2 - May

2. Financial performance2.8 Workforce trends

Month 2 - May

3. Delivery of CIP3.3 Efficiency and productivity

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% Touch time utilisation 82.0% 84.7% 82.3% 80.3% - 82.8%

% Opportunity for additional cases 16.9% 14.4% 11.6% 18.4% - 10.3%

% 4-hour-equivalent sessions closed

or unused21.9% 14.9% 9.9% - 22.7%

Number of 4-hour-equivalent sessions

closed or unused254 74 29 - 33

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Average length of stay for key

specialties - Elective admissions2.9 2.5 0.4 4.4 2.3

Average length of stay for key

specialties - Non-elective admissions4.3 3.9 3.1 7.8 4.2

Outpatient DNA rate 8% 12.3% 15.5% 11.4% 11.8%

Month 2 - May

This month - May

* Trust excludes Cancer Centre. Tower theatre excludes EGA,

DSU & Hybrid. Queen Square excludes IMRI & Virtual

Trust theatre utilisation across all sites has risen by 2.5 % to 82 % this month. This falls short of the 85% target considered good practice by the Model Hospital, and remains below the theatre productivity programme threshold of 86%. Tower theatres – The theatre productivity programme continues to increase utilisation of tower theatres. The surgical huddle has led to a decrease in cancellations and an increase to 476 (+94) cases from April to May. GI has increased utilisation by 11% to 79% despite consultant sick leave. They still challenge session utilisation of 60% or less on a monthly basis. Paediatrics saw a further increase to 63% utilisatio. Urology increased from 9% to 72% utilisation. EGA increased to 81%. Breast and gynaecology are approaching the Model Hospital definition of good practice with 84.6% utilisation. This is due to breast achieving 91% utilisation. WMS Theatres – Decreased slightly by 2% to 80% because planned robotic activity was reduce over bank holidays. Planned consultant leave and juniors undertaking clinical activity led to an increase in the number of potential cases that could have been operated on. Late starts are decreasing though inter-case downtime is getting worse. The number of cancellations on the day continues to decrease. RNTNE – Utilisation for this month has increased very slightly to 82.8%. A weekly timetable and review of the historical lists takes place to ensure that list are used, or closed if not fully utilised. Communication continues with surgeons to improve the use of lists. Inter-case downtime is better than the national average and should be continued. Queen Square – Theatre utilisation was impacted by pressure on patient flow and critical care beds. When using the best possible case mix, theatres achieved 82%. Inter-case down-time was long at 39 minutes. Early finshes and late starts were due to lists being held while attempts were being made to increase bed capacity. The increase in potential cases that could have been operated on was due to some elective activity being postponed: there were six non-elective cases undertaken within elective sessions. Our contract with our new benchmarking provider has now commenced. The performance team are currently working with them to obtain our expected length of stay which drives our LOS targets. For May we have generated an amended version of the length of stay report. The target is based on the previous 12 month length of stay average with either a 10% or 5% improvement based on whether the specialty was better or worse than the expected performance respectively. Our elective and non-elective length of stay is worse than target.

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4. Access4.1 Emergency flow

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All A&E attendances within 4 hours 95% 86.3% 86.3%

UTC attendances within 4 hours 97% 92.0% 92.0%

A&E to admission conversion rate 20% 14.2% 14.2%

Tower bed occupancy 94.0% 98.1% 92.9%

Delayed transfers of care days 862 445 247 170

% discharges by noon 35.0% 14.4% 18.3% 15.8% 11.2%

This month

Month 2 - May

9500

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A&E Attendances A&E attendances within 4 hours Target

In May we reported 86.3% performance against a trajectory of 91% for the four hour standard. This means that we can no longer meet the Q1 trajectory for the STF funding. UTC performance has been variable and impacted by increased difficulty covering medical shifts. An approach to locum cover rates along with the recruitment of GPs and emergency nurse practitioners will help. While there has been an improved availability of beds in the hospital this has not yet translated into the required reduction in bed delays. We need to understand where there are unnecessary delays in the process and develop plans to address what is likely to be a range of issues. This will need a combined effort of both ED and the Coordination Centre to focus improvement. Specialty review times have started to improve following consistent attention. EAU continues to be ring-fenced for CDU admissions only with no DTA patients moved to this area. This is to protect EAU for the pathways that it should be used for. The rapid assessment and treatment pathway (RATs) has now commenced in the old paediatric area creating , which has created additional majors capacity. Early results have been positive, with much improved ambulance handover times. We have agreed a new Emergency Access Improvement Plan to take the place of the old ED RAP. June forecast Performance for the end of June is likely to be less than 83.5%.

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Bed Specialty delay Diagnostic ED Delay Other Transfers

4. Access4.2 Access Targets - Referral to treatment

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% incomplete pathways < 18 weeks 92% 91.2% 95.5% 93.3% 89.5%

Patients waiting > 52 weeks 0 4 4

Patients waiting 40-52 weeks 81 4 16 61

% data quality issues on waiting list 5% 9.3% 10.2% 14.9% 7.1%

% Diagnostic waiting list within 6 weeks 99% 98.1% 100.0% 98.5% 96.9%

% Last Minute Cancellations to Elective

Surgery0.6% 3.1% 2.9% 2.5% 4.1%

% Cancelled Operations Readmitted Within

28 Days95% 99.7% 100.0% 100.0% 99.4%

Outpatient Cancellation Rate – Hospital

(adjusted to include only postponed

appointments)

5.7% 4.6% 7.6% 5.1%

This month

Month 2 - May

70%

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% Diagnostic waiting list within 6 weeks

% Diagnostic waiting list within 6 weeks Target

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Referral to treatment

% incomplete pathways < 18 weeks

Our agreed 18/19 plan is to deliver the 92% RTT standard from July but to maintain above 91% performance in April, May and June. May We met our plan for May (91.16%, up 0.05% from April). The total number of patients waiting over 18 weeks (backlog) decreased slightly by 16 to 3,826. The following divisions were not compliant: - RNTNE – 88.3% (up 0.7%) Improvement was driven by considerable backlog decrease in adult ENT. Further backlog reduction is forecast for to continue. -Eastman Dental Hospital – 88.7% (down 1.2 %). Deterioration driven by backlog increase in oral surgery. Backlog decrease is now expected due to improved booking processes, which will ensure quicker first outpatient appointments. - Queen Square – 90.1% (up 0.3%). Slight improvement driven by slight backlog decrease in neurosurgery and diagnostic and support. Further backlog decrease in neurosurgery are expected over coming months due to tighter monitoring of 40 week+ waiters and improved validation. - Women's Health - 90.9% (down 2%). Deterioration driven by backlog increase in gynaecology. The specialty has agreement for a waiting list initiative , which will provide extra capacity to reduce backlog. We reported four 52 week breaches overall, down four from the eight in April: three in neurosurgery and one in paediatric dentistry. The paediatric dentistry patient was also reported last mont. The harm review identified the potential for clinical deterioration, which has been attributed to the patient not attending appointments. However, safeguarding processes were correctly followed. No harm is expected for the other patients. We did not meet the diagnostics standard. This was driven by a higher number than normal breaches amongst the imaging modalities. Extra breaches had been caused by PTL visibility issues as a result of the switch to the Soliton RIS upgrade. Solutions are now in place to reduce these breach numbers. Non-compliant modalities were: - Neurophysiology - 98.9% (up 1.1%). There were 5 breaches at QS. - CT - 98.6% (down 0.8%). There were 11 breaches in imaging and a further 10 breaches at QS. - Ultrasound - 98.5% (down 1%). There were 41 breaches in imaging. - MRI - 96.9% (down 0.8%). There were 55 breaches at QS and a further 44 breaches in imaging. - Urodynamic - 75.3% (down 9.4%). There were 21 breaches at QS. June forecast - RTT performance is forecasted to remain above 91% as per our plan. - Diagnostics will remain non-compliant in June, with a forecast of 139 breaches. We are expecting to recover compliance by August.

4. Access4.3 Access Targets – Cancer

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Two week wait from referral to date first seen93% 92.6% 91.1% 92.9% 92.7% 84.7%

Two week wait from referral to date first seen: breast symptoms 93% 78.2% 78.2% 18.5%

31-day wait from diagnosis to first treatment 96% 95.5% 100.0% 96.1% 92.9% 96.1%

31-day wait for second or subsequent treatment: surgery94% 90.9% 76.5% 100.0% 95.2%

31-day wait for second or subsequent treatment: drug treatments98% 100.0% 100.0% 100.0% 100.0%

31-day wait for second or subsequent treatment: Radiotherapy94% 98.6% 97.6% 100.0% 100.0%

31-day wait for second or subsequent treatment: other96.0% 91.7% 100.0% 72.7%

62-day wait for first treatment from urgent GP referral to treatment85% 69.3% 72.7% 55.9% 87.5% 70.9%

62-day wait for first treatment from screening service referral90% 90.0% 100.0% 75.0% 60.0%

62-day wait for first treatment from urgent GP referral to treatment

Internal only85% 72.2% 76.5%

Number of 104 day waits (from GP referral) Internal2 0 1 1

Number of 104 day waits (from GP referral) External15 1 11 3

% Inter trust referrals treated within 24 days of referral16.0%

* The trust threshold is an aggregate of individual clinical board thresholds

Month 2 - May

This month (not yet validated), May

0%10%20%30%40%50%60%70%80%90%

100%


Cancer 62 day referral targets

Target (GP referral to treatment) Cancer 62 day referral from screening to treatment

Target (screening to treatment) Cancer 62 Day GP referral to treatment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Cancer 2 week referral targets

Cancer GP referral to appointment Cancer 14 day wait from referral (symptomatic breast) Target

We have agreed a trajectory to deliver overall compliance for June 2018. May's provisional position (69.3%) is 12.9% below our trajectory. We expect to report 13 internal and 14 shared breaches (27 pathways). Provisional internal performance (77.2%) is non-compliant and 6.8% below trajectory (84%). We are assessing each breach for avoidability to understand any learning to prevent future recurrence. We have increased our focus on managing shared pathways, including delivering treatment in 24 days where a referrals reaches us after day 38. Applying the future breach reallocation rules would deliver a 2.4% uplift in performance to 71.7%. There is particular pressure in urology due to an increase in the number of shared pathways referred for robotic surgery. Patients are currently being booked beyond day 24. The service has increased capacity to maximise all opportunities including weekend lists, increasing lists from 2 to 3 patients and using private sector We expect to narrowly miss compliance with the two week wait standard and the breast symptomatic standard. This is due to patient choice. May's performance will be finalised on July 5th June forecast: Our trajectory is to deliver 82% overall. Our current best known position is approximately 7% below this. We are expecting 11 internal breaches. However, we do not yet know the full extent of shared pathways and so there is risk that performance may deteriorate. Geoff Bellingan has written to all clinical directors, MDT and managerial leads to remind them of the importance of tight monitoring and early escalation of issues to improve performance through June and July.

5. Quality5.1 Infection

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Number of MRSA Bacteraemias 0 0 0 0 0

Number of clostridium difficile cases

reported (excluding successful

appeals)

16 17 5 7 5


due to lapses in care0 0 0 0


under review17 5 7 5


successfully appealed0 0 0 0

Number of MSSA Bacteraemias 5 3 1 1 1

% - Infection control improvement

compliance (this month)95.0% 95.9% 90.2% 96.2% 96.9%

* The trust threshold is an aggregate of individual clinical board thresholds

YEAR TO DATE

Month 2 - May

0

1

2

3

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

MRSA bacteraemia / infections - All Services

MRSA actuals monthly MRSA threshold monthlyMRSA actuals YTD MRSA threshold YTD

0

50

100

150

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Clostridium difficile infections post 48 hrs - All Services

CDiff Actuals Monthly excl. successful appeals CDiff Threshold Monthly

CDiff Actuals YTD excl. successful appeals CDiff Threshold YTD

We have reported 17 cases of C diff as at the end of May against a year to date threshold of 16. All cases are under review and none have been found to be lapses in care by the Trust. There was one case of MSSA for May. This occurred within emergency services on ward T01. The patient, who was an intravenous drug user, was admitted with infected abscesses. There were no lapses in care identified. Infection control improvement compliance was better than threshold for the trust. Medicine board was worse than threshold, driven by the infection and critical care divisions being worse than target.

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% Harm free care (National Safety

Thermometer)95.0% 95.0% 86.5% 97.0% 98.5%

% Harm free care (Hospital acquired

only)95.0% 97.6% 95.5% 97.4% 99.3%

Patients with preventable dose

omissions8.0% 6.3% 5.4% 3.1% 9.9%

Dose omissions audit - % submission

compliance100.0% 84.1% 100.0% 93.3% 72.7%

% eVTE Risk Assessments completed 95.0% 96.7% 95.1% 97.6% 96.3%

The trust threshold is an aggregate of individual clinical board thresholds

This month

Month 2 - May

5.2 Safety

5. Quality

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%


Patients with preventable dose omissions- All Services

Preventable dose omissions Target

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%


VTE risk assessment - All Services

Percentage of Completed eVTE Risk Assessments Target

We were slightly worse than threshold for harm free care at 94.99%. Medicine board is not achieving compliance but this is because a number of patients had acquired issues in the community. We were better than threshold for dose omissions. Specialist hospitals board was worse than threshold which was driven by women's health at 30% compliance. The division acknowledge this exception and are driving through actions to improve performance. The trust was better than threshold for the VTE assessment measure across the three boards.

5. Quality5.3 Safety

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Inpatient falls with serious harm 0 1 0 1 0

Falls per 1000 beddays 1.5 5.0 4.3 3.5 6.8

Falls with harm per 1000 bed days 1.1 1.3 1.0 1.1

Pressure ulcers acquired 7 6 4 2 0

Grade three pressure ulcers acquired 0 0 0 0 0

Grade four pressure ulcers acquired 0 0 0 0 0

The trust threshold is an aggregate of individual clinical board thresholds

This month

* falls with serious harm include severe, and death categories in Datix

Month 2 - May

0

1

2

3

4

5

6

0

20

40

60

80

100

120

140

160

180


Patient falls per 1,000 bed days and Overall - All Services

Inpatient falls with harm Patient falls Falls per 1000 beddays

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4

6

8

10

12

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Pressure Ulcers acquired at UCLH split by Grade/Category - All Services

Grade 4 Grade 3 Grade 2

There were 95 falls in total in May. There were 67 no harm, 28 low harm and one with severe harm. We have agreed with commissioners to only report falls on the Gower's unit of moderate harm and above. The one severe harm for the GI division which was on T09N, where a patient sustained a hip fracture after a fall. The incident is being investigated as an externally reportable serious incident. During the month of May there were no grade 3 or grade 4 hospital acquired pressure ulcers (HAPU). There were six grade 2 HAPU which was a slight improvement on April's figure of seven, and better than the trust threshold of seven. There were two suspected deep tissue injuries, but no unstageable ulcers. No omissions of care were identified but patient compliance and engagement remains a factor. However the clinical teams continue to invest energy in exploring avenues to improve this.

5. Quality5.4 Outcomes

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Emergency readmissions within 30

days3.1% 3.5% 7.8% 3.1% 1.5%

% Complete vital signs collected 96.0% 99.3% 98.4% 99.3% 99.5%

% deteriorating patients escalated

according to protocol90.0% 99.5% 100.0% 100.0% 99.0%

Local summary hospital-level mortality

indicator (1 yr rolling data)

This month

Month 2 - May

75%

80%

85%

90%

95%

100%


% Complete Vital Signs collected - All Services

Percentage of Complete Vital Signs New Target Linear (Percentage of Complete Vital Signs New)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18

Emergency readmissions within 30 days (with PbR exclusions)

Emergency readmissions within 30 days (with PbR exclusions)

We were slightly worse than threshold for emergency readmissions within 30 days for May. Under-performance in the medicine division was driven by the medical specialties division at 5.2% and emergency services at 9.1%. This is most likely due to admissions within EAU. We were better than threshold for vital signs observations in May. All boards were compliant with this measure. Local SHMI is not currently available as we are still establishing the process for obtaining this data from our new benchmarking partner. We anticipate this will be mid-July and so data should be available for next month.

5. Quality5.5 Patient Experience

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Complaints responded to within target

time85.0% 67.1% 77.8% 48.0% 85.7%

Inpatient friends and family test 96.5% 94.3% 95.0% 93.5% 95.9%

A and E friends and family test 95.0% 82.5% 82.5%

Outpatient friends and family test 92.1% 92.2% 92.3% 92.0%

Response rate -Friends & Family Test (IP

survey)30.0% 18.9% 23.1% 17.1% 17.7%

Response rate- Friends & Family Test

(AE survey)20.0% 15.1% 15.1%

Response rate- Friends & Family Test

(OP survey)8.6% 7.8% 9.0% 8.7%

% of hospital appointments postponed by

hospital5.7% 4.6% 7.6% 5.1%

Choose and book slot issues (two months

in arrears)27.6% 20.9% 23.3% 34.7%

This month

Month 2 - May

0

20

40

60

80

100

0%10%20%30%40%50%60%70%80%90%

100%


Patient experience - Complaints received

Number of Patient Complaints Complaints responded to within target time Target

0%

20%

40%

60%

80%

100%


Patient Experience - FFT scores and response rate (IP & AE)

Friends & Family Test (IP survey) New FFT AE score Friends and Family - IP Response Rate FFT AE response rate %

We were worse than threshold for patient complaint response times in May at 67.1%. Medicine board was slightly worse than threshold at 77.8% . This was driven by clinical support reporting three of the seven complaints in target time. This includes transport complaints. All other medicine divisions were 100% compliant. Specialist hospitals board was better than target. All divisions were compliant with the exception of women's health with seven of the ten complaints done in target time. Staff within the division have been reminded of the importance of timely complaints management. The surgery and cancer board was worse than threshold. In the cancer division only one of seven complaints was completed in time which was due to multiple complex cases. The division is reviewing resources allocated to complaints. The inpatient FFT is made up of both inpatient and daycase areas. Data collection is via iPad/paper for inpatient areas and text/instant voice messenger for daycase. The response rate has increased slightly this month by 1.1% to 18.9%. Improvements in response rates can be seen in both medicine and surgery and cancer boards. The recommended score and the not recommended score remains stable this month at 2.9%. Feedback in A&E is collected via text/instant voice messenger for majors and UTC, and paper for paeds. The response rate has fallen this month by 3% to 15.1%. The fall is seen in all areas. The main driver is paediatrics who had a response rate of just 1% this month. Despite the fall in response rates the recommended score for ED has remained stable this month at 82.5%, the not recommended score has also remained stable at 12.5%. Our OP response rate continues to remain stable for the sixth consecutive month. Work is underway to reframe the wording on the text message as a different narrative may encourage an increase in responses. The recommended score and the not recommended score remains stable this month at 4.2%.

6. Workforce6.1 Performance indicators

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Staff in Post N/A 8078.2 1586.9 2567.0 3073.5 850.9

% Temporary as part of the Total Workforce N/A 11.0% 16.3% 9.5% 8.9% 13.1%

Vacancy Rate 8.0% 10.9% 13.9% 12.7% 10.4% 12.0%

Stability Rate 85.0% 83.7% 81.7% 84.0% 85.7% 79.7%

Month 2 - May

This monthStaff-in-Post: Staff-in-post levels have increased by 9 wte between April and May 18/19. Though UCLH committed to apply new pan-London rates from April, some large acute trusts in north London have been unable to commit to those and are now offering significantly enhanced rates to deal with activity challenges. This has affected UCLH’s ability to retain and recruit locums on bank rates in areas of significant demand including the emergency pathway.

Temporary Staffing: The proportion of staffing that is made up of temporary staffing has increased by 0.8% between April and May.

Vacancy Rate: The trust vacancy rate increased by 0.4% from April to May, partially driven by slight increase in establishmen. In May, international recruitment programmes were on hold - in view of visa and wider immigration restrictions.

Stability Rate: Trust stability rate has increased by 0.2% between April and May.

Equality & Diversity: The Workforce Committee has encouraged we add headline indicators from our equality and diversity action plan into monthly reporting. We propose to add three KPIs: relative likelihood of BME staff being subject to a disciplinary procedure, relative likelihood of white candidates being appointed across all grades and specifically for posts at 8c and above. Those indicators would match those we are reviewing regularly to assess progress against the workforce race equality standard. The performance and planning team is compiling proposals on new indicators across the performance pack with a full proposal to go to the SDT in August 2018.

6. Workforce6.2 Performance indicators

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Sickness absence rate (%) 12m

RollingN/A 3.4% 3.4% 3.5% 3.6% 2.2%

All appraisals completed (Tier 1 & 2)

95% (by the

end of May

2018)

45.7% 36.2% 47.9% 54.0% 36.4%

% Statutory and Mandatory training

compliance90% 85.9% 86.0% 84.7% 85.5% 92.9%

Average time to recruit (advert to final

offer- weeks)8.0 10.3 10.3 10.9 10.4 9.0

Month 2 - May

This month

Sickness Absence: Sickness rates have remained steady at 3.4% between April and May.

Appraisal: Tier 2 staff were due to complete their appraisals by the end of May. This target has not been met. The Director for Education is continuing to regularly review. After completing each written and face to face appraisal, managers need to confirm their detail on the NHS electronic staff record. ESR now relies upon access to windows 11 and the application was unstable in M2. Hence this report’s data under reports the number of appraisals that have been completed.

Mandated Training: Now all honorary contract holders are included in the denominator, we are working to encourage sustained improvements in compliance. We expect to sustain the rate of improvement from April to May, between June and July. Training compliance increased by 1.6% between April and May. We continue to work with SMEs to ensure sufficient classroom capacity, along with a requirement for clinical staff to complete duty of candour training.

Time to Recruit: Trust average time to recruit has increased slightly by 0.1 between April and May. UCLH has coordinated work across our STP n resourcing. The latest target of that work is to move to a 8 week target for this metric. To further our own progress we are exploring a “one stop shop” assessment process whereby interviews, outcomes and pre-employment checks (including occupational health) are delivered on the same day.

Junior Doctors: This KPI is a new indicators proposed by the planning and performance director to measure the agreed objective to improve working conditions for junior doctor.

6. Workforce6.3 Nursing and Midwifery Detailed Workforce Dashboard

Month 2 - May

Nursing and Midwifery Detailed Dashboard - Month 2, 2018/19

Key Workforce Metrics &

Indicators

NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All

Establishment FTE* 166.5 558.7 29.7 754.9 289.5 972.3 42.7 1304.5 260.3 1196.4 53.1 1509.8 4.4 46.5 16.6 67.5 720.7 2773.9 142.1 3636.7

Staff in Post FTE* 152.9 478.9 29.5 661.3 243.1 847.8 48.0 1138.9 235.6 1028.0 51.8 1318.3 14.5 99.7 19.6 134.8 646.1 2454.4 148.9 3253.2

Vacant Posts FTE* 13.6 79.8 0.3 93.6 46.5 124.5 -5.3 165.7 24.7 168.4 1.3 191.5 -10.1 -53.2 -3.0 -67.3 74.6 319.5 -6.8 383.5

Starters FTE 0.0 6.0 0.0 6.0 5.0 7.0 0.0 12.0 9.0 7.0 0.0 16.0 0.0 2.0 0.0 2.0 14.0 22.0 0.0 36.0

Leavers FTE 0.6 21.4 1.0 23.0 3.0 0.0 0.0 3.0 0.0 6.3 2.0 8.3 0.0 2.0 0.0 2.0 3.6 29.7 3.0 36.3

Vacancy Rate* 8.2% 14.3% 0.8% 12.4% 16.0% 12.8% -12.4% 12.7% 9.5% 14.1% 2.4% 12.7% -229.5% -114.4% -18.1% -99.7% 10.4% 11.5% -4.8% 10.5%

Turnover Rate 4.7% 18.2% 26.5% 15.4% 8.0% 14.4% 6.5% 12.7% 8.1% 17.2% 15.6% 15.6% 6.8% 20.9% 20.3% 19.1% 7.2% 16.6% 15.6% 14.7%

Temp Staffing Usage 35.7% 20.3% 30.8% 14.7% 27.6% 14.6% 12.1% -5.0% 30.4% 15.3%

Sickness Absence 7.4% 2.4% 1.8% 3.5% 5.5% 3.7% 2.5% 4.0% 5.4% 4.7% 0.5% 4.6% 5.1% 4.1% 0.9% 3.7% 5.9% 3.9% 1.4% 4.2%

Right Staffing Level by Shift 89.7% 96.8% 87.8% 95.9% 91.0% 104.3% N/A N/A 89.5% 99.8%

Notes: The increase in establishment reflects the increase in establishment to support the development of nursing associates and nursing apprenticeships. Trust N&M vacancy rate in May is 10.5%. Nursing

recruitment is a key focus within the 18/19 resourcing plan for the trust. Sickness levels have fluctuated from from 4.1% December 17/18, to 3.9% in April 18/19, to 4.2% in May. Turnover has decreased from

16.9% to 14.7% between April and May.

Medicine Board Surgery & Cancer Board Specialist Hospitals Board Corporate Board UCLH Trust

100.2% 100.6% 109.1% N/A 104.4%

16.8% 12.3%-6.5%12.1%11.5%

0%

2%

4%

6%

8%

10%

12%

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40

60

80

100

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May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18

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Nursing and Midwifery Starters and Leavers

Starters Leavers Vacancy Rate

0%2%4%6%8%10%12%

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3500

3550

3600

3650


Esta

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Nursing and Midwifery Vacancy Rate, Vacancy Projection and Establishment

Establishment Actual Vacancy Position Vacancy Projection %

Estimated riskThresholds Weighting May 18 Q1 Comments

16 1.0 17 17 8 cases successfully

reviewed

92% 1.0 91.2% 91.1%See page 8 for detail.

85% 69.3% 73.1%See page 15 for detail.

90% 90.0% 71.4%See page 9 for detail




96% 0.5 95.5% 95.2% See page 9 for detail



95% 1.0 86.3% 83.6%See page 8 for detail

2 2

7. Externally Reported Frameworks7.1 NHS Improvement Indicators – Compliance Framework

Indicators

62 day wait for first treatment from urgent GP referral

1.0

62 day wait for first treatment from consultant screening service referral

Incidence of Clostridium difficile year to date

Month 2 - May

31-day wait from diagnosis to first treatment (all cancers)

Two week wait from referral to date first seen: all cancers

0.5

Two week wait from referral to date first seen: symptomatic breast patients

Maximum time of 18 weeks from point of referral to treatment - incomplete pathways

Single Oversight Framework

31 day wait for second or subsequent treatment: Surgery

1.031 day wait for second or subsequent treatment: anti cancer drug treatments

31 day wait for second or subsequent treatment: Radiotherapy

A&E: Maximum waiting time of four hours from arrival to admission/ transfer/ discharge

The new Single Oversight Framework that has been put in place by NHS Improvement, and replaces the Monitor Assurance Framework. We have been notified that we have been

placed in segment two of this framework (this is of four segments; one denotes high performing, whilst four denotes formal turn-around). Our segment two status reflects non-

compliance with three of the four operational standards within the framework (diagnostic waits, A&E and cancer 62 day; we are achieving the RTT standard). This puts us in the

bracket of requiring targeted, but not mandated, support from NHSI.

Improvement Plan Monthly Update Refreshed Improvement Plan Signed off June 2018

Date of review

Forum reviewed in

Refreshed plan

Latest position against trajectory

November December January February March April May June July August September

Trajectory

(submitted to

NHSI in May)

Refreshed

trajectory agreed in

December. Below is

Nov actual.

88.1% 90.4% 93.0% 95.1% 91.0% 90.3% 92.2% 91.4% 91.7% 90.9%

Actual 85.5% 86.1% 85.9% 85.4% 84.6% 83.7% 86.3% ~83.5%

Drivers of any

variance from

trajectory

28/06/2018

Operational Excellence and Emergency Access Board

Reduced rates for locum doctors went live across London on 15th May, which has resulted in fewer available locum doctors to fill vacant shifts. This caused some

issue over the last week as doctor absence, especially middle grades, meant UTC and Majors delays built up throughout the afternoon, putting additional pressure

onto night time staff.

The LAS attendance profile on some days created a challenge as we saw peaks of high activity within a short space of time throughout the afternoon and evenings.

Peaks of Mental Health patients presenting to the department cause additional delays/blockages, especially in the evenings and weekend, when upwards of 6 MH

patients can be in the department at any one time.

With agreement from the A&E delivery board there has been a refresh of our improvement plan.

Performance through Q1 has been very challenging with performance in the region of 84.5% against an STF trajectory of 91.2%. June performance seems likely to

end below 83.5%.

Specialty review times have started to improve. UTC performance has been variable and impacted by increased difficulty covering medical shifts. While there has

been an improved availability of beds in the hospital this has not yet translated into the required reduction in bed delays.

The emergency assessment unit is continuing to be ring-fenced for CDU admissions only with no DTA patients moved to this area. This is being done to protect EAU

for the pathways that it should be used for. Rapid assessment and treatment (RATs) has commenced with good results (much improved ambulance handover

times) in the old paediatric area creating additional majors capacity.

Improvement Plan Update

Number of actions open by RAG status: 0 3 27

Commentary on all red and amber work packages (identified as priority areas which have maximum impact on performance)

ref Reason why red / amber

Impact on

trajectory

Y

Y

Y

Key new learning from recent weeks

Month:

Area

ED breaches

Bed breaches

Issue: UTC performance is variable.

Action: The staffing model needs to change to include more ENP & GPs (13 GPs were being interviewed on the 4th

July).

Improve portering response times:

AMBER as while auto-portering has been switched on in ED

there are a number of outstanding issues that hinder

improved performance

Action: resolve technical issue that prevents porters knowing specific

ED location (June)

Action: resolve technical issue that prevents nurse being informed

porter en-route (June)

Action: More detailed analysis of demand in relation to staffing

available.

June

Recovery actions / expected date of completion

Compliance with patient flow systems.

AMBER as while there is some improvement we are behind

trajectory.

Action: Improved reporting to show compliance against all

trajectories (June)

Action: Change emphasis from ward improvement work led by the

programme team to divisional responsibility (June)

New issues since last report and actions to address

Review ED staffing model:

AMBER due to situation worsening with ability to cover shifts

especially out-of-hours

Action: Agree approach to locum rates (June)

Action: Agree timing of funding for additional staff (July)

Action: Recruitment of GPs and ENPs (starts July)

Issue: The time from decision to admit to transfer, when there are empty beds, needs to be improved.

Action: We need to understand where in the process there are unnecessary delays and develop plans to address what

is likely to be a range of issues. This needs to be a combined effort of both ED and the Coordination Centre to focus on

this and help achieve the 4-hour target.

Remedial Action Plan Monthly Update

Date of review

Forum

Latest performance against revised trajectory agreed in December 17

Trajectory December January February March April May June

62 day internal (%) 79% 76% 81% 84% 87% 84% 87%

Internal breaches (#s) 9 10 8 7 6 7 6

62 day shared (%) 57% 49% 59% 69% 74% 79% 86%

Shared breaches (#s) 15 16 14 12 10 8 5.5

Overall (%) 68% 64% 70% 77% 81% 82% 86%

Overall 62d breaches(#s) 24 26 22 19 16 15 11

Actual Actual Actual Actual Actual Unvalidated

62 day internal (%) 88.0% 68.0% 83.0% 87.8% 89.1% 77.2%Internal breaches (#s) 5 14 7 6 5 13

62 day shared (%) 67.3% 51.0% 49.0% 63.2% 62.3% 54.8%

Shared breaches (#s) 9 15.5 17.5 16 14.5 14.0

Overall (%) 79.9% 61.0% 68.0% 76.2% 76.9% 69.3%

Overall 62d breaches(#s) 14 29.5 25 22.0 19.5 27

Breach Reallocation 84.8% 71.7%

62d breaches (#s) 13.0 26

Notes:

Shared pathways count as half each.

Action Plan Update

Commentary on current red issues

Action Ref Issue

Impact on

breach #s?

CP 1

Urology

Any new risks or emerging issues?

Actual /

provisional

Actions to bring back on track

Backlog - there continues to be an increase in the backlog which is predominately driven by Urology referrals on a shared pathway. The number of shared

pathways has more than doubled in the last 12 weeks and there is concern that more referrals are yet to be sent to UCLH for treatment. There are weekly

escalations and reports to NHSI who are aware of the challenging situation. The Urology service has maximised robotic capacity so there are little additional

capacity opportunities. Although the 24 day target is not being met the majority of patients are being treated within 31 days of a DTT. Whilst Urology is under

such pressure the performance of other tumour sites is being closely managed to ensure no further slippage.

Further deep dive on all tumour sites

Awaiting review of RCAs to identify suitable tumour sites where further deep dives and

organisational learning opportunities exist

Update on timetable for future

support meetings

Y

RAG rating reflects performance v trajectory rather than 85%

20/06/2018

EAB 22/6/2018

Bilateral Meetings/Actions

Date of referral from NCL

Agreement of date of referral on the urology pathway with Royal Free as UCLH are

undertaking counselling on treatment options

NUCLH Urology service to send

rationale to RFH

As agreed with NHS Improvement the RAP will be a live document. Some new actions in the work packages have been added and end dates for these specific work packages have been adjusted.

PTL Development - a programme of review and updating of current cancer reports has commenced. A reporting strategy is due for completion by end of June which will include an implementation timeframe. Priority of development has been given to the shared pathways and 24 day target, but it is recognised that new PTL designs are also required for 62 day and all 31 day standards.

Key learning from internal breaches in last reported month

Month:

Tumour site Issues and learning Avoidable?Breast

Lung

Sarcoma

Urology

Shared Pathways

Haem

Gynaecology

Head & Neck

3

Lung

Sarcoma

2

UGI

2

Urology

4

Actions that were closed at the last reviewAction Ref Action description

GI1

L1

Complex via LGI family unable to bring for further diagnostics

Note these are where these have not been successfully managed within 24 days of referral to UCLH

Ensuring sector ITT

operating protocol is being

usedEnsuring sector ITT


usedThree referred late in

pathways with a variety of

other delays: patient delays,

Medical reasons an

complexity. All are being

discussed with clinical team.

Delays to transfer are

subject to sector bilateral

plans

Difficulties in diagnosing can

be an issue but not an action

for the RAP

April - final

Patient engagement issues throughout all steps of pathway

Patient referred out to renal SMDT pre day 38 then referred back for treatment day 58 - then delayed

due to medical reasons

No

Patient did not attend OPA where decision to treat would have been made.



for the RAP

Learning / new action

added to RAP?

Review of patient

engagement underway to

ensure support is given at all

stages off the pathway

Was to have local treatment from SMDT but chose to have at centre - no ITR sent at this point

Not correctly tracked after MDT - was to be for local treatment then sent to centre for treatment not

correctly informedReferred day 49 then patient delays to OPA's at treating trust

Referred day 51 - patient not contactable to arrange OPA at treating trust

Referred day 41 - patient wanted to explore alternative treatment options

Patient referred to specialist centre pre day 38 and not treated within 62 days

Embed optimal lung pathway - additional clinics in place and nurse navigator commences in July



for the RAP

Ensuring sector ITT


used



for the RAP

Multiple diagnostics to determine the most appropriate treatment then required 2 surgical teams

Reduction in lower GI backlog - achieved to levels agreed

No

Complex diagnostic pathway

No

No

Head and Neck to Haematology - patient delays during diagnostics then decided wanted to be treated at

another organisation

Day 54 referral with complex needs at preassessment and then capacity for PAU bed

Incorrect pathway detail sent so unaware on 62 day pathway

Complex diagnostics requiring multiple biopsies to confirm diagnosis

Patient delays and changed mind on treatment options

No pathway detail received from referring organisation - unaware until day of final upload cut off

AprilFinal reported

breakdown by

tumour siteNo. Delays %

Brain Internal -

External -

Total 0 0 -

Breast Internal 9 1 88.9%

External 0.5 100.0%

Total 9.5 1 89.5%

Lung Internal 6 1 83.3%

External 4.5 1 77.8%

Total 10.5 2 81.0%

Haematology Internal 4 100.0%

External 2 0.5 75.0%

Total 6 0.5 91.7%

Upper GI Internal -

External 1.5 1 33.3%

Total 1.5 1 33.3%

Lower GI Internal 3 100.0%

External -

Total 3 0 100.0%

Dermatology Internal 4 100.0%

External -

Total 4 0 100.0%

Gynaecology Internal 4 100.0%

External 5.5 1.5 72.7%

Total 9.5 1.5 84.2%

Urology Internal 9 2 77.8%

External 17 5.5 67.6%

Total 26 7.5 71.2%

Head and Neck Internal 4 100.0%

External 5.5 3.5 36.4%

Total 9.5 3.5 63.2%

Sarcomas Internal 1 1 0.0%

External 2 1.5 25.0%

Total 3 2.5 16.7%

Childrens Internal -

External -

Total 0 0 -

Acute Leukaemia Internal -

External -

Total 0 0 -

Testicular Internal 2 100.0%

External -

Total 2 0 100.0%

Other (CUP) Internal -

External -

Total 0 0 -

Grand Total Internal 46 5 89.1%

External 38.5 14.5 62.3%

Total 84.5 19.5 76.9%

GP 62 day - internal vs external referrals

E

Quarterly report on Safe working hours for doctors and dentists in

training

QUARTERLY REPORT ON SAFE WORKING HOURS

DOCTORS AND DENTISTS IN TRAINING

Guardian of Safe Working Hours, Dr Prasad Korlipara

1st January 2018 – 31st March 2018

1. EXECUTIVE SUMMARY

By the end of the reference period 508 junior doctors were on the 2016 contract.

70 exception reports were submitted by junior doctors in relation to working hours during the reference

period.

No work schedule reviews have been requested.

No fines were levied for serious safety breaches.

2. PURPOSE OF REPORT

This Quarterly Report on Safe Working Hours within UCLH covers a period from 1st January 2018 to 31

March 2018. This is a requirement of the 2016 junior doctor contract and the aims of the report are to

provide:

a current view of working practice in relation to working hours;

assurance that safety criteria are being met;

highlight areas of concern; and

seek to give confidence to junior doctors that the trust is upholding the standards set in the national

terms and conditions.

3. HIGH LEVEL DATA

Number of doctors / dentists in training (total): 525

Number of doctors / dentists in training on 2016 TCS: 508

Number of doctors / dentists in training on 2002 TCS: 17

Number of educational supervisors with UCLH 287

Recommended amount of job-planned time 0.25 PAs per trainee

for educational supervisors:

4. ABBREVIATIONS

GSWH – Guardian of Safe Working Hours

MWT – medical workforce team

MDES – Medical and Dental Education Service

ES – Educational Supervisor

5. EXCEPTION REPORTS (WITH REGARD TO WORKING HOURS)

No exception reports were carried over from the last report. No exception reports were submitted under

the category ‘unable to take breaks’

Specialty Rota Grade No of

doctors

submitting

exception

reports

No.

exceptions

raised

Outcomes/ Comments

Neurology ST3+ 2 2 Approved, time off in lieu (6.25hrs)

Gastro FY1 2 14 Approved, time off in lieu (5.5hrs)

Payment (29.5hrs)

Medical

Oncology

CT 3 6 Approved, time off in lieu (8.5h)

ST3+ 1 5 Approved, time off in lieu (17.25hr).

Clinical

Oncology

ST3+ 1 6 (6) report submitted outside 14 day period,

clinical department informed

Care of the

elderly

FY1 1 9 Approved, time off in lieu (15.5 hrs)

FY2 3 11 Approved, time off in lieu (15 hrs)

Resp. Med FY1 1 2 Approved, time off in lieu (3.5 hrs)

General Surgery FY1 2 2 Approved, time off in lieu (2 hours)

Infectious

diseases

FY1 1 7 One submitted after 14 days – clinical

department informed

Remainder approved- time off in lieu (9.5

hours)

Trauma and

orthopaedics

FY2 1 2 Approved, payment (3.5 hrs)

Clinical

Haematology

CT 1 2 report submitted outside 14 day period,

clinical department informed Other

approved, time off lieu (0.83)

ST3+ 1 1 hours noted but no time off in lieu required

for work during an on call period

6. ANALYSIS OF EXCEPTION REPORTS BY SPECIALITY:

NEUROLOGY: Two exception reports were submitted by SpRs. On one occasion this was following a

weekend shift on the hyper acute stroke unit- the numbers of admissions/referrals from Accident and

Emergency resulted in the trainee having to stay late during a weekend shift on the hyperacute stroke unit

to complete all discharge paperwork. The clinical supervisor acknowledged that the trainee was diligent

and the work could not be handed over, and a result of reduced clinical staff at the weekend, but noting

that staffing levels may improve with the introduction of mechanical thrombectomy. The second exception

report was submitted from the Medical ITU Neurology SpR. This is a firm in which workload issues had

been highlighted in previous reports. The trainee pointed out that the outpatient clinic template resulted in

the last patient being booked in after the finish time for the SpR. This issue was escalated to the service

manager and the templates amended appropriately. No exception reports were submitted during this

quarter by CMTs, after a large number of reports in the last two quarters. The CMT doctors through

informal feedback have reported that there has been an improvement in working hours.

GASTROENTEROLOGY: 14 exception reports in relation to excess hours were submitted by foundation

doctors. This follows a similar clustering of exception reporting during the previous quarter. All exception

reports were related to heavy workload, and other factors were mentioned including late admissions and

lack of computers. Feedback from the department was that they were hoping to reduce administrative

work by using a clinical assistant and that trainees were asked to handover non-essential tasks. The

Guardian of Safe Working Hours has requested meetings with the trainees. Informal feedback from this

and discussions at the junior doctors’ forum was of an extremely busy clinical department, and a

perception that submitting exception reports would not be viewed favourably.

ONCOLOGY (MEDICAL AND CLINICAL ONCOLOGY): 6 exception reports were submitted by 3 CMTs

during this quarter – due to a combination of rota gaps, excessive workload, and unwell patients. The

clinical supervisor recognised the impact of CMT level/trust grade rota gaps. This has resulted in trainees

covering for absent colleagues and heavy workloads, particularly when dealing with acutely sick patients.

The department is looking at systems of internal cross cover to enable trainees to attend training

opportunities. I have been informed that the department has been trying to recruit to these Trust grade

posts, and is also looking at longer term solutions including the increased use of advanced nurse

practitioners. It was recognised that the CMTs were very diligent but practical advice on which tasks can

be handed over was offered. The rota gaps at CMT/trust grade level has also impacted upon the workload

on ST3+ trainees in medical and clinical oncology. Discussions and feedback from trainees indicate a

supportive Consultant workforce but a very heavy workload with a number of contributory factors,

including a lack of day care doctor, cross cover of absent registrars and clinical nurse specialists,

administrative burden and heavy clinics which overrun straight into MDT meetings. There is a fear that

rota gaps may lead to unsafe cross cover arrangements and the GSWH has met the clinical and medical

oncologists and has requested that the department produces a written policy on the cross cover

arrangement in the event of unfilled rota gaps, particularly out of hours.

CARE OF THE ELDERLY: Twenty exception reports were submitted by F1/2 doctors over this quarter –

all of which related to excessive workload on the firm. The number of exception reports on this firm had

decreased in the previous quarter and this number represents a significant further increase since then. All

the exception reports highlight the extremely heavy workload, particularly when colleagues are away. The

Guardian of Safe Working Hours has met the trainees and Consultant body to highlight the problems. The

department has looked at the split of trainees in different clinical areas, particularly to increase the

numbers of trainees dealing with outliers. In the long term staffing levels will be changing in care of the

elderly with an increased number of CMTs. Two of the exception reports were submitted by trainees on St

Pancras Hospital as there were only one or two doctors covering three wards. The clinical supervisor has

put measures to reduce further risk, including only allowing one doctor to be away at any time, arranging

for late admissions to be reviewed by the medical team and RAPIDS nursing team, and ongoing meetings

to try and promote more efficient transfer of care.

RESPIRATORY MEDICINE: Two exception reports were submitted and were due to the trainee staying

late to complete urgent clinical and administrative tasks. As the exception reports were submitted after two

weeks, the clinical supervisor has asked trainees to submit sooner so that the clinical department can take

action sooner.

GENERAL SURGERY: two exception reports were submitted by F1/2 trainees. On one occasion the

trainee had to stay to attend to an ill patient, and could not hand over to a colleague. On the other

occasion the FY2 had to cover the general surgery and T&O shifts out of hours and so the workload was

very intense and the trainee was unable to take breaks. The educational supervisor was asked to discuss

this with the trainee to ensure that this was not part of a recurring problem.

INFECTIOUS DISEASES: Seven exception reports were submitted during this quarter, due to volume of

clinical jobs causing trainee to stay late – supervisor met trainee and confirmed that the trainee had

started to leave earlier due to improved handover planning.

TRAUMA AND ORTHOPAEDICS: two exception reports were submitted by foundation year doctors –

due to excessive workloads and late ward round on one occasion, and the clinical supervisor has fed back

to other consultants to avoid late ward rounds.

CLINICAL HAEMATOLOGY: Two exception reports were submitted by CMTs. On one occasion the

trainee had to hold cover the on call duties for longer than expected due to colleague’s absence due to

sickness, and this delayed completion of their own jobs. On the second occasion the trainee stayed

because of urgent clinical jobs but the exception report was submitted after the 14 day period. The

educational supervisor met the trainee to discuss workload and delegation of tasks. One report was

submitted by an ST3+ level trainee who had to stay until 2100 to supervise an FY2 doctor –the trainee

was on call and so no further action was required except to monitor the situation for signs of a recurrent

problem.

7. WORK SCHEDULE REVIEWS

No work schedule reviews were requested by trainees between 1/1/2018 to 31/3/2018

8. FINES

Fines (cumulative)

Balance at end of last

quarter

Fines this quarter Disbursements this

quarter

Balance at end of this

quarter

124.56 0 0 124.56

9. TRAINEE VACANCIES AND LOCUM USAGE (1/1/2018-31/3/2018)

Appendix A lists the vacancies in the training posts and total locum usage, listed by grade and speciality,

across UCLH. The data was compiled by the Medical Workforce team. The Medical and Dental Education

Service provided the vacancy data, which only refers to training posts (Foundation, and ST 1-7) and does

not include trust doctors. Bank Partners supplied the locum usage data. This is the total locum usage

(trainees and trust doctors) – however the data is not provided in such a way which allows us to determine

whether the locum was to fill a trust doctor or a training vacancy. The departments with the highest levels

of locum usage were Neurosurgery, ENT and Urology, and no exception reports were submitted in these

specialties. Therefore the exception reporting process did not provide any evidence to suggest that gaps

in these specialties had a detrimental impact on the safe working hours of trainees in these departments.

I could not identify any association between the number of trainee vacancies and the submission of

exception reports. Specifically in oncology and gastroenterology, specialties with significant numbers of

exception reports, there were no reported vacancies. Similarly in care of the elderly, there was one

vacancy at CMT level in January.

10. COMMENTS:

There was a slight increase in the number of exception reports submitted during this quarter, but there

were no serious safety breaches

There was a clustering of exception reports in medical/clinical oncology, gastroenterology and care of

the elderly. These are very busy clinical departments and there are ongoing discussions about how

conditions can be improved. In care of the elderly there will be an increase in CMTs from August

2018, and it is hoped that this will improve the situation.

In medical and clinical oncology, working conditions and hours have been adversely affected by gaps

at CMT level trust grade positions. The medical and oncology departments are aware of the difficulties

and have been trying to recruit to the vacant posts and make the posts more attractive. The trainees

expressed concerns about the potential for serious safety breaches in working hours and a lack of

clear policy in response to unfilled out of hours shifts. I have asked the clinical department to produce

a written policy on the departmental response in such situations. These issues were also reflected in

Health Education England’s visits to medical and clinical oncology. The trainee feedback highlighted

insufficient staffing levels and clinical supervision as a potential risk to patient safety, although there

were no events that required a report of a serious incident. Trainees reported that it was rare to be

able to get a lunch break. Following this this on site visit the Trust has been asked to submit its plan on

how it will tackle its rota gaps and ensure appropriate cover at all times

From April 2018, the Medical Workforce team will be able to provide for the first time data on trust

grade vacancies in addition to trainee vacancies. This is essential information that will now enable me

to report more accurately the impact of rota gaps on trainees. This is well illustrated in Oncology,

where the data I have received have indicated no trainee vacancies at CMT level, whereas the

department has had up to four to five unfilled trust grade posts, which has had a very significant

impact on working hours.

The role of the Guardian of Safe Working Hours was presented at the UCLH Leadership Forum. In

addition there were presentations by the Medical Workforce Team, Paediatrics, Neurology, and the

Chief Registrar. It highlighted some of the work being done across the Trust to bring the experiences

of junior doctors to the fore and the improvements that have been achieved. It was suggested that a

forum, where ideas for improvement can be shared and developed, would be highly desirable. This

proposal will be discussed with the Medical Education department and the Medical Workforce team.

Informal feedback from trainees suggests that in some clinical areas there is explicit or implicit

discouragement from submitting exception reports, often in departments with heavy clinical workloads.

UCLH continues to have a very low number of exception reports when compared with similar central

London trusts. Therefore it is likely that the number of exception reports is an under-representation of

excess working hours within the Trust. In order to assess and quantify this further, I have developed in

conjunction with a trainee, a survey about exception reporting that will be disseminated to all trainees

within the Trust.

11. RECOMMENDATION

The Board of Directors are invited to consider my report.

Prasad Korlipara

Guardian of Safe Working Hours

UCLH Foundation Trust

APPENDIX A: TRAINEE VACANCIES AND LOCUM USAGE (1/1/2018-31/3/2018)

SURGERY

AND

CANCER

BOARD

GRADE

Number

trainees

when

fully

established

TRAINEE VACANCIES

LOCUM

USAGE: No

shifts (HRS) Jan Feb Mar

Anaesthetics ST1-2 9 0 0 0 0

ST3+ 30 3 2 2 3 (38)

General

Surgery

FY1 7 0 0 0 2 (15)

FY2 3 0 0 0 0

ST1-2 2 0 0 0 73 (835.09)

ST3+ 7 1 1 1 112 (583.83)

GI medicine FY1/2 5 0 0 0 0

ST1-2 1 0 0 0 16 (152.75)

ST3+ 8 1 1 1 37 (66.5)

Radiology ST4+ 23 1 2 2 23 (98.75)

Nuclear

medicine

ST3+ 3 1 1 1 0

Haematology FY1/2 1 0 0 0 0

ST1-2 6 0 0 0 48 (497.83)

ST3+ 18 0 0 0 0

Trauma and

Orthopaedics

F1/2 5 0 0 0 5 (56.5)

ST1-2 2 0 0 0 17 (208.5)

GP 0 0 0 0 0

ST3+ 6 1 1 1 38 (260.42)

Urology ST1-2 N/A 67 (769.75)

ST3+ 8 2 2 2

28 (274.5)

Oncology ST1-2 5 0 0 0 18 (200)

ST3+ 18 0 0 0 7 (82)

SPECIALIST

HOSPITALS

BOARD

GRADE

Number

trainees

when

fully

established

TRAINEE VACANCIES LOCUM

USAGE: No

shifts (HRS)

Jan Feb Mar

Anaes NHNN ST1-2 N/A 0

ST3+ 18 2 1 2 55 (629.5)

Anaes RNTNE ST1-2 N/A 0

ST3+ See above 142 (157)

ENT ST3+ 15 5 5 5 48 (578)

ST1-2 3 0 0 0 73 (729.5)

GP

ST1-2

2 0 0 0 0

Neurosurgery

ST1-2 1 0 0 0

ST1-3 6 0 0 0 129 (1304)

ST4+ 9 2 2 2 38 (351.5)

Obs and

Gynae

ST1-2 6 0 0 0 6 (74)

FY1/2 2 0 0 0 0

ST3+ 15 3 3 3 17 (132)

GP 5 0 0 0 0

Oral medicine DCT1/2 1 0 0 0 0

DSpR 5 3 3 3 0

OMFS

DCT 6 0 0 0 0

DSPR 2 1 1 1 0

HTP 1 0 0 0 0

Orthodontics DSPR 19 2 2 1 0

Paediatrics/

Neonates

ST4+ 18 2 2 1 106

(1188.08)

ST1-3 12 0 0 0 20 (162.5)

GP 4 0 0 0 0

Restorative DSPR 6 1 1 1 0

DCT 1/2 2 0 0 0 0

Neurology ST1-2 11 0 0 0 17 (155.5)

ST3+ 18 5 4 4 30 (239)

MEDICINE

BOARD GRADE

Number

trainees

when

fully

established

TRAINEE VACANCIES LOCUM

USAGE: No

shifts (HRS) Jan Feb Mar

Emergency

medicine

F1/2 8 1 1 1 7 (69.5)

GP 5 0 0 0 13 (124.25)

ST1-3 3 0 0 0 62 (584)

ST4 5 1 0 0 681(6340.32)

Clinical

Neurophysiolo

gy

ST3+ 4 1 1 1 0

Critical Care

ST1-2 9 0 0 0 4 (52.5)

FY2 1 0 0 0 0

ST3+ 5 0 0 2 3 (41)

AMU

FY1/2 9 0 0 0 0

ST1-2 12 0 0 0 0

GP 2 0 0 0 0

ST3+ 1 0 0 0 0

Care of

Elderly

F1/2 7 0 0 0 0

CMT 1 1 0 0 0

ST1-2 1 0 0 0 0

ST3+ 1 0 0 0 0

Rheumatology

F1/2 1 0 0 0 0

ST1-2 1 0 0 0 0

ST3+ 3 0 0 0 55 (411)

Respiratory

F1/2 2 0 0 0 0

ST1-2 1 0 0 0 0

ST3+ 2 0 0 0 39 (333)

Endocrinology

F1/2 N/A 0

CMT N/A 24 (198)

ST3+ 4 0 0 0 0

Clin Pharm F1/2 3 0 0 0 0

ST3+ 5 0 0 0 0

Dermatology ST1-2 N/A 55 (536)

ST3+ 2 0 0 0 44 (457)

Histopatholog

y

ST3+ 9 1 1 3 0

ST1-2 2 0 0 0

Infectious

diseases

F1/2 2 0 0 0 0

ST3+ 7 0 1 1 19 (171)

F

Guidance for Boards on FTSU

This has been included for Board Members only

G

Freedom to Speak Up self-review tool

This attachment has been included for Board Members only.

H

Freedom to Speak Up Guardian Annual Report

FREEDOM TO SPEAK UP GUARDIAN – ANNUAL REPORT

1. Background

Following an independent review into creating an open and honest reporting culture in the NHS

undertaken by Sir Robert Francis, all NHS trusts and NHS foundation trusts are now required by the NHS

contract to nominate a Freedom to Speak Up (FTSU) Guardian. The review recommended that all NHS

organisations should ensure that there is a range of persons to whom concerns can be reported easily

and without formality.

UCLH first piloted the Guardian Service in May 2016. In July 2017, the Audit Committee received its

annual whistleblowing / raising concerns report and endorsed the provision of an external service. As

such, a tender exercise was undertaken later that month and the Guardian Service were the successful

bidders for providing the service until March 2019.

Our Guardian Service is an independent and confidential staff liaison service. It was established in 2013

by the then National NHS Patient Champion in response to The Francis Report. The Guardian Service

provides staff with an independent, confidential 24/7 service to raise concerns, worries or risks in their

work place. The Guardian Service covers patient care and safety, whistleblowing, bullying and

harassment and work grievances. They work closely with the National Guardian Office (NGO) and attend

the Freedom To Speak Up workshops, regional network meetings and Freedom To Speak Up

conferences.

2. Cases

Since April 2017, there have been 54 cases and of those cases 13 were escalated and 8 are currently

open. Of the 54 cases, 13 related to what is termed an ‘amber concern’ (e.g. allegations of bullying,

harassment or risks to staff safety); 31 related to a ‘green concern’ (e.g. a grievance concerning a change

in work conditions). No red concerns (concerning any reported concern relating to patient safety, safe

guarding and care, staff safety, issues of potential danger to any individual including self-harm) has been

received. There have been 10 cases where there has been no discernible risk.

RAG (Red, Amber and Green) concerns are treated differently by the Guardian. Where an issue is agreed

for escalation the system is used as follows:

Red These scenarios require immediate escalation and response within 12 hours

Amber A response is required within 48 hours

Green A response is required with 72 hours

All calls that have been escalated at UCLH were responded to within the agreed timeframe. Contacts from

staff to the Guardian have been via email (73), telephone (248) and face to face visits (60). The Guardian

encourages face to face meetings yet follow ups tend to be by telephone or email. 3. Themes

The table below outlines the types of cases that the Guardian has received since April 2017:

Theme Number of cases*

Policies and procedures (concerns relating to

perceptions of misapplication) 27

Bullying and harassment 5

Discrimination 2

Inequality 4

Poor Patient Experience 2

Concerns with line manager 6

Concerns with a colleague 5

Other – concerns related to recruitment, APA

programme, facilities and communication 6

*Cases can have more than one theme.

Concerns raised are addressed by:

Local management of all concerns raised; the Guardian Service has told us that they have been

assured by the swift response to any matters that have been escalated.

A quarterly report circulated to HR Business Partners to encourage discussion within divisions and

to triangulate with other data sets.

Attendance of lead Guardian at DESG to report on themes and outline any recommendations.

Promotion of existing mechanisms of support available internally; there have been a number of

cases whereby mediation has been effective at resolving concerns further to staff logging a case

through the Guardian Service.

Since the Guardian Service has not yet been used by staff to raise patient safety issues we have worked

to consider how its potential value can be communicated. As such, the Guardian Service General

Manager has worked with the Director of Quality and Safety to consider ways in which the service can be

promoted. This has included promotion in the Quality and Safety (QS) Bulletin and the service signposted

in relevant policies.

4. Promotion of the Guardian Service

Building and maintaining awareness of the Guardian Service is a critical element in ensuring that staff

have confidence to call a Guardian and discuss their concerns. Indeed, the number of contacts to the

Guardian Service was initially low yet there has been a steady increase since the commencement of the

new contract in August 2017 which has led to increased and targeted promotion. Since August, monthly

meetings have been held with our Guardian to manage effective communication with a view to reaching

as many staff as possible. The service has been promoted alongside campaign materials for the ‘Where

Do You Draw the Line?’ campaign in order to signpost staff who may have experienced or witnessed

inappropriate behaviour. Indeed, at Trust induction the rotating Director promotes the service when

introducing the campaign video, emphasising our values and encouraging a culture of speaking up. Cards

promoting the service are also given to staff during induction. Promotion continues throughout UCLH with

the aim of increasing awareness of the Guardian Service and thus the number of contacts. Feedback

from the Guardian Service indicates that the majority of staff who have contacted the service have been

made aware of it through their colleagues.

5. Well led domain (CQC)

Inspection of how Trusts support employees to speak up is assessed under the ‘Well Led’ domain; how

Trusts support speaking up will potentially affect the overall rating inspectors give for ‘Well Led’. The NGO

has worked with the CQC to ensure that an assessment of speaking up is at the heart of inspecting the

‘Well Led’ domain – including:

Drafting guidance for inspectors to assess speaking up

Meeting with inspection teams to explain the work of the NGO and Freedom to Speak Up

Guardians (FTSU)

6. National Guardian Office – Board Guidance

Guidance has recently been produced jointly by the National Guardian’s Office and NHS Improvement to

set out expectations of boards and board members in relation to Freedom to Speak Up. A self-review tool

has been published alongside the guide to enable boards to carry out an in depth review of leadership and

governance arrangements in relation to FTSU.

1 How Trusts support the role of FTSU Guardian

Evidence that Guardians can

regularly access their board and

CEO

The lead Guardian attended SDT in March this year as an

observer and plans are in place for them to meet the CEO. They

shall also attend the July Board to present their first annual report.

Evidence that the role is

appropriately communicated and

accessible

The role has been communicated via Insight and is communicated

at corporate induction by a member of the Executive Board.

The Chief Executive promotes the service in the team brief.

Promotional visits have been held in the restaurants at the Atrium,

Tower, Queen Square, Westmoreland Street, EDH and RNTNEH.

Briefing sessions have been held by GSL on numerous wards and

departments and at safety huddles and team meetings throughout

the hospital. The promotional work is on-going.

The Guardian has joined walkarounds in Queen Square and

Women’s Health.

Postcards are also circulated at briefing sessions that detail how

staff can contact the Guardian.

The introduction of the ‘Where Do You Draw the Line?’ campaign

included a launch by the CEO where the GSL was promoted as

an avenue of support open to staff.

Evidence that the Guardian has the

necessary resources, support and

independence to effectively

undertake the role

Monthly meetings are held with a designated representative from

the Trust to discuss recommendations, themes, the way concerns

are handled and general feedback. Any gaps in departments/staff

groups are identified and access to these areas facilitated. The

Guardian meets the Workforce Director on a quarterly basis and

discusses any case they wish to with him.

The Guardian is independent of the Trust and available 24/7.

Managers are supportive in giving access to their teams and also

in understanding and promoting the service.

2 How Trusts respond to the concerns raised by their workers

Is there an appropriate speaking

up/whistleblowing policy?

The Trust has a Raising Concerns Policy which was published

15/12/2015 and due for review 30/11/2018.

The Guardian Service is referenced in the Raising Concerns

Policy. The policy was amended on 23.11.17 to include

information about the Guardian Service

Evidence that trusts appropriately

investigate concerns and feedback

All concerns raised have been investigated appropriately and

feedback given to the member of staff.

3 Evidence of a positive speaking up culture in the trust

What steps or initiatives have trust

taken to promote speaking up?

The Trust has launched the ‘Where Do You Draw the Line?’

campaign which was designed by staff through a series of focus

groups. This initiative provides advice to staff on how they can

deal with situations of conflict independently as well as

highlighting where support can be accessed.

Through the campaign, senior managers have been asked to

inform staff of the Guardian and highlight how they can be used to

raise concerns should staff not wish to use the internal processes

available to them.

The trade unions are aware of the GSL and have highlighted the

service to their members.

What steps has the trust taken to

support minority and vulnerable staff

groups to have a voice?

The Guardian attends the BAME network and is to attend the next

LGBT network group.

The Guardian attended the Staff Network Event at the beginning

of May.

Are staff who are suspended

permitted access to their Guardian?

All staff who are suspended and are the subject of a formal ER

process have access to the Guardian and this is stated in their

suspension letter.

The Guardian has been contacted from a member of staff who

has been suspended as they were given the details in their

suspension letter. This provided additional support to the member

of staff and helped them understand the process.

Assessment of FTSU at UCLH

The assessment below has been compiled by the lead Guardian, June-Anne Murray.

How UCLH compares with other organisation’s for FTSU

Detailed below are the comparisons between UCLH and other similarly sized Trusts for which data is

available.

Q1=Quarter one

PS=Patient safety

BH=Bullying and Harassment

NDA=No Data Available

Name of Trust Q1 PS BH Q2 PS BH Q3 PS BH Q4 PS BH

UCLH 4 0 1 6 0 0 18 0 1 18 2 3

Barking Havering and

Redbridge

8 0 0 13 0 6 12 2 5 15 1 8

East London NHS

Foundation Trust

NDA 4 2 2 14 5 6 22 5 14

Lewisham and Greenwich

NHS Trust

NDA NDA 7 0 7 5 4 1

London Ambulance 0 0 0 1 1 1 1 0 1 5 1 3

Service

London North West

Healthcare NHS Trust

NDA NDA 0 0 0 0 0 0

North East London NHS

Foundation Trust

NDA NDA NDA 3 1 2

How UCLH deal with the concerns brought to them is more important than figures. If you receive high

numbers of concern but are not dealing with the issues then the numbers are irrelevant.

The positives are the engagement in comparing the data with that from the staff survey; inviting the

Guardian to brief staff at events so that staff are encouraged to speak up; identifying areas of concern;

information about the service included on the Quality and Safety News bulletin; continuous briefing

sessions at safety huddles and team meetings at all the sites. It is very difficult to give a comprehensive

answer when comparing UCLH with other Trusts as you are not comparing like for like. Some Trusts have

more resources available than others. The number of staff in each Trust varies as a medium sized Trust

relates to 5,000 staff to 10,000 staff. The CQC result for each Trust under the Well-Led domain can also

vary depending on when the FTSU Guardian commenced.

Assessment of UCLH and any key learning points that are important to share

Managers at UCLH need to discuss the speaking up agenda at every opportunity. Staff will notspeak up unless they know that they can do so without fear of reprisal.

The communication that is sent out from the Chief Executive includes information about the servicewhich is very beneficial as staff see that the Trust is encouraging them to speak up.

The Education team invited the Guardian to brief staff at the Violence and Aggression at Workevent so that they are aware of the service. The HR Business Partner for Surgery and Cancerboard also invited the Guardian to attend their Bullying and Harassment session. This collaborationis important in embedding a Freedom to Speak Up Culture.

Where do you draw the line campaign is ongoing and future sessions, where possible, will includethe Guardian. Ways of improving how this can be disseminated to the rest of the organisationneeds to be looked at.

The monthly walkabout with Jon Melbourne, Divisional Manager for Queen Square, was verybeneficial and showed staff that he encourages staff to speak up. This is also being undertaken byWomen’s Health. It is recommended that this is replicated at other sites / services / division.

Although concerns raised are responded to within the timeframe, the length of time taken toinvestigate the issue is sometimes a worry. However, the Guardian will constantly chase, escalatewhere necessary and raise with the HRBP until an outcome is received.

Although the cancer division has the highest number of calls, the numbers can indicate that issuesbeing reported are being dealt with and staff are informing others of the service.

Managers recruit their own staff and sometimes the process is not deemed to be fair. Staff withinthe team are already aware who will be recruited as open discussions are held. Perhaps

intermittently a member of HR can attend interviews to ensure no discrimination is taking place. If this does not happen, managers could attend refresher courses.

A few staff had raised concerns regarding relatives working together and managing each other. APolicy is required regarding working with and managing relatives to combat this; this is in theprocess of being developed by UCLH.

When an incident is logged on Datix, some staff have advised that they are not given feedbackregarding the outcome.

The introduction of a Non-Executive Director is required to ensure that Freedom to Speak Up ispart of and kept on the board agenda.

What more we can do to communicate the service?

Invitation to events that support the speaking up agenda. I attended the Violence and Aggression at Work

event and also the Bullying and Harassment for Surgery and Cancer board session. These are the types

of events that are important for UCLH to invite the Guardian to. When the staff survey was released I

worked with the HR Business Partner responsible for the Guardian Service and the Staff Experience

Team so that I could go into those areas where there was deemed to be a problem with bullying and

harassment. Speak Up Champions for each directorate / service could be introduced. They would

champion a speaking up culture and help in communicating the service thus embedding a speaking up

culture. Managers that have had concerns raised with them could speak to staff at team meetings

regarding the benefits of speaking up and how they have helped staff.

Ensure that posters advertising the service are in staff areas at all the sites and that post cards are also

available. All walkabouts to include and promote the freedom to speak up message. An additional

question on the appraisal form can be asked regarding speaking up.

Appendix 3 – Schedule of Visits

August 2018

Theatres and Anaesthetists

Queen square induction

June 2018

Divisional Leadership Forum – RNTNEH

Divisional Audit meeting – Women’s Health

Women’s Health walkabout

Haematology induction

Porters Queen square

Cleaners Queen square

A & E

AMU

Westmoreland Street restaurant

Guardian of Safe Working Hours

May 2018

Queen square David Ferrier ward

Queen square Victor Horsley ward

Queen square Molly Lane Fox ward

Queen square Nuffield ward

Queen square Outpatients admin

Queen square Phlebotomist – Basil Samuels

Clinical Research Haematology

Neuro critical care

Staff Network event

Bullying and Harassment – Surgery and Cancer board

April 2018

Event on Violence and Aggression

Pharmacy

Staff improvement group Queen Square

March 2018

Catherine Mooney, Quality and Safety

Westmoreland Street 4th floor Thoracic

Westmoreland Street 3rd floor WMS

Westmoreland Street Theatres

Westmoreland Street Short stay ward x2

Promotion in the Tower

Staff survey

February 2018

Neuro critical care team day

Imaging x ray reception LG floor

RNTNEH promotion lunch time

Macmillan Support and Information Service

Imaging 3rd floor East

Paula O’Brien – Westmoreland Street

Promotion at Atrium

Elderly Medicine – MDT – Clinical Governance

January 2018

Lady Anne Allerton Ward x 2

Jules Thorn Telemetry Unit

Security

Switchboard

Contact centre

Brian Manley – Operations Manager

Diversity and Equality Steering Group

Ground Floor meeting Macmillan Cancer Centre

Second Floor meeting Macmillan Cancer Centre

December 2017

Chaplaincy

RNTNEH – B Ward

RNTNEH Reception

Labour Ward

Birth Centre

November 2017

Faith Thornhill – Staff partners

Pain Clinic – MDT meeting

Theatres and Anaesthetics anaesthetic and scrub staff

Theatres and Anaesthetics recovery and support staff

RNTNEH – C Ward

Queen’s Square – Basil Samuels OPD (GOS)

T16 N and T16 S

Maternity Care Unit Ward Manager

Macmillan Cancer Centre

Dr Andrew Wilson

Maternity Care Unit

October 2017

RNTNEH

Queen Square – Hughlings Jackson Ward

Queen Square – Basil Samuels OPD

Queen Square – Day Care Unit

Queen Square – Radiography team meeting (2)

EDH – Staff nurse forum

The Tower - T10 / T13N / T8 / T14S / T14N

Chalfont Centre for Epilepsy

August -September 2017

Disciplinary / ELC workshop

The Tower – T13 Sisters and Matrons meeting

Communications meeting

Claire Painter andGeorgia Seiti

Integrated Discharge Service team meeting

Communications meeting

Matthew Nolan – Induction Tonyeh Vincent – Learning and Development

Queen Square – SMT meeting

Cardiology Out-patients

Neonatal Unit – ward handover

I

CQC Registration documentation

20120326 100457 1.01 Statement of purpose Pt 3 1

Form 9 University College Hospital & Elizabeth

Garrett Anderson wing

Statement of purpose Health and Social Care Act 2008

Part 3

Location(s), and

the people who use the service there

their service type(s)

their regulated activity(ies)


Fill in a separate part 3 for each location

The information below is for location no.: 9 of a total of: 10 locations

Name of location University College Hospital (incorporating the Elizabeth Garrett Anderson Wing, the Macmillan Cancer Centre, the Institute of Sport, Exercise and Health (ISEH), the UCLH@home service and the Camden Integrated Care service. We are applying to add the LIGHTHOUSE location to this registration.

Address 235 Euston Road

London

Postcode NW1 2BU

Telephone 0203 447 7633

Email [email protected]


Description of the location

(The premises and the area around them, access, adaptations, equipment, facilities, suitability for relevant special needs, staffing & qualifications etc)


The University College Hospital offers the following services: accident & emergency; cancer care; critical care; endocrinology; general surgery; weight loss, metabolic and endocrine surgery ophthalmology; dermatology; general medicine; gynaecology; general neurology; rheumatology; orthopaedics; paediatrics and adolescents and urology. The Elizabeth Garrett Anderson Wing provides comprehensive care for women and their babies in the areas of gynaecology, maternity and neonatal care. Maternity services offer access to a full range of care options in different settings including home birth, community care, a co-located birth centre, labour ward and two dedicated theatres. The gynaecology service offers both inpatient and outpatient care. It runs a wide range of clinics, including general and specialist gynaecology, antenatal clinic and ultrasound, and fetal medicine. The UCH-Macmillan Cancer Centre houses haematology/oncology daycare, Teenage and young adults cancer service, apheresis, outpatients, theatres, imaging, nuclear medicine and phlebotomy. The Macmillan Support and Information Service provides a range of support and information to all patients seen and treated in the Cancer Centre, and to any other patient with cancer treated elsewhere within the Trust. The PET/MR Unit operates the UK’s first PET/MR system, which includes both a PET camera and 3T MR scanner in the same physical unit so that both tests can be performed simultaneously in one single session. The ISEH at 170 Tottenham Court Road is a collaboration between health, academic and sports organisations – UCLH, UCL, British Olympic Association, English Institute of Sport and private hospital group HCA. It is an integral part of the National Centre for Sport & Exercise Medicine and houses research, teaching and training in sport and exercise medicine and allied fields. The purpose-built facility includes eight consulting rooms, 3T MR imaging, Ultrasound, X-Ray, Interventional treatment rooms and a well equipped physiotherapy gym. Although the ISEH is a partnership facility, NHS patients treated there continue to be treated under the care of UCLH. The other service provided by UCLH at 170 Tottenham Court Road is the clinical research facility which is registered as an additional location. The Hospital @ Home service is a team of experienced nurses and therapists who provide care within the patient’s own home, enabling them to leave hospital earlier. The service is available to patients with the following conditions, general medicine, breast surgery, hip or knee arthroplasty, abscess removal and colorectal surgery. The service is expanding so that patients can benefit across the Trust's portfolio of services. The service enables patients who are clinically stable to go home and complete the remainder of their acute care at home. They remain under the care of their UCLH hospital consultant and receive daily visits from a dedicated team of nurses. This means patients receive the best care possible in their own environment. Being at home can also prevent complications like hospital acquired infections.

The service can now offer up to fourteen home visits per day. The number of visits each patient receives reflects their care needs. The Trust has outsourced the nursing care of Hospital @ home patients to HealthCare @Home Ltd which is registered seperately with CQC. The Trust is engaging with a charity run hostel under a service level agreement to provide Hospital @ home services for patients who are otherwise homeless. The Camden Integrated Care service (CICs), an integrated care hub for patients with long term conditions, in the community. Clinics staffed by UCLH clinicians are provided at various sites in the local area such as the Mary Rankin Unit at St Pancras hospital and at Stephenson House, 75 Hampstead Road. UCLH has teamed up with The Doctors Laboratory (TDL) and The Royal Free London NHS Foundation Trust in a pathology joint venture as recommended by Lord Carter, who was commissioned by the DoH in 2005 to review pathology services across the NHS. Lord Carter is to chair the new venture. The joint venture will use the efficient hub and spoke system, recommended by the Carter Report where on-site rapid response laboratories handle urgent, small volume work, and are linked to the core hub, which will process all non-urgent tests. We have included the service type ‘Hospice services (HPS)’ because the Trust hosts an ‘End of Life care team’. ADDITIONAL TEXT ATTACHED as appendix


No of approved places / overnight beds (not NHS)

CQC service user bands

The people that will use this location (‘The whole population’ means everyone).

Adults aged 18-65 Adults aged 65+

Mental health Sensory impairment

Physical disability People detained under the Mental Health Act

Dementia People who misuse drugs or alcohol

People with an eating disorder Learning difficulties or autistic disorder

Children aged 0 – 3 years Children aged 4-12 Children aged 13-18

The whole population Other (please specify below)


The CQC service type(s) provided at this location

Acute services (ACS)

Prison healthcare services (PHS)

Hospital services for people with mental health needs, learning disabilities, and problems with substance misuse (MLS)

Hospice services (HPS)

Rehabilitation services (RHS)

Long-term conditions services (LTC)

Residential substance misuse treatment and/or rehabilitation service (RSM)

Hyperbaric chamber (HBC)

Community healthcare service (CHC)

Community-based services for people with mental health needs (MHC)

Community-based services for people with a learning disability (LDC)

Community-based services for people who misuse substances (SMC)

Urgent care services (UCS)

Doctors consultation service (DCS)

Doctors treatment service (DTS)

Mobile doctor service (MBS)

Dental service (DEN)

Diagnostic and or screening service (DSS)

Care home service without nursing (CHS)

Care home service with nursing (CHN)

Specialist college service (SPC)

Domiciliary care service (DCC)

Supported living service (SLS)

Shared Lives (SHL)

Extra Care housing services (EXC)

Ambulance service (AMB)

Remote clinical advice service (RCA)

Blood and Transplant service (BTS)


Regulated activity(ies) carried on at this location

Personal care

Registered Manager(s) for this regulated activity:

Accommodation for persons who require nursing or personal care


Accommodation for persons who require treatment for substance abuse


Accommodation and nursing or personal care in the further education sector


Treatment of disease, disorder or injury


Assessment or medical treatment for persons detained under the Mental Health Act


Surgical procedures


Diagnostic and screening procedures


Management of supply of blood and blood derived products etc


Transport services, triage and medical advice provided remotely


Maternity and midwifery services


Termination of pregnancies


Services in slimming clinics


Nursing care


Family planning service


Appendix to FORM 9 University College Hospital & Elizabeth

Garrett Anderson wing Statement of purpose

Part 3

We wish to include the location of the LIGHTHOUSE at:

Alexandra Ciardi House, 7-8 Greenland Place, Camden, London NW1 0AP

It will provide a coordinated approach to supporting children and young people who

have experienced sexual abuse. All medical, advocacy, social care, police, and

therapeutic support will be delivered from one place. The aim is that children, young

people and their families receive the justice, support and therapy in a timely manner

meaning that they can move forward towards recovering from the abuse.

So will be providing

• Advocacy

• Front line safeguarding practice

• Assessment (paediatric medical (physical and sexual health), therapeutic and

safeguarding)

• Sexual health advice

• Therapy (The Letting the Future in therapeutic services)

• Psychological

• CBT

• EMDR

The service itself is being commissioned by NHS England – UCLH is the lead

provider with Tavistock and Portman and the NSPCC as partners.

J

Standards of Business Conduct Policy

Standards of Business Conduct

DRAFT

- including declaring interests, gifts,

hospitality and sponsorship

UCLH policy

If reading a printed copy, always check that it is the most recent approved version. This can be found on the Policies & Procedures page on Insight.

Policy number inserted by Policy Compliance Officer

Issue number inserted by Policy Compliance Officer

Issue date inserted by Policy Compliance Officer

Approved by inserted by Policy Compliance Officer

Responsible Director Chief Executive

Policy Author Director of Corporate Services

Review Body Audit Committee

Documents to read in conjunction with this policy

Anti-Fraud and Bribery Policy Disciplinary Policy and Procedure Maintaining High Professional Standards Policy ABPI: The Code of Practice for the Pharmaceutical Industry (2016) The Nolan Committee’s Seven Principles of Public Life Raising Concerns Policy Scientific Fraud and Misconduct Policy Standing Financial Instructions and Scheme of Delegation Standing Orders

Complete review by date

inserted by Policy Compliance Officer- review is normally every 3 years unless earlier review requested/required

http://insight/pandp/Pages/default.aspx


UCLH STANDARDS OF BUSINESS CONDUCT POLICY – DRAFT v.8

UCLH - 2018 ii Issue date: (dd/mm/yy) Review by date : (dd/mm/yy) Policy/procedure only current on date printed, visit the Policies & Procedures page on Insight for latest approved version.

Review amendment log

Must be completed each time the policy is amended.

Version No Date amendments made

Description of change

TBC This policy replaces the ‘Code of Conduct and Conflict of Interests’ policy (the policy title has been changed) to reflect NHSE guidance and model policy on managing conflicts of interest. Where the Trust’s Code of Conduct and Conflict of Interest Policy was more robust these rules have been retained in this policy for example:

- Publication of NIL declarations for Decision Making Staff

Environmental

Do you really need to print this document? Please consider the environment

before you print this document and where possible copies should be printed double-sided. Please also consider setting the Page range in the Print properties to avoid printing the policy in its entirety.

List of reviewers & contributors

Audit Committee members and attendees Local Counter Fraud Specialist A Non Executive Director Head of Charitable Giving Head of Research Director of Procurement Head of Staff Services (for PASG) Director of Quality and Safety (for PASG) Deputy Director of Workforce

Summary of main points from consultation

The policy now takes account of NHS England guidance; specifically the requirement on staff to declare Private Clinical Practice and that registers of interest should be made publically available by publishing them somewhere prominent on the organisation’s public website.

Review body Author to complete Name of review body

Audit Committee Date of meeting when policy reviewed: November 2017

Date of meeting when policy approved by Board of Directors

PCO to complete dd/mm/yy



UCLH - 2018 iii Issue date: (dd/mm/yy) Review by date : (dd/mm/yy) Policy/procedure only current on date printed, visit the Policies & Procedures page on Insight for latest approved version.

Table of contents Page Numbers

Overview of the general requirements of this policy and links to NHS England Q&A guidance

iv

1. Summary 1

2. Equality Impact Assessment 1

3. Introduction 1

4. Objectives 1

5. Scope 1

6. Definitions 3

7. Duties & responsibilities 3

8.

8.1-8.3 8.4-8.7

8.8

Details of the policy Identification, Declaration and Review of Interests What is an Interest? The responsibility for identifying and declaring actual, potential or perceived conflicts of Interest rests with the individual Review of interests

4

4 5 5 5

9. Records and publication 5

10. Implementing the policy Management of interests – general approach

6

11.

11.2 11.7 11.10 11.13 11.15 11.17 11.19 11.21 11.23 11.25 11.27

Management of Interests – common situations and what needs to be declared Dealing with Gifts Dealing with Hospitality Outside employment Shareholding and other ownership Patents and other intellectual property Loyalty interests Donations Sponsored events Sponsored Research Sponsored Posts Clinical Private Practice

6 6 6 8 9

10 10 10 11 11 12 13 13

12. 12.1 12.2 12.3 12.4

Management of Interests – advice in specific contexts Strategic decision making groups Procurement Pro Bono Work Awards and prizes

15 15 15 15 15

13. Dealing with breaches 16

14. Dissemination and training requirements 17

15. How the policy will be monitored 17

16. Review of the policy 19

17. References and related documents 19

Appendix A – Glossary of terms and definitions Appendix B – Common situations Appendix C – Dealing with gifts flow chart Appendix D – Declaration of interests sample form

20 22 24 25



UCLH - 2018 iv Issue date: (dd/mm/yy) Review by date : (dd/mm/yy) Policy/procedure only current on date printed, visit the Policies & Procedures page on Insight for latest approved version.

Policy Reference Guide For quick reference, this table summarises the actions required by this policy. However, this does not negate the need for staff and others to be aware of and to follow the further detail set out in this policy. Not adhering to the policy could damage the reputation of UCLH.

As a member of staff you should …. UCLH will ……

Know this policy and follow it. Refer to NHS England guidance for the rationale behind the policy

Seek guidance if you are not sure what is required of you

Speak up If you think the Trust is not living up to the policy

Regularly consider what interests you have and declare these as they arise. If in doubt, declare. <insert link to online form>

Use common sense and judgement to consider whether your interests could affect the way NHS monies 1 are spent

Make this policy and the supporting processes as clear as possible to help staff understand what they need to do.

Have in place a team or individual who will:

Keep this policy under review to ensureUCLH is in line with guidance

Provide advice, training and support forstaff on how interests should be managed

Maintain register(s) of interests

Audit this policy and its associatedprocesses and procedures at least onceevery three years

NOT misuse your position to further your own interests or those close to them

NOT be influenced, or give the impression that you have been influenced by outside interests or through the acceptance of gifts or hospitality

NOT allow outside interests to inappropriately affect the decisions you make when using NHS resources

NOT avoid managing conflicts of interest

NOT interpret this policy in a way which stifles collaboration and innovation with partners of UCLH

This policy is consistent with guidance published by NHS England. To further assist staff using the Policy the following Question and Answer documents have been created by NHS England and can be found using the following links:

NHS Provider manager Q&A

NHS Provider clinical staff Q&A

NHS Provider medical staff Q&A

Appendix B provides a brief summary of the most common situations that can give rise to the risk of a conflict of interest and which may therefore need to be declared, along with some key points for consideration.

1 taxpayers’ money


https://www.england.nhs.uk/wp-content/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/09/coi-qa-provider-managers.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/09/coi-qa-clinical-staff.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/09/coi-qa-medical-staff.pdf


UCLH - 2018 1 Issue date: (dd/mm/yy) Review by date : (dd/mm/yy) Policy/procedure only current on date printed, visit the Policies & Procedures page on Insight for latest approved version.

1. Summary

1.1 The Standards of Business Conduct Policy describes the business conduct behaviour UCLH expects from all staff who may potentially benefit as the recipient of gifts, hospitality or sponsorship arrangements or through the interests they may hold with third parties external to UCLH.

1.2 It aims to ensure that the people who work for and with UCLH are protected from any suspicion or allegations of impropriety or undue influence in the conduct of UCLH business.

1.3 It also serves as an important defence against any actions brought under the 2010 Bribery Act.

2. Equality Impact Statement

2.1 This policy has been subject to an Equality Impact Assessment (EIA), it is not anticipated that it will have an adverse impact on any of the protected equalities groups. The completed EIA form is available from the Policy Compliance Officer.

3. Introduction – why we need this policy

3.1 UCLH is committed to providing best value for taxpayers and ensuring that decisions are taken transparently and clearly.

3.2 This policy will help all staff, volunteers, and employees of organisations who do business with and on behalf of UCLH to act with the highest standards of integrity, use NHS monies wisely, and act in the best interest of the patient.

3.3 Not adhering to this policy could damage the reputation of UCLH and could expose UCLH staff and others to disciplinary action or criminal prosecution.

4. Objectives – what the policy is trying to do

4.1 This policy will help staff to manage conflicts of interest risks effectively. It:

- sets out consistent principles and rules; - gives guidance about how to approach and manage interests; and - provides simple advice about what to do in common situations.

4.2 It replaces the previous ‘Code of Conduct and Conflict of Interest Policy’ and should be read in conjunction with the associated documents listed in paragraph 17.

4.3 The policy cannot cover or anticipate all situations or circumstances that might arise, staff are therefore asked to think about the principles in this policy and take a common sense approach; ask yourself if your approach might compromise your own or UCLH’s reputation.

5. Scope – who the policy covers

5.1 This policy covers all individuals on differing employment terms and/or terms of engagement and will be referred to as ‘staff’ or ‘you’ throughout the policy and are listed below. Whilst the term staff will be used for the purpose of this policy this does not always imply/infer a contractual relationship.

- All salaried employees whether full time or part time, permanent or temporary - Individuals employed via an honorary contract




- All prospective employees who are part way through recruitment. This will be managed by Workforce.

- Bank and agency workers, and individuals employed via a personal services or company contract

- Contractors and sub-contractors - Non-executive directors - Governors - Volunteers - Committee or sub-committee and advisory group members (who may not be directly

employed or engaged by UCLH).

5.2 This policy is particularly applicable to staff who have a decision making influence – staff who can authorise expenditure and/or exercise discretion in the area of patient care – hereafter referred to as ‘decision making staff’ At UCLH this group includes:

- Executive and non-executive directors;

- Clinical directors and divisional managers;

- Senior directors reporting to an executive director;

- Hospital consultant staff;

- Those staff at Agenda for Change band 8d and above;

- Members of advisory groups or panels which contribute to direct or delegated decision making on the commissioning or provision of NHS or other taxpayer funded services;

- Administrative and clinical staff who are involved in the purchasing of goods, equipment, medicines, or medical devices and those who can make formulary decisions; and

- Administrative and clinical staff who have the power to enter into contracts on behalf of UCLH.

This reference to administrative and clinical staff will include:

Heads of departments or services Members of the estates and facilities directorate Members of the strategy directorate Members of the finance and commercial teams Members of staff undertaking research Pharmacy staff Procurement and ICT procurement staff.

5.3 Staff must also follow the code of conduct of their relevant professional body where appropriate.

5.4 Relevant staff are also strongly encouraged to give their consent for payments they receive from the pharmaceutical industry to be disclosed as part of the Association of British Pharmaceutical Industry (ABPI) Disclosure UK initiative. See Disclosure UK/APBI website. These “transfers of value” include payments relating to:

- Speaking at and chairing meetings - Training services - Advisory board meetings - Fees and expenses paid to healthcare professionals - Sponsorship of attendance at meetings, which includes registration fees and the

costs of accommodation and travel, both inside and outside the UK - Donations, grants and benefits in kind provided to healthcare organisations

The granting of consent to disclosure as part of the above does not negate the requirement to declare these payments in accordance with this policy.


https://www.abpi.org.uk/ethics/ethical-responsibility/disclosure-uk/



6. Definitions

6.1 A list and explanation of the terms used in this policy is set out in Appendix A. This includes the definition of an actual, potential and material conflict of interest.

7. Duties and responsibilities

7.1 The UCLH Board of Directors has a responsibility to ensure that conflicts of interest in business matters are avoided, and that there is a mechanism in place for recognising, reporting and dealing with potential conflicts for corporate decisions. The table below sets out the specific duties and responsibilities of directors, managers and staff.

Who Duties

Chief Executive Responsibility for ensuring that UCLH meets all duties in relation to this policy.

Trust Secretary – who is the Director of Corporate Services/Head of Corporate Governance

Delegated responsibility from the Chief Executive for ensuring that: - This policy is drafted and approved. - Mechanisms are in place for any breaches of the policy to be

appropriately investigated/ reviewed. - A process for the regular monitoring of this policy is identified. - The policy, once approved, is appropriately disseminated to

staff and persons associated with UCLH.

Directors, line managers, and heads of department

Are responsible for: - Ensuring that staff within their own directorates/departments

have read and understand this policy and are competent to carry out their duties in accordance with the procedures described.

- Report any findings of conflict of interest or ethical misconduct in business dealings to their relevant Executive Director or to the Chief Executive or to the Trust Chair or to the Trust Secretary for advice and/or action.

All Staff - Should familiarise themselves with the rules set out in this policy.

- Must ensure that they do not abuse their official position for personal benefit or for the benefit of any associate of theirs.

- Make their line manager or any other staff they work with or to aware of any material conflicts of interest they have.

- If staff have concerns regarding a conflict of interest or other ethical misconduct in respect of themselves or a colleague they should raise it first with their line manager. If they feel it is not adequately dealt with they should raise it with the Trust Secretary or raise it as an issue using the UCLH Raising Concerns Policy.

- If there is a suspicion or allegation of bribery or fraud, staff should use the processes set out in the Anti-Fraud and Bribery Policy and contact the Local Counter Fraud Specialists (LCFS) on: 07800 718680/ 07436 268325 or email [email protected] <replace this with nhs.net e-mail> or contact NHS Counter Fraud Authority on 0800 028 40 60.


http://insight/pandp/Trustwide%20policies1/Raising%20Concerns%20Policy.pdf


http://insight/pandp/Trustwide%20policies1/Anti%20Fraud%20and%20Bribery%20Policy.pdf


mailto:[email protected]

https://cfa.nhs.uk/about-nhscfa/contact-us



7.2 It is therefore the responsibility of all Staff to ensure there are no actual or perceived conflicts of interest between their interests and their UCLH duties.

8. Identification, Declaration and Review of Interests – the details of the policy

8.1 What is an Interest?

Interests fall into the following categories:

- Financial Interests: Where you may get direct financial benefit* from the

consequences of a decision you are involved in making.

*This may be a financial gain, or avoidance of a loss.

This could include where you are:

A board director, or senior employee, in another organisation which is doing,or is likely to do business with an organisation receiving NHS funding.

A shareholder, partner or owner of an organisation which is doing, or is likelyto do business with an organisation in receipt of NHS finding.

Someone in receipt of a grant or other payments such as honoraria. Someone in outside employment or in receipt of a secondary income. Someone in receipt of sponsored research.

- Non-financial professional interests: Where you may obtain a non-financial professional benefit from the consequences of a decision you are involved in making, such as increasing your professional reputation or promoting your professional career.

This could include where you are: An advocate for a particular group of patients. A clinician with a special interest. An advisor for a national body for example the National Institute of Health

Care Excellence. Someone in a research role.

- Non-financial personal interests: Where you may benefit personally in ways which are not directly linked to your professional career and do not give rise to a direct financial benefit, because of decisions you are involved in making in your professional career.

This could include where you are: A member of a voluntary sector board or a position of authority within a

voluntary sector organisation. A member of a pressure group or equivalent with an interest in healthcare.

- Indirect interests: Where you have a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest and could stand to benefit from a decision they are involved in making. This could include your close relatives, close friends and associates and business partners but could extend beyond to acquaintances with whom you have significant contact.

8.2 UCLH needs to be aware of all cases where staff, or their close relatives or a close associate, has a material interest.

8.3 Staff may also hold interests for which they cannot see potential conflict. However, caution is always advisable because others may see it differently and perceived conflicts of interest




can be as damaging as an actual conflict of interest. All interests should be declared where there is a risk of perceived improper conduct.

8.4 The responsibility for identifying and declaring actual, potential or perceived conflicts of Interest rests with the individual. All staff should identify and declare material interests at the earliest opportunity (and in any event within 28 days). If you are in any doubt as to whether an interest is material you should declare it, so that it can be considered.

8.5 Material interests should be declared: - On starting employment/on appointment with UCLH and at least annually for

decision making staff, thereafter - At the beginning of a new project/piece of work/tender panel - When you move to a new role or your responsibilities change significantly - As soon as circumstances change and new interests arise - In any meeting where interests you hold are relevant to the matters under

discussion.

8.6 Interests should be declared using the on-line Declarations of Interest Form or in exceptional cases where an individual is unable to access the intranet the Declarations Form at Appendix D and sent to The Trust Secretary, Trust Headquarters, 2nd floor Central, 250 Euston Road, London NW1 2PG

8.7 Individuals are required to keep their own records up-to-date.

8.8 Review of Interests We will prompt decision making staff annually to review interests they have declared and, as appropriate, update them. Decision making staff, even if they have no interests to declare, must still make a declaration confirming this at least once a year. This is called a NIL return.

8.9 Failing to declare interests or make an annual NIL return (as required), could result in disciplinary action.

9. Records and Publication

9.1 All declared interests will be recorded on the UCLH Register of Interests; interests declared using the paper form will be promptly transferred to the register by the Trust Headquarters Team.

9.2 Declared material interests will be published by UCLH on its website every six months. We will publish:

- The material interests declared by decision making staff in the UCLH Register of Interests along with the action taken to manage the perceived/potential/actual risks associated with these conflicts

- Refresh the information every six months - Make this information available to anyone on request

NOTE: If decision making staff have substantial grounds for believing that publication of their interests should not take place then they should contact the Trust Secretary to explain why. In exceptional circumstances, for instance where publication of information might put a member of staff at risk of harm, information may be withheld or redacted on public registers. However, this would be the exception. Information will not be withheld or redacted merely because of a personal preference.

9.2 After expiry, an interest will remain on the UCLH Register of Interests for a minimum of 12 months and an archived record of historic interests will be retained for a minimum of 6 years.




10. Implementing the Policy

10.1 Management of Interests – General approach

If an interest is declared but there is no risk of a conflict arising then no action is warranted. However, if a material interest is declared or a perceived or potential conflict is identified staff should seek advice from their line manager, and/or the Trust Secretary if required to discuss how that conflict might be resolved.

Options may include: - Reorganising the individuals responsibilities or changing their line management - Removing the individual from the decision making process, for example in a tender

exercise - Restricting the individuals access to information - Agreeing with the individual that they give up the interest - Agreeing that no action will be taken regarding the potential conflict but being aware

that it might become an actual conflict.

10.2 Each case will be different and context-specific, and UCLH will always clarify the circumstances and issues with the individuals involved.

10.3 Details of any action taken to mitigate against a conflict, must be recorded on the declaration form. Declarations must be made using the form available on the UCLH intranet wherever possible. A paper form is available (see Appendix D) for use in exceptional cases i.e. the individual has no access and has no way of gaining access to the UCLH intranet:

- Paper form must be signed by both the individual, their line manager and countersigned by the relevant head of workforce.

- Details from a completed paper form will be transferred to an online form and the form kept for 12 months.

10.4 If the member of staff is not happy with the resolution proposed to manage a conflict, they should raise it with the relevant Executive Director and Director of Workforce.

10.5 Staff should also make their line manager or any other staff they work with or to, aware of any relevant material interests.

11. Management of Interests - Common Situations

11.1 This section sets out the principles and rules to be followed in common situations, and what staff should declare. See Appendix B for a brief summary of common situations and the dealing with gifts flow chart at Appendix C.

Staff should be aware that the offer of a gift or hospitality may constitute a bribe and this should be considered in all circumstances in order to protect staff and the Trust from criminal prosecution. Where there is a suspicion that any offer may have a corrupt intention i.e. may constitute a bribe, it must be declined, declared and reported to the UCLH Local Counter Fraud Specialist.

11.2 Dealing with Gifts

Staff should not ask for gifts, or accept gifts or rewards that may affect, or be seen to affect, their professional judgement or if acceptance of a gift could affect or be perceived to affect the outcome of a business transaction. Staff should always ask themselves if a gift is excessive, or if it could it be construed as being able to influence a decision or cast doubt on the integrity of a decision.




It is better to declare an offer of a gift if you are not sure whether or not you are required to do so. If you are unsure about the appropriateness of the gift being offered it should be declined and declared.

Gifts of cash or cash equivalent e.g. gift cards, lottery tickets, and personal cheques whatever the value must always be declined and declared. However, if the donor is particularly insistent, they can be referred to the UCLH Charity – information about ways to give is available on the UCLH Charity public website: www.uclhcharity.org.uk

The offer of a trade or discount loyalty card from any company/organisation doing business with or seeking to do business with UCLH are classified as gifts and must be declined and declared. Staff may only take advantage of discounts which have been formally negotiated by UCLH. A list of these can be found on the Staff Benefits page on the intranet.

A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

11.3 Gifts from Patients, families etc

Gifts from a patient as a legitimate expression of gratitude should be dealt with as follows:

- Gifts up to the value of £50 may be accepted and need not be declared. - Gifts over £50 should be declined and declared. - Where it would cause unintentional or unnecessary offence to a patient or their

family or may be considered detrimental to the health of the individual to decline or return a gift valued at over £50, the item may be accepted on behalf of the UCLH Charity. This should be declared and the donor informed. Such gifts may then be raffled to raise funds for one of the UCLH charities.

- Multiple gifts from the same source received over a 12 month period, should be treated in the same way as a single gift over £50, where the cumulative value exceeds £50 and each gift declared once the limit has been exceeded.

11.4 Gifts from Actual and Potential Suppliers

- Gifts from suppliers or contractors doing business or likely to do business, with UCLH should be declined and declared whatever the value.

- Low cost branded promotional aids such as pens or calendars may, however, be accepted where they are under the value of £62 and need not be declared, although staff should consider if the acceptance can be justified.

11.5 Gifts from Foreign Dignitaries

Gifts up to the value of £50 may be accepted and need not be declared.

- Multiple gifts from the same source received over a 12 month period, should be treated in the same way as a single gift over £50, where the cumulative value exceeds £50.

- Gifts over the value of £50 should be declined and declared - Where it would cause offence to decline or return a gift valued at over £50, the item

may be accepted on behalf of the UCLH Charity. This should be declared and the donor informed.

11.6 Gifts - What staff should declare?

o Their name and role within UCLH.

2 APBI code of practice


http://www.uclhcharity.org.uk/

http://www.pmcpa.org.uk/thecode/Documents/Code%20of%20Practice%202016%20.pdf



o A description of the nature and value of the gift, including its source andcircumstances surrounding the offer.

o Details of previous gifts offered by same source where value of each gift fell below£50 and so were not declared at the time.

o Date of offer and receipt.o Whether gift was accepted or declined and reasonso Any other relevant information e.g. circumstances surrounding the gift, action taken

to mitigate against a conflict, details of any approvals given to depart from the termsof this policy.

11.7 Dealing with Hospitality

Staff should not ask for, or accept hospitality that may affect, or be seen to affect, their professional judgement or if acceptance of the hospitality offered could affect or be perceived to affect the outcome of a business transaction. The offer of hospitality where there is a suspicion that the offer may have a corrupt intention i.e. may constitute a bribe, must be declined and declared and reported to the UCLH Local Counter Fraud Specialist.

Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the occasion, nature and purpose of the event.

Staff should ask themselves if the offer of hospitality is excessive, if the frequency can be justified, or if the offer could it be construed as being able to influence a decision or cast doubt on the integrity of a decision. In any event the hospitality should be similar to the scale of hospitality that UCLH, as the employer, would be likely to offer or the member of staff would be prepared to pay for themselves. If in doubt contact your line manager or the Trust Secretary.

Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable. Senior approval must be obtained prior to acceptance.

Staff should be particularly cautious about accepting hospitality during a procurement exercise; any hospitality accepted must be declared and must be approved by the appropriate executive director prior to acceptance.

Invitations to sporting and entertainment events, tickets for non-work related meals or events , holidays (including accommodation) and free first class travel (rail or air fare) must always be declined and declared.

It is better to declare an offer of hospitality if you are not sure whether or not you are required to do so or whenever the hospitality could affect or be perceived to affect the outcome of a business transaction.

11.8 Hospitality includes:

Meals and Refreshments

- Hospitality up to the value of £25 may be accepted and need not be declared. - Where hospitality between £25 and £75 is accepted this must always be declared. - Hospitality over a value of £75 should be declined and declared unless (in

exceptional circumstances) senior approval is given. A clear reason why permission to accept has been given should be recorded on the Register.

- A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or a reasonable estimate).

- Staff should not accept repeated hospitality from the same source.

Travel and Accommodation




- Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

- Offers which go beyond modest, or are of a type that UCLH itself might not usually offer, need approval by an executive director, should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on the Register as to why it was permissible to accept travel and accommodation of this type. A non-exhaustive list of examples includes:

business class travel and accommodation (including domestic travel) offers of foreign travel and accommodation

11.9 Hospitality - What staff should declare?

o Their name and role within UCLH.o The nature and value of the hospitality including the circumstances surrounding the

offer.o Hospitality accepted from the same source received over a 12 month period, should

be treated in the same way as a single acceptance of hospitality over £75, wherethe cumulative value exceeds £75 and declared.

o Date of receipt.o Whether the offer was accepted or declined and reasonso Any other relevant information e.g. action taken to mitigate against a conflict, details

of any approvals given to depart from the terms of this policy.

11.10 Outside Employment

Staff should declare any existing outside employment on appointment and any new outside employment when it arises, this includes speaking at conferences and lectures for which a fee is paid directly to them, even if they donate this fee to charity.

Where a risk of conflict of interest arises, the general approach outlined in section 10.1 should be considered and applied to mitigate any risks.

If a member of UCLH staff is engaged in or wishes to engage in outside employment and their contract of employment or terms and conditions of engagement permit, staff must still seek prior approval from their line manager. This is to ensure UCLH is satisfied there are no conflicts of interest or health and safety issues for the member of staff and that this work will not adversely affect their UCLH employment. Such permission will not unreasonably be refused.

The line manager should record the decision, by email or more formally in a letter, and place a copy of the recorded decision on the individual’s personal file. The Trust Secretary must also be sent a copy of the decision made.

Where contracts of employment or terms and conditions of engagement permit, staff are required to seek prior approval from their line manager, if they are engaged in or wish to engage in outside employment to ensure UCLH is satisfied there are no conflicts of interest or health and safety issues for the member of staff and that this work does not adversely affect their UCLH employment. Such permission will not unreasonably be refused.

Examples of work which might give rise to a conflict include:

- Employment with another NHS Body - Employment with another organisation that supplies goods to UCLH - Self-employment - Undertaking private practice not related to clinical practice e.g. participating in

surveys and focus groups. If the organisation carrying out the survey or focus group is a supplier or contractor doing business (or likely to do business) with UCLH then the offer of payment should be declined.




11.11 UCLH may also have legitimate reasons within employment law for knowing about outside employment of staff, even when this does not give rise to risk of a conflict.

11.12 For the avoidance of doubt staff are reminded that they:

- Are not permitted to undertake work elsewhere whilst on sick leave from UCLH - Cannot engage in private work or work for an additional employer during hours

when they are employed to work by UCLH

Any individual suspected of either of the above may be referred to our Counter Fraud Service for further investigation; this could end in dismissal or possible prosecution.

11.12 Outside Employment - What should be declared?

o Staff name and role within UCLH.o The nature of the outside employment e.g. who it is with, a description of duties,

time commitment.o Relevant dates.o Other relevant information e.g. action taken to mitigate against a conflict, details of

any approvals given to depart from the terms of this policy.

11.13 Shareholding and other ownership issues

Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with UCLH.

Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general approach outlined in section 10.1 should be considered and applied to mitigate any risks.

There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts.

11.14 Shareholding and other ownership issues - What staff should declare?

o Their name and their role within UCLHo Nature of the shareholdings/other ownership interest.o Relevant dates.o Other relevant information e.g. action taken to mitigate against a conflict, details of

any approvals given to depart from the terms of this policy.

11.15 Patents

Staff should declare patents and other intellectual property rights they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by UCLH.

Staff should seek prior permission from UCLH and UCL before entering into any agreement with bodies regarding product development, research, work on pathways etc, where this impacts on UCLH’s own time, or uses its equipment, resources or intellectual property and in addition, abide by the requirements of the UCLH Intellectual Property Rights Policy.

Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general approach outlined in section 10.1 should be considered and applied to mitigate any risks.

11.16 Patents – What staff should declare?

o Their name and role with UCLH.o A description of the patent.


http://insight/pandp/Trustwide%20policies1/Intellectual%20Property%20Rights%20Policy.pdf



o Relevant dates.o Other relevant information e.g. action taken to mitigate against a conflict, details of

any approvals given to depart from the terms of this policy

11.17 Loyalty Interests

Loyalty interests should be declared by staff involved in decision making where they: - Hold a position of authority in another NHS organisation or commercial, charity,

voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role.

- Sit on advisory groups or other paid or unpaid decision making forums that can influence how UCLH or other NHS organisations spend taxpayers’ money.

- Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners.

- Are aware that UCLH does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities.

See Appendix A (Glossary of terms), for definition of ‘close relative’ and ‘close associate.’

11.18 Loyalty Interests – What staff should declare?

o Their name and role with UCLH.o Nature of the loyalty interest.o Relevant dates.o Other relevant information e.g. action taken to mitigate against a conflict, details of

any approvals given to depart from the terms of this policy

11.19 Donations

Charitable cash donations or other donations offered by suppliers or bodies seeking to do business with UCLH should be treated with caution and not routinely accepted. In exceptional circumstances they may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable.

A record of charitable cash donations accepted will be kept by the UCLH Charity. In the case of other non-charitable donations, advice and approval from the Director of Procurement must be sought before acceptance. Procurement will keep a record of offers made along with the estimated value in the case of equipment or other non-cash items.

Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties, or is being pursued on behalf of the UCLH charitable fundraising unit or for a charitable body linked to UCLH and is not for their own personal gain. Staff must obtain permission from UCLH if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign for a charity other than one linked to UCLH. Permission should be sought from the UCLH Head of Charitable Giving.

Cash donations, when received, should be made to a UCLH charity fund (never to a fund linked to an individual) and a receipt should be issued.

If a donor makes it a condition of their donation that it is to be used to purchase a nominated item or service the donation can ONLY be accepted if the goods or equipment are regarded as suitable for use at UCLH. In these cases the line manager should contact the procurement department in the first instance.




Staff wishing to make a donation to a charitable fund in lieu of receiving a professional fee may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

11.20 Donations – What should be declared?

The UCLH Charity will maintain records in line with the above principles and rules and relevant obligations under charity law.

11.21 Sponsored Events

Sponsorship of UCLH events by appropriate external bodies will only be approved if a reasonable person would conclude that the event will result in clear benefit to UCLH and the NHS.

During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

No information should be supplied to the sponsor from whom they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

At UCLH’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.

The involvement of a sponsor in an event should always be clearly identified and prior approval sought in accordance with the UCLH Advertising and Sponsorship Policy from both the Director of Procurement and Associate Director of Communications.

Staff within UCLH involved in securing sponsorship of events should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.

Acceptance of commercial sponsorship should not in any way compromise any purchasing decisions or be dependent on the purchase or supply of goods or services from the sponsor.

Staff arranging or participating in sponsored events, for example as a speaker, must declare this to UCLH.

11.22 Sponsored Events – What should be declared?

o UCLH will maintain records regarding sponsored events in line with the aboveprinciples and rules.

o Staff should declare any other interests arising as a result of their association withthe sponsor, in line with the content in the rest of this policy.

11.23 Sponsored Research

Funding sources for research purposes must be transparent.

Any proposed research must go through the relevant NHS Health Research Authority or other approvals process.

There must be a written protocol and written contract or agreement between staff and/or institutes at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services.


http://insight/pandp/Trustwide%20policies1/Advertising%20and%20Sponsorship%20Policy.pdf

https://www.hra.nhs.uk/approvals-amendments/what-approvals-do-i-need/



The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service.

Staff should declare involvement with sponsored research which is not managed by the UCLH Joint Research Office.

11.24 Sponsored Research - What should be declared?

Written records of sponsorship of research must be retained in line with the above principles and rules. The UCLH Joint Research Office maintains a database of research studies carried out at UCLH/UCL.

Staff should declare: o Their name and role within UCLH.o Nature of their involvement in the sponsored research.o Relevant dates.o Other relevant information e.g. what, if any, benefit the sponsor derives from the

sponsorship, action taken to mitigate against a conflict, details of any approvalsgiven to depart from the terms of this policy.

11.25 Sponsored Posts

External sponsorship of a post requires prior approval from UCLH and should initially be discussed with Procurement. Once agreed the appropriate pre-employment checks should be carried out in accordance with Workforce processes.

Rolling sponsorship of posts should be avoided unless appropriate checkpoints are put in place to review and withdraw if appropriate.

Sponsorship of a post should only happen where there is written confirmation that the arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. This should be audited for the duration of the sponsorship.

Written agreements should detail the circumstances under which UCLH has the ability to exit sponsorship arrangements if conflicts of interest which cannot be managed arise.

Sponsored post holders must not promote or favour the sponsor’s products, and information about alternative products and suppliers should be provided.

Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.

11.26 Sponsored Posts – What should be declared?

o UCLH will retain written records of sponsorship of posts in line with the aboveprinciples and rules.

o Staff should declare any other interests arising as a result of their association withthe sponsor, in line with the content in the rest of this policy.

11.27 Clinical Private Practice

Hospital Consultants (and associate specialists and speciality doctors or equivalent) employed under their respective Terms and Conditions of Service are already permitted to




carry out private practice in NHS hospitals. They are also required to provide their employer with information about their private practice3.

Consultants who sign new consultant contracts with UCLH will be subject to the terms applying to private practice in those contracts.

NHS Consultants should work on a partnership basis to prevent any conflict of interest between private practice and NHS work. It is also important that NHS Consultants minimise the risk of any perceived conflicts of interest and make a declaration; although no consultant should suffer any penalty (under the policy) because of perception.

Hospital Consultants should not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on their behalf.

Undertaking private practice/fee paying work in NHS time may constitute gross misconduct and will be dealt with in accordance with the Trust’s Anti-Fraud and Bribery Policy and Disciplinary Policy and Procedure.

Clinical staff should declare all private practice on appointment, and/or any new private practice when it arises including:

o Where they practice (name of private facility).o What they practice (specialty, major procedures).o When they practice (identified sessions/time commitment)

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):

o Seek prior approval of UCLH before taking up private practice.o Ensure that, where there would otherwise be a conflict or potential conflict of

interest, NHS commitments take precedence over private work.o Not accept direct or indirect financial incentives from private providers other than

those allowed by Competition and Markets Authority guidelines: CMA guidelines

Other grades of doctor or members of staff from other professions may undertake private practice or work for outside agencies providing fee paying services, providing they do not do so within the time they are contracted to UCLH work or use UCLH facilities without prior consent and they observe the conditions above.

11.29 Clinical Staff – What staff should declare?

o Staff name and role with UCLHo Descriptions of the nature of the private practice e.g. what, where and when staff

practice, sessional activity, etc (see detail in 11.28 above).o Relevant dates.o Any other relevant information e.g. action taken to mitigate against a conflict, details

of any approvals given to depart from the terms of this policy.

12. Management of interests – advice in specific contexts

12.1 Strategic Decision Making Groups

In common with other NHS bodies UCLH uses a variety of different groups to make key strategic decisions about things such as:

- Entering into (or renewing) large scale contracts.

3 Hospital Consultants are already required to provide their employer with this information by virtue of Para.3 Sch. 9 of the Terms and

Conditions – Consultants (England) 2003:



http://insight/pandp/Trustwide%20policies1/Disciplinary%20Policy%20and%20Procedure.pdf

https://assets.publishing.service.gov.uk/media/542c1543e5274a1314000c56/Non-Divestment_Order_amended.pdf

http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Consultant_Contract_V9_Revised_Terms_and_Conditions_300813_bt.pdf#page=18

http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Consultant_Contract_V9_Revised_Terms_and_Conditions_300813_bt.pdf#page=18



- Awarding grants. - Making procurement decisions. - Selecting medicines, equipment, and devices.

The interests of those who are involved in these groups should be well known so that they can be managed effectively. At UCLH these groups are:

- Board of Directors - Council of Governors - Use of Medicines Committee - All Established Tender Panels - Consultant Recruitment Panels - Board Remuneration Committee - Council Nomination & Remuneration Committee - Non-executive Director Appointment Panels

Committee

These groups should adopt the following principles: - Chairs should consider any known interests of members in advance, and begin each

meeting by asking for declaration of relevant material interests. - Members should take personal responsibility for declaring material interests at the

beginning of each meeting and as they arise. - Any new interests identified should be added to the UCLH register(s). - The vice chair (or other non-conflicted member) should chair all or part of any

meeting if the chair has an interest that may prejudice their judgement. - If a declaration is made during a meeting then the individual concerned must

remove themselves from the meeting when the Committee discusses topics that relate to the declared subject matter.

- If a member has an actual or potential interest the committee chair should consider the following approaches and ensure that the reason for the chosen action is documented in minutes or records:

o Requiring the member to not attend the meeting.o Excluding the member from receiving meeting papers relating to their interest.o Excluding the member from all or part of the relevant discussion and decision.o Noting the nature and extent of the interest, but judging it appropriate to allow

the member to remain and participate.o Removing the member from the group or process altogether.o The default response should not always be to exclude members with interests,

as this may have a detrimental effect on the quality of the decision beingmade. Good judgement is required to ensure proportionate management ofrisk.

12.2 Procurement

Procurement should be managed in an open and transparent manner, compliant with procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour – which is against the interest of patients and the public.

Those involved in procurement exercises for, and on behalf of, UCLH should keep records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes.




For example members of any tender evaluation or assessment group or members of the final decision making panel are responsible for declaring or re-declaring material interests at the beginning of the process and as they arise.

At every stage of procurement steps should be taken to identify and manage conflicts of interest to protect the integrity of the process.

If you are unsure of the process or for further advice about how to manage an effective and transparent procurement process staff should contact details of our procurement team are available for all procurement professionals though the UCLH website.

The Procurement Department operate fully transparent procurement processes and procedures for all contracting, tendering and quotations which are supported and underpinned by the Trust’s Standing Financial Instructions and Scheme of Delegation. A Procurement policy is currently under development which will cover all areas of procurement compliance.

12.3 Pro-Bono Work

Any pro-bono work that is, any work undertaken voluntarily and without payment or at a reduced fee, which is completed by an organisation should not affect any future tender decisions.

When any pro-bono work is offered to UCLH, this should be subject to review and must be approved prior to commencement by the Finance Director.

Pro-Bono Work – What should be declared?

o UCLH will retain a written record of Pro-Bono Work in line with the above principlesand rules.

12.4 Awards and prizes

If staff are approached by an outside organisation or individual about the offer of an award or prize which is in any way connected to their official duties, they must seek advice from the Trust Secretary before accepting it.

Staff will normally be allowed to accept the award, subject to consideration of propriety or risk of public scrutiny, and provided the award is: offered in recognition of personal achievement and is not or cannot be construed as a gift or inducement or payment for a professional or personal advantage to which other rules apply. Acceptance need not be declared providing prior advice has been sought from the Trust Secretary.

13. Dealing with Breaches

13.1 There will be situations when interests will not be identified, declared or managed appropriately and effectively. This may happen innocently, accidentally, or because of the deliberate actions of staff or other organisations. These situations are referred to as ‘breaches’.

13.2 Staff who are aware of actual breaches of this policy, or who are concerned that there has been, or may be, a breach, should report these concerns to the Local Counter Fraud Specialist, the Freedom to Speak Up Guardian, the Director of Workforce, the Trust Secretary or their line manager depending on the level of confidentiality they require.

13.3 To ensure that interests are effectively managed staff are encouraged to speak up about actual or suspected breaches. Every individual has a responsibility to do this. For further information about how concerns should be raised refer to the Trust’s Raising Concerns


http://insight/pandp/Trustwide%20policies1/Standing%20Financial%20Instructions%20and%20Scheme%20of%20Delegation.pdf




Policy. Any concern raised will be dealt with sensitively and in confidence where necessary, appropriate and explicitly requested.

13.4 UCLH will investigate each reported breach according to its own specific facts and merits, and give relevant parties the opportunity to explain and clarify any relevant circumstances.

13.5 Following investigation UCLH will: Decide if there has been or is potential for a breach and if so what the severity of the

breach is. Assess whether further action is required in response – this is likely to involve any

staff member involved and their line manager, as a minimum. Consider who else inside and outside the organisation should be made aware Take appropriate action as set out in the next section.

13.6 Taking action in response to breaches Action taken in response to breaches of this policy will be in accordance with the UCLH disciplinary policy and procedures and could involve leads from the workforce directorate, Local Counter Fraud Specialists, the Trust’s auditors, and/or members of the senior management or executive teams.

Breaches could require action in one or more of the following ways: Clarification or strengthening of existing policy, process and procedures. Consideration as to whether HR/employment law/contractual action should be taken

against staff or others. Consideration being given to escalation to external parties. This might include

referral of matters to external auditors, NHS Counter Fraud Authority, the Police,statutory health bodies (such as NHS England, NHS Improvement or the CQC),and/or health professional regulatory bodies.

Inappropriate or ineffective management of interests can have serious implications for UCLH and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches.

Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrongdoing or fault then UCLH can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach.

This includes: Employment law action against staff, (both informal and formal action) as set out in

the Trust’s Disciplinary Policy and Procedure and Maintaining High ProfessionalStandards Policy.

Reporting incidents to the external parties described above for them to considerwhat further investigations or sanctions might be.

Contractual action, such as exercise of remedies or sanctions against the body orstaff which caused the breach.

Legal action (which could include civil and criminal sanctions), such as investigationand prosecution under fraud, bribery and corruption legislation as set out in the AntiFraud and Bribery Policy.

13.7 Learning and transparency concerning breaches

Reports on breaches, the impact of these, and action taken will be considered by the Audit Committee at least annually.



http://insight/pandp/Trustwide%20policies1/Disciplinary%20Policy%20and%20Procedure.pdf

http://insight/pandp/Trustwide%20policies1/Maintaining%20High%20Professional%20Standards%20at%20UCLH%20Policy.pdf

http://insight/pandp/Trustwide%20policies1/Maintaining%20High%20Professional%20Standards%20at%20UCLH%20Policy.pdf





In the interest of openness, anonymised information on breaches, the impact of these, and the lessons learnt and action taken as a consequence will be published on the UCLH website.

14. Dissemination and training requirements

14.1 Staff should read and understand the guidelines laid out in this policy. The policy will be disseminated to staff through the operational line management structure and brought to their attention at induction.

14.2 There are no particular training requirements associated with the implementation of this policy. Ad hoc training sessions may be provided based on individual and group needs. A quick reference guide will be available on the Declarations of Interests page on the UCLH intranet.

15. How the policy will be monitored

15.1 The table below sets out how UCLH will monitor the delivery of the policy. Additional work may be commissioned to meet organisational needs.

15.2 Where a lack of compliance is found the identified group, committee or individual will identify required actions, allocate responsible leads, and target completion dates. An assurance report will subsequently be presented to show how any gaps have been addressed.

What in the policy is going to be monitored

Monitoring method

Who will lead the

monitoring?

How often? Where will it be reported?

That the procedures set out in the policy have been followed including the completion of the register(s)

Audit Trust

Secretary Annually

Audit Committee

Breaches Audit Deputy Finance Director

Quarterly

Audit Committee – through the regular reports of the LCFS – where fraud is the issue.

Breaches Audit Workforce Director

Annually

Audit Committee – through the raising concerns annual review

Breaches Audit Director of

Procurement Annually

Audit Committee – through the regular reports of the LCFS –




where fraud is the issue.

Training and awareness Audit

Local Counter Fraud

Specialist

Six-monthly Audit Committee

16. Review

16.1 The policy will be reviewed in three years’ time unless and earlier review is required. This will be led by the Trust Secretary.

17. References and Associated Documents

17.1 External Documentation/References

- ABPI: The Code of Practice for the Pharmaceutical Industry (2014) - ABHI Code of Business Practice - Conduct and Capability Procedures for Medical and Dental staff - Department of Health Document ‘Commercial Sponsorship – Ethical Standards for

the NHS’ - Freedom of Information Act 2000 - NHS Code of Conduct and Accountability (July 2004) - Staff Terms and Conditions of Service - The Nolan Committee’s Seven Principles of Public Life - NHS Employers: Managing Conflicts of Interest/Common situations - NHS Health Research Authority

17.2 Trust Documentation/References

- A Guide to dealing with Charitable Funds - Anti-fraud and Bribery Policy - Disciplinary Policy - Raising Concerns Policy - Supplier Representatives Policy - Standing Financial Instructions and Scheme of Delegation - Standing Orders - Starting at UCLH Policy - UCLH Constitution - Website and Social Media Policy




Appendix A

Glossary of terms

Term Explanation

Benefits in kind Any type of benefit that an individual receives that has some implicit value

Bribery and corruption

Dishonest or unethical conduct in an official capacity including:

To request, agree to receive, or accept (directly or through another party)a gift, financial or other advantage, as an inducement or reward for doing,or refraining from doing something

or showing favour or disfavour to any person to gain a personal,commercial, or other advantage

The scope of the Bribery Act 2010 extends to bribery taking place overseas, as well as conniving or turning a blind eye to bribery

Close association/close associate

A common sense approach should be applied to the term ‘close association’. Such an association might arise, depending on the circumstances, through relationships with close family members and relatives, close friends and associates including colleagues, and business partners but could extend beyond to acquaintances with whom you have significant contact.

Close relative: for example

Partner or spouse

Parents (or parents of a partner or spouse)

Children (or children of a partner or spouse)

Siblings (and their partners)

Grandparents (and their partners)

Aunt or uncle (and their partners)

A Conflict of Interest

A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.

A conflict of interest may be: Actual – there is a material conflict between one or more interests

Potential – there is a possibility or a perception of a material conflictbetween one or more interests

Declaration of interest

A formal statement of any, or no, interests in other organisations

Donations A charitable financial payment, which can be in the form of direct cash payment or through the application of a will or similar directive.

Fees Money paid to staff for a service provided to the individual or organisation

Gifts Gifts mean any item of cash, goods, or any service or a combination from a third party that is provided for personal benefit or at less than the commercial value.

Hospitality Food, drink, accommodation, entertainment, travel or attendance at an event as a corporate guest, for which no payment, or minimal payment is made by the recipient, or an offer to carry out work for the individual’s benefit by potential or current suppliers

Intellectual property Products of innovative and intellectual or creative activity and can include inventions, industrial processes, software, data, written work, designs and images.

Interest A claim, right, legal share, or participation in another organisation or involvement with another person that may have a business relationship with




UCLH, or the wider NHS.

Legitimate business reason

In the course of the employee’s official duties and responsibilities and has a benefit to the Trust

Material Interest An interest that a reasonable person would take into account when making a decision because the interest has relevance to that decision

Sponsorship Funding (all or part costs) from an external source including funding of all or part costs of staff members, staff training, events, equipment or posts, pharmaceuticals, costs associated with meetings, such as hotel and transport costs including travel (UK and abroad) and provision of any free services such as speakers

Research sponsor An individual, company, institution, organisation or group of organisations that takes on responsibility for initiation, management and financing (or arranging the financing) of the research.4

4 Health Research Authority


https://www.hra.nhs.uk/planning-and-improving-research/research-planning/roles-and-responsibilities/



Appendix B

Common situations5

Gifts

Staff should not accept gifts that may affect their professional judgement, and giftsof cash or vouchers offered to individuals should always be declined and declared.

Gifts valued at over £50 should only be accepted on behalf of an organisation (i.e.to an organisation’s charitable funds).

Gifts from suppliers or contractors should routinely be declined and declared, withthe exception of low-cost branded promotional aids.

Hospitality

Meals and refreshments must only be accepted where there is a legitimatebusiness reason and the value falls below £75.

Particular caution should be exercised when the offer is from actual or potentialsuppliers whatever the value.

Offers of business class or first class travel and accommodation need approval bysenior staff and should only be accepted in exceptional circumstances.

Outside employment

The involvement of staff in outside roles (i.e. directorships, non-executive roles, self-employment, consultancy work, charitable trustee roles) brings a wealth of skills,knowledge and experience but it’s important that the existence of these is known toavoid conflicts of interest occurring.

Shareholding

Staff should declare any shareholdings or other ownership interests in any companythat might reasonably be expected to do business with their employing organisation.

There is no need for staff to declare shares or securities held in pension funds.

Patents

Staff are encouraged to be innovative in their practice and the development andholding of patents is welcomed but needs to be appropriately managed.

Staff should declare patents and other intellectual property rights they hold andshould seek prior permission before entering into any agreement with bodiesregarding product development and research.

5 NHS Employers: Managing conflicts of interest/Common situations


http://www.nhsemployers.org/your-workforce/need-to-know/managing-conflicts-of-interest/common-situations



Loyalty interests

These are based on relationships (i.e. with another NHS organisation, charity,advisory group, family members, close friends, close business associates) and canoften be hard to define.

The scope of loyalty interests is potentially huge, so sound judgement is requiredfor making declarations.

Donations

Can be in the form of a direct cash payment or through the application of a will orsimilar directive.

Donations, when received, should be made to a specific charitable fund.

Donations from suppliers should be treated with caution/not routinely accepted, andmust always be declared.

Staff must obtain permission from their organisation if as part of their professionalrole they intend to undertake fundraising activities on behalf of a charitablecampaign.

Sponsored events/research/posts

Whilst sponsorship is vital in helping to meet the costs of running events, permitinnovative research to take place, and provide extra capacity and capability byfunding new roles, caution must be exercised to ensure there is no conflict ofinterest.

In all instances, sponsors should not have any undue influence, or access toinformation by which they could gain a commercial advantage.

Clinical private practice

Clinical staff should declare all private practice on appointment, and/or any newarrangements when they arise.

Hospital consultants are already required to provide their employer with thisinformation by virtue of their terms and conditions of service.

Clinical staff should seek prior approval from their employer before taking up privatepractice and ensure that NHS commitments take precedence over private work.




Appendix C

Gifts




Appendix D Declaration Form

[This form is available from the Trust Secretary or the DoI register administrator]

Section 1 – Details (please complete all of this section)

Name:

Job Title:

Staff Group: List decision making staff : Please highlight any that apply to you

Executive and non-executive directors

Clinical directors and divisional managers

Senior directors reporting to an executivedirector

Hospital consultant staff

Those staff at Agenda for Change band 8d andabove

Members of advisory groups or panels whichcontribute to direct or delegated decisionmaking on the commissioning or provision ofNHS or other taxpayer funded services

Administrative and clinical staff who areinvolved in the purchasing of goods,equipment, medicines, or medical devices andthose who can make formulary decisions.

Administrative and clinical staff who have thepower to enter into contracts on behalf ofUCLH to include:

Heads of departments or services

Members of the capital, estates andfacilities directorate

Members of the finance and commercialteams

Members of staff undertaking research

Pharmacy staff

Procurement and ICT procurement staff

Board:

Base/location:

Telephone Number:

Email address:

Name of line manager:




Reason for completing the declaration: Annual declaration required Declaring a gift Declaring hospitality Other – wish to declare a relevant interest

This declaration relates to: Gifts Please complete sections 2 and 11 Hospitality Please complete sections 3 and

11 Outside Employment Please complete sections 4 and 11 Shareholdings and Other ownership Please complete sections 5 and 11 Patents Please complete sections 6 and 11 Loyalty Interests Please complete sections 7 and 11 Sponsored Research Please complete sections 8 and 11 Sponsored Post Please complete sections 9 and 11 Clinical Private Practice Please complete sections 10 and 11

Section 2 – Gifts – complete this section even if the gift was declined

Name of the person or company who donated/offered the gift

Details of Gift offered/received: Please state what the gift was and the reason for the offer/donation including details of previous gifts offered from same source

Reasons for accepting or declining the offer

Estimated value of the gift offered/received:

£

Was the gift accepted Yes / No

Was management advice sought prior to acceptance?

Yes / No

Details of any contract the donor is interested in:

Was the Gift from a Pharmaceutical Company?

Yes / No




Section 3 – Hospitality - complete this section even if the hospitality was declined

Name of the person or company who donated/offered the Hospitality

Details of Hospitality offered/received:

Please state what the nature of the hospitality was and the reason for the offer and acceptance if taken

Estimated value of the Hospitality offered/received:

£

Was the Hospitality accepted Yes / No

Was management advice sought prior to acceptance?

Yes / No

Details of any contract the donor is interested in:

Was the Hospitality from a Pharmaceutical Company?

Yes / No

Section 4 - Outside Employment Do not use this section for Clinical private practice - go to section 10)

Please detail the nature of the Outside Employment:

Name of employer days/hours of work

Please outline the relevant dates:

From: mm/yy To: mm/yy

Other Relevant Information: (e.g. action taken to mitigate against a conflict, details of any approvals given to depart from the terms of the policy).

Section 5 - Shareholdings and Other ownership

Please detail the nature of the Shareholdings and Other ownership



Other Relevant Information (e.g. action taken to mitigate against a conflict, details of any approvals given to depart from the terms of the policy).

Section 6 – Patents or other intellectual property

Please provide details of the




Patent

Other Relevant Information (e.g. action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy)

Section 7 – Loyalty Interests

Please detail the nature of the Loyalty Interests




Section 8 - Sponsored Research

Please detail the nature of your involvement in the Sponsored Research



Other Relevant Information (e.g. what, if any, benefit the sponsor derives from the sponsorship, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of the policy).

Section 9 - Sponsored Post

Please detail the nature of the Sponsored Post and the name of the Sponsor

Please outline the relevant dates: From: mm/yy To: mm/yy

Other Relevant Information (e.g. declare any other interests arising as a result of your association with the sponsor, in line with the content in the rest of the policy

Section 10 - Clinical private practice

Please detail the nature of the Clinical private practice:

Please provide details of: name of place where private practice carried out; speciality and major procedures undertaken;




Hours worked: Sessions undertaken, i.e. days, times, regularity

Please outline the relevant dates: From: mm/yy To: mm/yy


Section 11 - Signatures (please complete all of this section) The information submitted will be held by University College London Hospitals NHS Foundation Trust for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that UCLH holds.

I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to University College London Hospitals NHS Foundation Trust as soon as practicable, and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, internal disciplinary or professional regulatory action may result. I do / do not [delete as applicable] give my consent for this information to published on registers that University College London Hospitals NHS Foundation Trust holds. If consent is NOT given please give reasons below:

Signed by staff member:

Date:

Name of Manager:

Manager Signature:

Date:

For any queries in relation to the completion of this form, please contact the Director of Corporate Services/Head of Corporate Governance on <INSERT tel.no.> or via email at <insert> Once completed, please return this form to <INSERT EMAIL ADDRESS>


K

Board Assurance Framework

BOARD ASSURANCE FRAMEWORK, 2018-19, updated June 2018

Page 1 of 17

UCLH strategic theme: Provide the highest quality of care within our resources Responsible monitoring committee: Quality and Safety Committee (QSC)

PRINCIPAL RISKS Description of risks

LEAD

Which director leads on manage-

ment of this risk

KEY CONTROLS What controls / systems are

already in place to manage the risk

ASSURANCES ON CONTROLS

What evidence can be used to show that our controls

are working

CONTROLS AND ASSURANCE GAPS AND ACTIONS What controls should be in place to manage the risks but

are not?

What evidence should be in place to show the controls are working / or effective but is not currently in place

Risk rating

Likelihood x impact = risk

Gap Date Current Target

Weaknesses in tracking patients requiring review or treatment could lead to failures to provide best care

Datix ID 1794

Gill Gaskin [as medical director lead for patient admin-istration workstream]

Administrative processes in divisions for booking and tracking patients after A&E attendance, outpatient or inpatient stay

Patient administration system booking lists and waiting times reports

Report functionality now available to track whether future bookings have been provided to patients marked as needing an appointment, but needs to be made part of an agreed business as usual process

Our Clinical Data Repository has been updated so that we can flag abnormal results helping to reduces the risk of missing important findings in diagnostic tests

Internal Audit undertake annual reviews of a sample of Cancer and RTT data to validate against board level reporting/returns.

Control gaps

Administrative skills to track patient pathways: training of administrative staff being progressed by elective access manager and through uclh future Administration and Patient Access programme

Business process and business as usual reporting to track whether future bookings have been provided to patients marked as needing an appointment

Build mechanisms for imaging results review and oversight of long term patients as an interim solution prior to EHRS implementation.

Quality account priority: to improve the imaging flagging rate and ensure specialities have processes to note and action results

Confirm that controls and assurance mechanisms are built into EHRS plans

Assurance gaps

No high-level indicators demonstrating that booking and tracking systems are operating appropriately: need to generate performance indicators for key management reports

Across 2017/ 18 and 2018/19

Mar 18

Dec 17 (new date tbc)

Mar 18 (new date tbc) June 2018

Mar 18

(new date tbc)

5 x 3 = 15

3 x 3 = 9


Page 2 of 17

Delivering required levels of financial savings / efficiency in our long term financial model, or delivering tactical responses to deficits, reduce the quality of care at UCLH

Datix ID 1797

No change in status

Medical directors

Quality impact assessment of savings schemes prior to acceptance into the programme, refreshed for 2017/18

Use of safer nursing care tool to determine ward staffing levels

UCLH Future emphasis on targeting waste and improving patient experience through greater efficiency.

Medical Director (and, where appropriate, other clinical) scrutiny of CIP plans before implementation.

Quarterly Quality and Safety Committee review of quality indicators

Quarterly Monitoring of complaints and patient experience surveys

Monthly improving care walk rounds

Monthly Reporting of actual staffing vs desired staffing

Oversight of DATIX incident reporting

None noted 4 x 3 = 12

3 x 3 = 9

State of disrepair on older parts of the estate has a sustained and significant impact on provision of high quality services for patients in a period of constrained capital funding / potential reliance on emergency funding

Datix ID 1779

No change in status

Director of Estates and Capital Investment

Planned preventative maintenance regime, enhanced checks and (re)validation of areas

Capital programme is in place and project works are being undertaken

The replace and refresh / backlog programme for 2017/18 is progressing with projects being carried out across the portfolio, with circa 80% of scheduled works now complete for this period.

Schemes for 2017/18 have been agreed by CIB and are being developed and prioritised

The Capital Estates and Facilities Division are monitoring the relevant service provider to ensure checks and monitoring is taking place as required (ongoing)

This strategic backlog maintenance risk is reviewed every year alongside the condition B survey and planned preventative

None noted 3 x 4 = 12

1 x 4 = 4


Page 3 of 17

Phase 4 and phase 5 will have a positive impact on risks associated with older estate

Backlog maintenance contribution from Ifm continues through the period 2017/18

Annual condition B survey

Technical Estates compliance audits continuing through 2017/18

CEF-D engineers proactively and reactively audit sites throughout the portfolio in accordance with agreed SLA and contract monitoring with Ifm.

Surveys and risk assessments of existing infrastructure

Review of building cladding for compliance with fire safety regulations, in line with NHS guidance. All tests passed.

maintenance programme.

Audit on Backlog maintenance and management found no gaps / issues


Page 4 of 17

Insufficient capacity to deal with the number of patients referred to the Trust means that UCLH incurs financial penalties / lost income (regulatory / contractual interventions and lost activity)

Datix ID 1780

Chief executive

Demand and capacity modelling

Ongoing relationships with commissioners: new focus on escalation of delayed discharges, with discharge to assess pathways now in place

Modelling and planning for strategic building projects, and subsequent delivery of new capacity

Development of new models of care

UCLH Future plans to improve pathways and reduce length of stay

Strategic capacity planning steering group to assess longer term requirements / potential gaps

Revised 7 day bed prediction modelling tool in place

Monthly monitoring of performance against waiting times standards and other access and flow metrics including mixed sex breaches; cancelled operations

Quarterly reports on referral numbers and market share

Control gaps

Develop patient flow modelling as part of the clinical coordination centre workstream under the UCLH Future programme

Further work required on diagnostics modalities: CT; ultrasound; sleep studies

Strengthen bed and theatre longer term modelling and use to test scenarios based on growth and efficiency assumptions; progress made, but further work to complete

Demand and capacity modelling for discharge to assess pathways outside of UCLH

Finalising new operational processes and governance arrangements around the coordination centre as a driver for freeing up bed capacity

Turnaround programme for theatre utilisation

Information team working on improvement of outpatient room and template utilisation metrics which are not yet wholly reliable. Template redesign to be integrated with planning for EHRS scheduling.

Date to be confirmed

Plan by Q1 18-19

Q2 18/19

Q1 18/19

Q218/19

Ongoing

Ongoing

4 x 3 = 12

2 x 3 = 6


Page 5 of 17

UCLH fails to deliver benefits from technology change (lack of investment or implementation failures) leading to quality issues or financial loss

Datix ID 1896

Director of digital services

Baseline assessment of digital maturity to identify areas of weakness.

Digital Services Delivery Board

Leading digital roadmap programme on behalf of NCL

Participation in NHSE regional and national digital programmes to ensure awareness of latest standards and strategic plans

Digital Transformation Partner (DTP) contract signed with ATOS in December 2016. Service transition starts in January 2017 with service go-live by July 2017

Epic EHRS solution in implementation phase.

New Design decision Groups created for clinical / operational matters and for admin and reporting decisions. This is strongly aligned to an initial Digital Services technical triage process that together ensure we make good technology decisions now aligned to Epic and DTP implementations, and to NCL and national standards.

EHRS programme governance established with progress reporting to every Board meeting. Monthly assessments of UCLH progress provided by Epic, with integration to non-Epic decision making.

Confirmed as Fast Follower in the national Global Digital Exemplar programme, with oversight by NHS Digital.

Joint working with stakeholders from CCGs, providers and local authorities within the sector.

Monitor progress against digital roadmap milestones.

Annual improvement in digital maturity assessment score, including indicators.

External review of EHRS business case and readiness for EHRS implementation

Indicators for use of national applications such as e-Referrals

Control gaps

Alignment of UCLH digital plans to NCL local digital roadmap STP plans.

Governance structure to ensure digital technologies are adopted and utilised consistently across the organisation and that national standards are implemented.

Programme of work to be established to address the universal capabilities required to improve digital maturity and meet central digitisation targets.

Comp-lete

Comp-lete

On-going

4X3=12 2X3 =6


Page 6 of 17

A cyber-attack could lead to critical IT systems not being available, with an impact on quality of care and income streams for a prolonged period

Director of digital services

Cyber Security desktop exercise completed

Cyber Security Risk Assessment completed in partnership with IT outsourced provider

Technical Controls provided by IT outsourced provider which include Anti-Virus, Anti-Malware, Firewall, Encryption

Annual network penetration tests

Cyber Security Incident Management Policy included as part of the Emergency Preparedness, Resilience and Readiness action card for Digital Services (ICT)

Additional Cyber Security services included in the Digital Transformation Partner contract

Technical IT Security Manager provided as part of the Digital Transformation Partner contract.

Comprehensive review of remaining and repeatable patching requirements for desktops and servers.

Cyber Security training built into compulsory IG training module.

Human factors security testing undertaken.

Annual penetration tests reviewed by Digital Services and IT Outsourced provider

Internal audit of IG Toolkit undertaken which reported significant assurance with minor improvement opportunities

Internal audit on cyber security undertaken which reported significant assurance with minor improvement opportunities

Consider an agreement with commissioners to secure monthly payments in the event of a cyber-attack?

More detailed proactive monitoring of network traffic

Addition of advanced threat detection services to the existing Digital Transformation Partner contract

Physical security demonstrably poor enabling walk-in local access and attacks to be possible. Further building security and procedures being considered.

Business continuity plans to be tested for ability to deal with period without IT systems (given risk that not all attacks can be repelled)

Improved perimeter threat detection

Improved protection for oldest servers

TBC

Apr 18

Apr 18

Apr 18

Q2 2018

May 2018

May 2018

3 x 5 = 15

Change from 4 x 4 = 16 on account of reassessment of nature of risk

2 X 4 = 8


Page 7 of 17

UCLH strategic theme: Support the development of our staff to deliver their potential Responsible monitoring committee: Picked up in relevant Board committees as needed


LEAD


ment of this risk





are working


are not?


Risk rating



The likelihood of new controls on movement of people into the UK as a result of Brexit and changes in immigration policy could lead to increased vacancies and employment costs for clinical, scientific and specialist posts

Datix ID 1781

Director of Workforce

Recruitment rates into posts are regularly reviewed and national/international markets are targeted where supply is credible

UCLH are lobbying opinion formers to encourage positive policy solutions and recognition of our forecast reliance on international supply for clinical roles where national shortages remain.

The Senior Directors Team reviewed our recruitment framework for 2018/19 at their 28 March 2018 meeting and agreed headline supply targets for non-medical recruitment informed by forecast inflow and outflow from mainland EU sources

Vacancy rates

Turnover rates for EU and other non-UK staff

Though the UK Government has published helpful detail on the right to remain process it hopes to help retain key professionals post Brexit, it is too early to gauge the reaction and preference of foreign nationals currently working at UCLH and/or our attractiveness to mainland European staff we will wish to attract.

Qualitative data on the views of our current mainland European staff interest/preference where Brexit may lead to them shortening their placements in UK/at UCLH

3 x 3 = 9

3 x 3 = 9


Page 8 of 17

Lack of long term Organisational Development (OD) and succession / leadership plans lead to negative impact on the effectiveness of the organisation.

Datix ID 1782

Director of Workforce The first stage of senior leader

development is now complete.

Plans in place for a second programme for the 150 most senior leaders being led by Yogi Amin. To complement this, a series of quarterly master classes was planned for all those in senior positions (band 8 and above) to develop skills to support digital transformation however the current perceived gaps in management training are more pressing and being addressed as a matter of priority. An appplicatio for funding a new management development programme is being prepared for the charity’s review in September. . All of our aspirations for succession and development are being underpinned by the development of a learning strategy for the trust in support of our right capabilities goal within our strategy refresh.

For team leaders, there is a new leader development programme covering leadership, change and improvement. Priority will be given to those leading teams supporting the APA and EHRS programmes.

.

Quarterly reports to the Board on progress of UCLH Future with evidence of progress against milestones and indicators.

From the last meeting of the Workforce Committee in June, we are also moving to quarterly deep dives and dedicated reviews on staffing at our BoD.

The Leading Teams Programme which includes, leadership, change management and quality improvement has now run 3 cohorts and is receiving good feedback.

The second senior leader development programme has been piloted and is being run. Early feedback is strong.

Lack of succession planning for key posts within the organisation

Further degree and masters development opportunities are planned as part of a wider talent management programme, with the aim of using apprenticeship levy monies in support.

Starts March 2015, then on-going

[Date tbc]

[Date tbc]

3 x 4 = 12

2 x 4 = 8


Page 9 of 17

Junior doctor post vacancies at UCLH (currently estimated at 10-15% of total junior doctor posts) could place undue additional clinical service requirements on those junior doctors in post with an impact on the quality of training and education that they receive


The CEO has secured charity for part research and part clinical roles. 27 posts were approved in 2017/18As part of the ESR/GL reconciliation process, all medical workforce budgets are being reviewed and aligned across Finance, Workforce, Education and HEE. This will provide clarity on where our junior doctor gaps are and enable us to develop focussed strategies to fill any confirmed gaps in rotas.

A trust doctor strategy is being developed to ensure that we become the employer of choice for this staff group.

A medical workforce plan for which includes international recruitment and new types of rotation is being put in place.

Fill rate of junior doctor posts

Agency spend covering junior doctors

GMC trainee survey overall satisfaction and workload information

Number of vacant posts

Agency spend

Exception reports filed for breach of hours and inadequate training

Oversight and Scrutiny Board: Medical Workforce plan

Lack of knowledge as to whether the staff exist to fill the posts and the impact of the EU referendum results and junior doctor contract discussions and vote on the number of available doctors.

Cont-inue to track

3 x 3 = 9

2 x 3 = 6


Page 10 of 17

National shortages in key staff groups and impact of Brexit on immigration leading to gaps in rotas puts at risk patient safety and the ability of the trust to deliver planned activity levels


Senior Directors Team approval of recruitment framework, including headline supply targets for non-medical and medical recruitment. Focus on hard to recruit areas, with innovative supply ideas. This effort provides the underlying plan for the workforce framework that underpins our strategy refresh.

A sequence of charity bids to support work to improve staff experience at UCLH will follow from July.

The creation of a medical workforce recruitment team whose objectives are to focus on developing new recruitment routes for national shortage areas and to reduce time to hire in medical and dental staff.

Focus on streamlining the way we manage joint appointments between UCL and the trust and facilitating the deployment of staff between NHS organisations to fill identified gaps at UCLH.

Initiatives to improve all leave planning and detailed work on the training requirements for staff will support the trust to manage staffing levels across the trust during the critical period for implementation.

Business continuity planning process is underway with the EHRS Operational Readiness Owners

Monitored in the CEO performance pack:

1. Vacancy rates

2. Stability rates

3. Time to Hire forall staff and for junior doctors

Staff Survey 2018/19

The shortages in certain staff groups identified are a long-term challenge. Whilst the trust can work to identify new supply routes and developing its reputation as an employer of choice, the labour market for these identified areas is limited.

Service areas need to review the way they deliver our services to look for opportunities for new ways of working that enables the trust to deliver the quality of service we aspire to, but with different staff, new ways of working and automation where possible. This shall involve developing new education pathways, experimenting with different roles to deliver the service and looking at AI options.

TBC 3X4 = 12

3 x 3 = 9


Page 11 of 17

UCLH strategic theme: Achieve financial sustainability Responsible monitoring committee: Finance Committee


LEAD


ment of this risk

KEY CONTROLS What controls / systems are already in

place to manage the risk


What evidence can be used to show that our controls are working

CONTROLS AND ASSURANCE GAPS AND ACTIONS What controls should be in place to manage the risks but are not?


Risk rating



UCLH is set efficiency targets or control totals that it is unable to achieve, with a consequent loss of sustainability funding and risk to financial sustainability

Datix ID 1778

Finance Director

Two-year planning process for 2017/19 with a focus on delivery and implementation of cost improvement plans

New programme management office now in place, leading work with “special measures” areas with significant financial challenges, and with a focus onTrust-wide schemes that are crucial to delivery of the 2018/19 control total.

UCLH, Shelford Group & NHS Providers engaging with NHS Improvement and NHS England to assure sustainability funding is received.

Maximising productivity improvements through the Carter / productivity programme led by the Finance Director.

Revised governance for financial improvement including a dedicated Senior Directors Team meeting.

NHS Improvement’s review of financial planning and in-year position

Two year planning process

In-year monthly financial reporting and forecasting

Recovery plan and progress against identifying cost improvement plans monitored through dedicated Senior Directors Team meeting

Increased emphasis on productivity, including Carter metrics, to be published monthly

Assurance gaps

Ongoing work and assurance needed to understand the impact of the STP on the trust.

Further work required with NHS Improvement to agree an approach to EHRS, PFI funding and control totals.

Control gaps

Robust link between forecasting and planning, particularly in relation to activity and capacity.

Deliver strengthened capability in relation to the Carter productivity agenda with focus on providing good, useful information to all areas of the business to deliver productivity improvements through existing structures

Potential gap in future Health Education England dental education funding stream, Under active discussion through EDH DCD..

Ongoing

Ongoing

Ongoing

Ongoing.

4 x 5 = 20

4 x 4 = 16


Page 12 of 17

UCLH Future and cost improvement plans now tracked at a granular level through a common process (in Finance Directorate)

2 year delivery plans for multi-year programmes agreed (Access and Patient Administration, As Is +, EHRS). All clinical productivity and redesign programmes now reviewed at Productivity Delivery Group / Carter programme.

Due to the lack of national funding allocated to the NHS, there is a risk that STP partners and NHS England specialist commissioners shift financial risk, exposing the trust to stranded costs / unfunded activity if the STP proposals fail to deliver

Datix ID 1784

Finance Director

Active engagement with North Central London Sustainability and Transformation Plan (STP) to review partnerships and pathways which make more efficient use of acute provider capacity

Closer working relationships with CCG commissioners and other local providers including the Whittington.

Dedicated expertise as part of commercial and contracts function, working closely with the existing NHS contracts team, to mitigate the risk of new payment models

Monthly reporting to Finance and Contracting Committee on key service developments

Reporting to Investment Committee on tender / new business opportunities and financial risks as needed

Finance Director linked into STP and national discussions about payment models and tariffs

Control gaps

Deliver and embed bid support expertise in the trust.

Increase clinical leadership and project resources supporting those STP workstreams critical to UCLH’s financial sustainability.

Commercial team in place

4x 4 = 16

3 x 4 = 12

NHS-wide financial constraints resulting in non-payment for activity by local and specialist commissioners, or reduced prices for specialist activity,

Finance Director

Stronger approach to cash management ensuring close engagement with commissioners in relation to service developments and activity growth

NHS Improvement’s review of financial planning and in-year position

Contract process

Assurance gaps

Continue to seek assurance around fairness of national policy on tariff setting, particularly for specialist work, in relation to whether higher costs demonstrate complexity or inefficiency.

Ongoing 4 x 4 = 16

3 x 4 = 12


Page 13 of 17

risking delivery of financial targets

Datix ID 1786

Continued work with NHS Improvement and NHS England to ensure that local prices are not reduced and that control totals are set fairly.

Active involvement in the development of the North Central London Sustainability and Transformation Plan to help find system solutions to affordability issues

Contract negotiations framework including accelerated timescale for agreement ensures rigour in assessing and mitigating the impact

Focus on cash flow secured as part of the 2017-19 contract agreement.

UCLH patient level costing data is used as part of benchmarking group, to reduce further threat to specialist prices.

monitoring through Senior Directors Team and Board of Directors

In-year monthly financial and contractual reporting and forecasting

UCLH is unable to adapt as quickly as required to new payment mechanisms that may replace Payment by Results, leading to a lack of alignment with the wider health economy and a threat to UCLH’s own financial sustainability

No change in status

Finance Director

Engagement with STP

Leadership of new care models that use different tariff arrangements, leading to exposure to different ways of funding and running clinical services

Focus upon cost reduction rather than income growth in CIP plans.

Acknowledged engagement of commissioners in strategic intent document and annual planning process

Control gaps

Specific awareness raising for clinical and management staff on the move to new payment mechanisms

Training mechanisms for technical staff on new tariff arrangements and how they can be used to support running of services and improved patient outcomes

On-going

4 x 4 = 16

3 x 3 = 9

UCLH Future programme does not generate sufficient financial and non-financial

Director of Innovatio

Ongoing review of the UCLH future programme performance ensuring a clear link with:

Monthly and quarterly reports on progress of cost

Assurance gaps

Need further robust programme governance in

On-going 3 x 4 = 12

3 x 3 = 9


Page 14 of 17

benefits

Datix ID 1787

n a) Cost ImprovementProgramme (CIP)

b) Carter programmec) Ongoing service

improvement

improvement programmes (including Trust-wide / UCLH future schemes) and the overall financial position.

Internal / external audits on progress against efficiency programmes

relation to delivery of benefits from UCLH future programmes, including access and patient administration, co-ordination centre and others

Material decline in London property values or other disposal restrictions, including potential impact of Brexit leads to failure to deliver assumptions on disposal values in long term financial model

Datix ID 1789

Finance Director (with Director of Estates)

Board reviews the LTFM when making capital commitments.

LTFM has sensitivities around the value of asset disposals.

Structure of Eastman Dental Hospital sale to UCL designed to mitigate against the risk of declining property values.

Ongoing discussion at Board and Investment Committee to ensure the timing of asset disposals is optimised

Control gaps

Need for ongoing review of optimisation of timing and value of asset disposals and link to potential new investment requirements at UCLH

On-going 3 x 4 = 12

3 x 4 = 12

Brexit generates risks across a range of disparate issues, either because of impact of withdrawal from European Union (EU) regulation (for example medicines or procurement), lack of EU funding sources (for example research) or the impact of wider economic changes (for example property values)

No change in status

Specific risks will be drawn out from this general risk and added to the BAF as/if they emerge over time.


Page 15 of 17

UCLH strategic theme: Improve patient pathways through collaboration with partners Responsible monitoring committee: Strategic Programme Board


LEAD


ment of this risk





are working


are not?


Risk rating



STP proposals for redesigning care pathways could fail to deliver the activity shifts at sufficient pace, with impact on delivery of access standards and financial plans

Datix ID 1791

Director of strategic develop-ment

Active participation in

STP governancemeetings

STP clinical workinggroups

Weekly meetings withCamden CCG to monitorlocal delivery

Exploration of partnership working, including collaboration with the Whittington, the Haringey & Islington Wellbeing Partnership and Camden Local Care Strategy

UCLH STP coordination calls to identify concerns and agree escalations

Improved information sharing within UCLH

A&E delivery board co-chaired by UCLH and Camden CCG

Feedback on STP from external agencies

Improving relations with local partners

Joint working on system leadership projects as both system leader, partner or contributor

Control gaps

Develop closer relationships with GPs, in particular in their CHIN groupings. Understand their priorities and how UCLH can contribute to delivering them.

Secure clinical leadership roles for STP work streams that will have most impact on UCLH

Advocate for a better alignment of CCG resources to STP work streams to stop duplication of design effort across CCGs

Transition to an A&E Delivery Board co-chaired by UCLH and the Whittington to oversee STP UEC work stream implementation locally

On-going

On-going

On-going

Complete

4 x 4 = 16

2x4=8


Page 16 of 17

Risk that through lack of engagement in the governance and plans of the specialised Sustainability and Transformation Plan (STP) that we lose opportunities / autonomy to develop critical mass and world class services in our strategic service areas, leading to less clinical resilience, loss of status and loss of income

Datix ID 1792incre

No change in status

Director of strategic develop-ment

Founding membership and participation at all major UCLP events

Leading engagement in underpinning financial analysis, solutions development and implementation of the specialised services STP

Influencing specialised STP focus to areas of opportunity for UCLH e.g., drugs, imaging, referrals,chronic-disease management

Acknowledged engagement of commissioners in strategic intent document and annual planning process

Exploring whether UCLH can have a more formal role in representing NCL STP on the London Specialised Planning Group.

Use sector wide clinical leadership roles to ensure decision-making regarding changes to patient flows are based on an evidence based assessment of the full financial and care quality impact of affected providers, in particular via:

Cancer vanguard/ alliance

London neurosciences network

On-going 3 x 4 = 12

2 x 4 = 8


Page 17 of 17

UCLH strategic theme: Generate world-class research Responsible monitoring committee: Board of directors


LEAD

Which director leads on

manage-ment of this risk





are working


are not?


Risk rating



Risk that some annual research funding streams will be constrained over time leading to budgetary pressure on workstreams that underpin delivery of our research objectives

No change in status

Corporate medical director

Delivery mechanisms within the biomedical research centre (BRC), clinical research facility and wider research community ensure that we meet standards that are used to allocate this income

BRC governance structures

Clinical research facility governance structures

Quarterly performance reports

Control gap

Lack of control over future funding constraints that may lead to reduction in income streams from NIHR and comprehensive research network

3 x 3 = 9 2 x 3 = 6

L

Agenda item 9

Finance Director’s Report

Plan Actuals Variance Plan Actuals Variance

£'000 £'000 £'000 £'000 £'000 £'000

Trust

Medicine Board 1,281 2,128 847 1,296 1,946 650

Specialist Hospitals Board 10,383 9,358 (1,025) 5,978 5,183 (795)

Surgery & Cancer Board 2,194 2,754 560 1,965 3,148 1,184

Research & Development - 1 1 - 0 0

Education (621) (607) 14 (335) (307) 28

Corporate Directorates (29,393) (29,504) (111) (14,624) (14,699) (75)

Board Contingency (1,333) (1,333) - (666) (666) -

Other Central Budgets 23,596 22,618 (978) 11,720 10,907 (813)

EBITDA 6,107 5,415 (691) 5,334 5,513 180

ITDA (before donation adjs.) (12,025) (11,621) 404 (6,017) (5,708) 309

I&E before exceptional items (5,918) (6,206) (288) (683) (194) 489

Exceptional items (control total)

Other exceptional items (included within

control total performance)(2,803) (2,311) 492 (1,406) (1,173) 233

Control total performance (8,721) (8,516) 205 (2,089) (1,367) 722

Exceptional items (non-control total)

Donations / donated asset adjs. (341) (116) 225 (231) (14) 217

Core PSF 2,072 1,451 (621) 1,036 1,451 415

Net surplus/(deficit) (6,990) (7,181) (191) (1,284) 70 1,354

Year-to-date In-month

2018/19 Month 2 financial performance

BOARD OF DIRECTORS MEETING

11 JULY 2018

FINANCE DIRECTOR’S REPORT

Brief Summary of the Report

This report updates the Board of Directors on the financial position of the Trust at the end of May 2018.

The Board of Directors is asked to note the financial performance for the 2 months to the end of May 2018

1. Month 2 Position

1.1 The May position as reported against the Trust’s control total shows an in-month deficit of £1.4m against a £2.1m deficit plan, a favourable position of £0.7m against plan. This brings the year to date position to a £8.5m deficit, £0.2m better than plan. It is important to note that the plan in May involved a significant step up, from a £6.6m deficit plan in April to a £2.1m deficit in May, but that significant further improvement is needed through the year for the Trust to achieve its overall control total plan.

1.2 The summary financial position for month 2 is shown in table 1 below.

Table 1 – Month 2 Trust summary financial position

1.3 The in-month position reflects favourable positions in Medicine Board and Surgery and Cancer (£0.7m and £1.2m respectively) and an adverse position in Specialist Hospitals (£0.8m).

The main drivers of the in-month position within each of the clinical boards are detailed below:

1.4 Medicine Board reported a £1.9m contribution, £0.7m better than plan. Within ESD, high attendances and activity in ED and CDU were offset by lower than planned non-elective activity.

1.5 Specialist Hospitals Board reported an in-month contribution of £5.2m, £0.8m below plan. There were adverse positions in most divisions. The Paediatrics position was impacted by low bone marrow transplant activity in month (which is typically volatile, low volume and unpredictable) and markedly lower day case and chemotherapy income. After a good first month, the Women’s Health position was £0.4m adverse in May, driven by a shortfall of 50 births against plan as well as lower complexity of neonatal activity. EDH activity continues to be below plan, driven in part by consultant vacancies which are in the recruitment pipeline.

1.6 The Surgery and Cancer position was a contribution of £3.1m, £1.2m ahead of plan. Cancer day case and chemotherapy activity was above plan. Whilst still reporting an adverse position, May’s elective activity in GI showed a significant improvement compared to April

1.7 Whilst the Trust’s forecast to NHS Improvement is in line with the control total, there remain a number of significant risks to this forecast such as CIP identification and delivery. There is currently an estimated £4.7m shortfall in the CIP forecast and a number of divisions and directorates are forecasting adverse variances to their financial plan. Work continues to identify new schemes and to translate recovery plan projects into more certain CIP schemes. It has been made clear to all areas of the Trust that they are accountable for delivery of their financial plan rather than for delivery of their current forecast, and that recovery plans are required to ensure that the financial plan is delivered.

1.8 The Trust’s cash balance at 31st May 2018 was £156.9m, £3.3m higher than plan.

2. Use of Resources Assessment

2.1 UCLH’s Use of Resources assessment has been confirmed for 8 August. This forms part of the overall Trust CQC rating. Preparatory work is underway, focussing on productivity metrics and key lines of enquiry that NHS Improvement (who lead the assessment on behalf of the CQC) will assess the Trust on.

Vicky Clarke on behalf of Tim Jaggard

Deputy Finance Director

M

Agenda item 10

EHRS Report

Board of Directors Meeting

11 July 2018

EHRS Programme Update

This paper reports on the progress of the EHRS Programme for the period May to June 2018.

1. Programme Plan

The programme plan showing the implementation overview for EHRS is set out in Diagram 1 below.

Diagram 1 – Implementation Overview

This diagram shows key milestones on the EHRS programme plan since July 2017 that are completed ( ) or are on track to be completed ( ) at the appropriate time in Phase 2. It should be noted that there are remaining items from build cycle 3 being completed during build cycle 4.

Workstream Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

1. Design

2. Build

3. Developments

4. Reporting

5. Integrated Areas

6. Interfaces & Contracts

7. Technology

8. Testing

9. Training

10. Operational Readiness

11. Go-Live

12. Benefits Management

13. People Readiness

14. Communications

15. Programme Control

16. Financial Control

17. Assurance

EHRS DASHBOARD (03.07.18)

Satisfactory (on track)

Watch (up to 10% off-track)

Serious (over 10% off-track)

We are currently ON TRACK for the planned Go-Live date and ON BUDGET against plan, taking into account appropriate use of provisions, although there are risks that are being actively managed, as set out below.

2. Dashboard

The Dashboard in Table 1 shows the status of the 17 EHRS work-streams during June 2018.

1) Design. We completed the third cycle of EHRS adoption with subject matter experts from 5 to 7 June.

We achieved operational signoff on 88% of workflows presented. Outstanding workflows will be

reviewed with participants to resolve by the end of build in mid-July. Amber

2) Build. 70% of Wave 0 to 4 workflows were completed as of 29 June 2018. Workflow build continues to

be off-track with 6/20 modules in high risk category now subject to daily review of progress and for

which additional build staff are being deployed to recover build. The research team’s build is ahead of

schedule. Red

3) Developments. A number of Epic application developments have been approved and are underway,

as follows: (a) pathology specimen accession numbering; (b) national cancer waiting time dataset

changes; (c) clinical coding enhancements; (d) Child Protection Information Sharing; and (e) national

Emergency Care Data Set changes. Such developments are a normal part of keeping EHRS up to

date with local and national changes. Amber

4) Reporting. The requirements for the new CDS (Commissioning Data Set) and billing engine

(replacement URSA) were specified, on schedule, in June. Because timelines are very tight, there are

risks regarding (a) delay to the procurement of the “replacement URSA” solution (due early September

2018); and (b) the implementation of the “replacement URSA” solution (due to complete from

December 2018 to March 2019). The CDS Billing Working Group, chaired by Simon Knight is

managing these risks and Tim Jaggard will become more directly involved in ensuring all income

streams are covered adequately. Amber

5) Integrated Areas. 21 of the 25 integrated (cross-module) areas defined by Epic are either in a green

(satisfactory) or amber (watch) status. The red integrated areas are: (a) PAS Data Migration

(Conversions) is red because we are awaiting confirmation of the PAS data migration scope by

ARDDG (Administrative and Reporting Decision Design Group); (b) HODS (Hospital Outpatient

Departments) is red because of the delays in receiving department analysis workbooks for Cadence

scheduling build completion (we have agreed a recovery plan with Rishi Das Gupta’s support to help

deliver the remaining workbooks); (c) Scanning and Transcription is red because we are awaiting the

OnBase test system to be stood up to support interface testing with Epic. The EHRS Patient Safety

Lead (Yogini Jani) started on 3 July 2018. Amber

6) Interfaces and Contracts. Interface contracts are off-track with 23 out of 33 contracts completed and

7 out of 33 test systems ready for testing. Additional staff members have been brought in for interface

build/testing, integration engine build, and project management. The pathology interfaces are

progressing well and the Winpath interface is now in test. PAS data migration scope was confirmed by

ARDDG in June 2018. CGI is cooperating in delivering the PAS extracts for data migration. Red

7) Technology. Several technical dependencies are of concern in respect of (a) timeliness of desktop

rollout and Windows 10 upgrade; (b) WiFi: Atos survey started later than planned and carries a

potential upgrade cost; (c) Epic platform server upgrade and cost; and (d) printers/specimen label

printers roll-out. The Technical Working Group meets weekly to resolve these issues and a regular

Technical Report is now being submitted to the Programme Board each month. Amber

8) Testing. The Testing Strategy was approved at the June Programme Board. There are 5 Testing

roles. The Testing Manager role has been offered and we await start date. One Testing Analyst

started on 5 June 2018. One Testing Analyst role has been offered, another’s salary is being

negotiated and the last is being advertised. Green

9) Training. A Training Retreat in May reviewed training principles, timeline, deliverables and tools. The

training plan has been reset to achieve the training milestones. There is progress being made on

training calculations, training curriculum development, planning of classroom facilities, and the UCLH

internal Learning Management System (LMS) being made fit for purpose. Additional Principal Trainers

were approved at the June Programme Board. A final and fully costed training plan is being prepared.

Amber

10) Operational Readiness. The Operational Readiness work-stream continues to be on-track. The

Operational Readiness Owners (Divisional Managers) are led by Rishi Das-Gupta and meet weekly.

Leave planning and activity management are on the July Programme Board agenda. Green

11) Go-Live. Over 800 Super-Users have been nominated to support the go-live, testing and training

processes and mapping to clinical areas and roles is underway. We have identified the go-live

planning manager within the PMO and Epic worked with the Operational Readiness Owners to launch

the go-live planning process on 13 June 2018. One of the current activities is to draw up options for

locating the Go-Live Command Centre. Green

12) Benefits Management. Dr Rishi Das-Gupta, Director of Innovation, has recruited a Benefits Manager

and a benefits management plan is being prepared. Green

13) People Readiness. Lisa Hancock has recruited Vicky Dunne and Alex Redford into her Change

Management Team. This team is working with stakeholder groups to develop their ability to provide

input to EHRS implementation and adoption at go-live. They have supported end-to-end Epic demos

for nursing and research SMEs which have been very well received. Lisa has also been providing

support to the EHRS Programme team. Green

14) Communications. Regular updates to Clinical Boards and Divisions continued in May/June. Gerrie

Coertzen, the EHRS Communications Manager, has helped to organise and communicate key

scoping decisions made by the PB to relevant SMEs, Epic and build teams. An updated

communications plan is on the July Programme Board agenda. Green

15) Programme Control. The Programme Management Office continued to follow the weekly cycle of

activities to: (a) monitor work-stream project plans; (b) review the Decisions, Issues and Risks Logs;

(c) review off-track tasks on the programme plan and (d) escalate issues to the weekly Escalation

Group chaired by G Gaskin. The daily build progress reports are now sent by PMO to EHRS and Epic

team members to help support build recovery. Green.

16) Financial Control. The EHRS Programme is currently on-budget. However, a range of cost pressures

have risen this period and are being evaluated against available budget and contingency in July

Programme Board (Part 2). Green.

17) Assurance. Chris Belmont (ex-CIO of MD Anderson) and Maurits Ros (IT Director at Academic

Medical Center, Amsterdam) are returning for their second assurance visit on 19 and 20 July 2018 to

support the Programme Board review of the programme as we move from Phase 2 (Build and

Adoption) into Phase 3 (Testing). A KPMG internal audit of oversight and coordination of technical

planning across the UCLH EHRS and Digital Services teams, ATOS and Epic has been completed

and a report is being finalised. Green.

3. Key Accomplishments

The main EHRS accomplishments during May/June 2018 were as follows:

(a) Design and Build

The contract was signed for Epic’s new endoscopy module (Lumens) and a Lumens Designer is

starting on 9 July 2018. The Epic Applications Manager for Lumens has started on-site (Lisa Pan). A

demo of Lumens for GI clinicians took place on 11 June 2018. Middleware to link the endoscopy stack

(and other endoscopy modalities) to Epic is currently being selected.

The Manchester Triage System (for the ED) was procured and the contents of the system have been

received.

In May, Wai Keong Wong facilitated an engagement session on research and Natasha Phillips led

nursing and midwife demo sessions at Queens Square. Both events were successful with high

attendance and engagement levels.

(b) Adoption 3

Adoption cycle 3 was completed between 5 and 7 June 2018 with a high level of Subject Matter Expert

attendance and engagement, including consultants and some junior doctors. SMEs for Grand Central,

UCH Radiology and Anaesthesia had strong engagement and progressed the adoption of workflow

design.

(c) Testing

Lin Horley and Anna Change (Epic Application Manager) presented the Testing Strategy to the Programme Team.

(d) Programme Control

A change control process was developed by the PMO for managing requests for changes to scope,

decisions, and the movement of completed build across Epic environments (databases). It is

recognised that any de-scoping (e.g. to accelerate build if necessary to meet critical timelines) may

reduce benefits and will only be considered with appropriate governance and safety checks.

4. Current Key Challenges

The current key challenges, and mitigations, for the EHRS programme are set out as follows:

(a) Build

(b) As stated above, we continue to be behind on workflow build and we have 2 weeks left in order to

complete our build for the end of build wave 4 on 20 July 2018. Gill Gaskin led a detailed module by

module review to identify key blockers and agree actions. We concluded that the six modules at

highest risk of late completion of build are (in order): Grand Central PAS, Cadence PAS, Orders,

Beacon, Radiant and Cogito. These are the areas of greatest focus. In some areas, UCLH’s clinical

activities are more complex than predicted for an Epic organisation of similar size and function e.g.

number of chemotherapy protocols, number of patient questionnaires, extent of external reporting and

audit requirements and work is underway to see how this can be simplified.

(c) The build recovery plan includes: weekly task plans for each builder in each team, end of day build

progress checks by the Epic Application Manager and the UCLH Module Coordinator to ensure that

each team’s build tasks are fully logged in the build tracking system (Orion), administrative support for

teams for meeting logistics, and dedicated build days (build turbo days) and quiet areas. Wai Keong

Wong and Rishi Das Gupta are using their contacts and expertise to deal with some specific module

challenges.

5. Board Action

The Board of Directors is requested to note the progress being made in the EHRS Programme and is invited to make any comments or suggestions. Dr Gill Gaskin, Medical Director, Specialist Hospitals Board and EHRS Programme SRO David Kwo, Director of EHRS and Informatics 3 July 2018

N

Agenda item 11

Quality and Safety Committee report

Quality and Safety Committee (QSC)

Report to the July Board of Directors

11 July 2018

Report of the May 2018 Meeting

1. Clinical research governanceIn 2017-18, 283 studies received permission to begin recruitment at UCLH. 36% of these studies were sponsored by commercial companies, 24% were sponsored by UCL, 5% by UCLH, and 36% by other non-commercial sponsors, such as other Universities or NHS Trusts. 43% of the studies were drug trials.

The Regenvox and Inspire trials remain suspended at UCLH. The ‘Task and Finish Working Group on Regenerative Medicine at UCL’ has developed an action plan based on the recommendations of the Special Inquiry into Regenerative Medicine Research at UCL.

Work is underway to ensure that UCLH and UCL studies recruiting or receiving data after May 25th comply with HRA requirements in relation to The General Data Protection Regulation (GDPR).

2. Trust quality and safety committee performance reportDuring the month of March there were no grade three pressure ulcer incidents reported, and only one grade four. A root cause analysis found that there were no significant lapses in care.

It has been agreed with our commissioners to exclude falls at Sir William Gowers Unit, the epilepsy assessment ward, from the performance report unless the fall is with harm.

3. Mandatory training update

UCLH current rate of completion is 85%. This is lower than previous months due to the inclusion of honorary contract holders into our reporting and the addition of Duty of Candour training to the curriculum. It has been agreed that the target completion target is reduced to 90% (except for information governance training which will remain as 95% as this is a nationally set target). This will bring us in line with other similar trusts. The burden of Epic training on the organisation is enormous. We will aim to ensure that we are not asking staff to complete both mandatory training and Epic training during the same time period. The sustainability and transformation plan (STP) work on portability of mandatory training is continuing. In order for the work to be successful we will need to move mandatory training from the Learning Portal to a portal called OLM, which sits within the Employee Service Records (ESR). This is a large piece of work, and given our desire to keep our training to a minimum during the latter part of this year, it is proposed that we do not implement the STP wide system until summer 2019.

4. Trauma working group update

The TARN (Trauma Audit and Research Network) report March 2018 highlights that the Ws statistic (excess deaths or survivors standardised according to hospital case mix using the TARN fraction) shows an unexpected survivor rate of 3.32 at UCLH. This follows a positive trend of unexpected survivors at UCLH over the last few years. UCLH is currently the only Trauma unit across the North East London and Essex Trauma Network (NELETN) which is compliant with targets for data completeness and quality of data submission.

Trauma services at UCLH were reviewed in September 2017 as part of the national trauma peer review process, following reviews in 2015 and 2016. The review team highlighted a number of areas of good practice and noticed significant achievement in comparison to the previous reviews. Nevertheless a few areas were highlighted as immediate risk or serious concerns and these are being addressed.

The spinal care pathway was implemented in June 2017 to ensure timely and appropriate assessment, diagnosis, treatment and potential transfer of spinal patients presenting to the Emergency Department (ED) at UCLH with suspected spinal trauma, spinal cord compression and Cauda equina compression syndrome. Since then, the spinal trauma element of the pathway has been updated to bring it in line with a uniform trauma network guided approach to spinal trauma across North East London and to ensure safe and high quality care provision to all spinal trauma patients here at UCLH. The out-of-hour (OOH) provision of 24/7 MRI availability at University College Hospital (UCH), will further promote the timely assessment of patients on this pathway.

5. Medication safety

QSC received the annual report from the medication safety committee for April 2017 to March 2018, and details of the 2018-19 objectives.

Key achievements for 2017-18 include improving oxygen prescribing by updating guidelines, and including audit of oxygen prescribing to the trust Exemplar Ward programme, improving safety of injectables by developing drug library for smart infusion pumps and an improvement in medication security compliance.

6. Controlled Drugs (CD)

QSC received the quarterly report on CD management to NHS England London CD Local Intelligence Network from the CD Accountable Officer. Key headlines included that 110 CD incidents were reported during the quarter, of these 52 incidents were categorised as ‘patient safety incidents’. There was a low degree of harm associated with these incidents.

7. Patient safety committee

The patient safety committee report includes key learning messages from serious incidents, internal red

incidents, 72 hour reviews and near misses reported on Datix in the last quarter. It includes the monthly

Duty of Candour (DOC) report. Compliance with DOC for serious incidents for 2017/18 is 83%. There has

been no improvement with completion of historic moderate harm and above incidents which are Duty of

candour applicable and which are still open on Datix.

Learning from the patient safety committee is shared with the medical directors and through them with the

divisional directors and managers and learning also features in the monthly quality and safety bulletin.

Report of the June 2018 Meeting

1. Claims and inquest management

The purpose of the annual claims and inquest report is to provide assurance of monitoring systems to

ensure that the trust complies with the Clinical Negligence Scheme for Trusts (CNST) / Risk Pooling

Schemes for Trusts (RPST) standards. The report incorporates information relating to the number and

types of claims, time taken to resolve claims and their associated costs, learning from claims and inquests

and any significant developments during the year relating to this area of work. There has been a

reduction in number of new contacts for the purposes of bringing / potentially bringing a claim. This is

likely to be in part due to the new General Data Protection Regulation (GDPR) that came into effect on the

25th May 2018, which lays down that subject access requests are now free of charge, where historically

there has been a £50 charge, per request. It is thought that this will now lead to an increase in disclosure

requests.

Findings of the audit undertaken by the UCLH legal team for 2017/18 demonstrate that the majority of

actions arising from claims have been completed within agreed timescales.

There has been a significant increase in the number of claims being reported to NHSR. Some of this

increase is as a result of the Early Notification Scheme for Obstetrics. The scheme requires trusts to

report all maternity incidents occurring on after 1 April 2017 which are likely to result in severe brain injury.

NHSR aim to increase the level of support provided to teams when these rare incidents occur. There

have been no prevention of future death (PFDs) rulings made by the Coroner against UCLH in the last

eighteen months.

2. Litigation in Surgical Specialities

NHSR and NHS Improvement and ‘Getting it right first time (GIRFT) published a ‘Litigation in Surgical

Specialities’ data pack for all NHS Trusts in December 2017 which QSC reviewed in February 2018. One

of the recommendations was triangulation of learning from complaints, inquests and serious incidents.

UCLH is able to demonstrate compliance with these recommendations, although recognises that systems

need strengthening. Divisions receive a bi-annual report of their current claims profile and are asked to

provide evidence of actions taken. The update showed that responses were at 60% overall and the

medical directors (MDs) were asked to ensure divisional responses are more timely.

3. Patient safety committee

The patient safety committee report includes key learning messages from serious incidents, internal red

incidents, 72 hour reviews and near misses reported on Datix in the last quarter. Duty of Candour (DOC)

e-learning has now been added to mandatory training for the trust.

There were a total of 12 alerts received by the trust in April 2018. There was one patient safety alert

requiring the adoption of the revised National Early Warning Score (NEWS2) by 31st March 2019. We will

be compliant as it is being built into Epic.

4. Risk coordination board report

This includes new and existing red, high amber and current moderate risks and the Health and Safety

Annual Report. It also notes work on linking risks to specialist committees, and trust risk manager link in to

the relevant risks arising from the Epic programme.

5. Care Quality Commission Executive Steering Group (CQCESG)

Preparations are underway for the imminent core, well led and use of resources inspections at UCLH. We

have been reviewing the CQC reports of other trusts for learning and to help identify areas to focus on. A

UCLH Quality Guide is being compiled with the primary function of informing and supporting staff around

key quality issues.

6. NICE guidance /technology appraisals

This report is an update on the UCLH position on NICE monitoring and includes the UCLH response to the

CQC Provider Information Request (PIR) regarding NICE guidance.

For all NICE guidance there is a systematic system in place for the review and circulation of the guidance

to relevant clinical leads and/or divisions with a requirement for the guidance to be taken forward. UCLH

has ensured implementation within the three month deadline for all mandatory (statutory) Technology

Appraisals (TAs) and Highly Specialised Technologies (HSTs). Medicines related TAs and HSTs are

monitored by the Use of Medicines Committee (UMC) which reports to the CESG.

An exercise was undertaken to assess divisions’ compliance with the policy for NICE guidance

implementation and monitoring. For a number of divisions a gap was identified about notifying the MDs

about non-compliance with NICE publications.

7. Corporate audit

QSC approved the proposed audit programme for 2018-19.

8. Infection control

QSC received an update on performance against the MRSA and Clostridium difficile indicators to June

2018. There have been zero bacteraemia cases this financial year to date.

The target for healthcare attributable (HA) C.difficile for 2018-19 is less than 96 cases. To date UCLH has

had twenty HA cases. There is a rise in C.difficile infections, related to the rise in broad spectrum

antibiotic use and is not due to transmission. Although UCLH will meet the required targets we will revisit

the C.difficile action plan. There is an increase in cases of measles and whooping cough as the

vaccination rate has declined. Many junior doctors have not seen these diseases and additional education

will be provided to raise awareness.

9. Trust quality and safety performance

Infection control improvement reporting was worse than threshold for the trust but this is a data collation

issue and work is underway to improve. The threshold for grade two pressure ulcers has been adjusted to

seven in agreement with the commissioners.

10. Patient experience

Following discussions at QSC, the governance of patient experience is being reviewed and the Patient

Experience Committee (PEC) and Improving Experience Group (IEG) are expected to be replaced by a

single new committee. Draft terms of reference and governance structure were discussed and are subject

to further engagement with clinical boards and discussion at IEG later this month.

11. National inpatient survey results

The survey used a sample of inpatients who were in hospital during July 2017 and results are compared

with all England Trusts. In comparison with 2016 three questions have deteriorated. These are being

given enough privacy in A&E, being given all the necessary information about the condition or illness from

the person who referred them and hospital food. In the expected range for trusts UCLH was better than

other trusts on “if you brought your own medication with you to hospital, were you able to take it when you

needed to?”, worse than other trusts on “did hospital staff discuss with you whether you would need any

additional equipment in your home, or any adaptations made to your home, after leaving hospital?” and

are about the same on the rest. Key findings for UCLH are that patients’ overall experience remains good,

we have maintained performance from 2016, are still number one in London and compare well to peers in

a number of areas, and our areas of focus are consistent with national challenges and linked to transitions

of care.

12 Nutrition and Hydration Steering Group report

The group reported on the governance, policies and guidelines, quality improvement work and assurance

against regulatory standards for nutrition and hydration across the trust.

The priorities for 2018-19 include addressing governance and organisational reporting to enable

prioritisation of nutrition and hydration, achieving compliance with Hospital Food Standards, specifically

recommendation 1: “that all NHS hospitals develop and maintain a Food and Drink Strategy”, with

organisational support, embedding our Nutrition Champion Community of Practice, and reviewing all

nutrition and hydration performance metrics, including assistance with meals.

Cathy Mooney Director for Quality and Safety on behalf of Professor Tony Mundy, Corporate

Medical Director

N1

Agenda item 11.1

Mortality Surveillance Report

Board of Director meeting

11 July 2018

Mortality Surveillance Report

1. Introduction

This paper is the third report on deaths and learning to the Board for the period October to December 2017. This report provides the:

- Numbers of deaths in the period October to December 2017.

- Number of deaths due to be reviewed according to UCLH criteria (based on NHSI guidelines)

- Number of deaths actually reviewed and whether they are more likely than not to be due to problems in care.

Deaths have been reviewed either by existing processes such as complaints and serious incident investigations or using the structured judgment review (SJR). It also sets out the learning from those reviews.

2. Background

From April 2017, all trusts are required to collect and publish information on deaths and serious incidents, including evidence of learning and improvements being made as a result of that information. This is part of a systematic, NHS-wide approach to reviewing and learning from deaths, being led by the Department of Health, NHS Improvement (NHSI) and the Care Quality Commission (CQC).

National guidance has been provided to ensure a consistent approach to identifying and reporting, investigating and learning from deaths, and where appropriate, sharing information with other services and organisations.

Most deaths at UCLH are already thoroughly reviewed for learning through existing processes such as serious incident investigations, coronial inquests, the maternal death review process, the child death panel, the Learning Disabilities Mortality Review (LeDeR) programme, cardiac arrest rapid reviews (CARR) and complaint investigations. As a result of the national guidance we have extended the criteria for reviews of deaths and introduced the structured judgment review (SJRS) which is a mortality tool developed by the Royal College of Physicians used to undertake case record reviews. Most deaths that have met the criteria for a SJR to date have been deaths where the coding was elective admissions.

UCLH is fourth lowest in the UK for the Summary Hospital-level Mortality Indicator (SHMI).

3. About this report

Appendix A is and update on actions from deaths reported in quarter 1 and 2 where actions are still outstanding and a summary of deaths reviewed in quarter 3 and the learning. Appendix B is a detailed breakdown of deaths for review according to the UCLH mortality surveillance and learning from deaths policy.

3.1 Overview April to December 2017

The total number of deaths from April to December was 690. The total number of deaths in October - December 2017 was 234. The table in appendix B shows the number of deaths to

be reviewed, the number of reviews completed and those deaths judged more likely than not to be due to problems in care.

3.2 Stillbirths, neonatal deaths, childhood deaths (under 18) maternal deaths These are investigated by the Women’s’ Health division via the multidisciplinary Clinical Incident Review Group (CIRG) and/ or the Child Death Panel. No concerns have been noted following these reviews.

3.3 Deaths where the coding was elective admission (SJR) These deaths are reviewed using the structured judgement review template. Case record reviews can identify problems with the quality of care so that common themes and trends can be identified, which can help focus our quality improvement work. Review also identifies good practice that can be spread.

This is the area that requires most work as only a small percentage of cases that meet the criteria for an SJR have been reviewed to date. This is mainly due to lack of trained reviewers. The trust currently has four tier 1 trained reviewers who are able to train other SJR reviewers and two more are booked into training in July 2018 with the National Mortality Record Review Programme. An additional 12 reviewers will be trained by the end of July 2018. The Mortality Surveillance Group has identified that the trust requires approximately 20 reviewers and plans are in place to increase the number of reviewers trained and it is anticipated that this will be achieved by September 2018. This will help to address the number of SJRs still to be undertaken.

We have also determined that the majority if not all of those identified so far are cancer patients where the elective coding refers to a procedure to alleviate symptoms. Whilst this does generate learning it might be that resources should be directed to other deaths. This will be discussed when we review our position at year end.

3.4 Deaths following Hospital Acquired Thrombosis (HAT) For the period April 2017 – December 2017 two patients died following hospital acquired thrombosis in quarter one. No concerns were identified.

3.5 Deaths of patients with a learning disability (LD) All LD deaths are referred to the Learning Disability Mortality Review Process for Adults

For the period April - December 2017, there were two deaths relating to Learning Disability patients. No concerns were identified.

3.6 Deaths of patients with severe mental illness/whilst detained under the Mental Health Act For the period October - December 2017, there were four cases of patients who were coded for serious mental health illness. These have been reviewed by the corporate medical director (trust mortality surveillance lead) and it was not felt that their disability contributed to their death. It was considered that their deaths were not likely to be due to problems in care.

3.7. Mortality outlier notification There were no notifications received for the period April – December 2017.

3.8 Deaths subject to serious incident investigation Serious incident investigations are more in-depth than case record review as they gather information from many additional sources and are subject to root cause analysis. Four serious incidents from quarter three were reviewed by the Mortality Surveillance Group (MSG) and all were considered not likely to be due to problems in care. The details are set out in appendix A.

3.9 Complaints received following deaths in Q3 (which occurred in Q1 or Q2). These are complaints where a relative or carer has raised concerns about the care of the

patient who has died. There were 9 complaints closed in Q3 after a death. Only one met the

criteria for a review.

See appendix A for further information.

3.10 Significant concerns raised via Bereavement - End of life care survey/letter Concerns can be raised by relatives via the bereavement team, using the end of life care survey or directly with the trust. One concern was raised by a relative and the case was reviewed by a consultant and the family was reassured that the care was appropriate.

3.11 Deaths which occurred in the community within 30 days of discharge

There were no notifications received for the period of April – December 2017.

3.12 Deaths which occurred where at the time of death the patient was not under the care of UCLH but where another organisation suggests that that the trust should review the care provided to the patient in the past. There were no notifications received for the period of April – December 2017.

4. Learning

4.1 Learning from deaths reported in quarter three and updates on learning and actions from deaths reported in quarters one and two These are outlined in appendix A. These do not include deaths previously reported where there are no further actions.

4.2 Learning from Structured Judgement Reviews (SJR)

As the number of deaths being reviewed thus far has been low it is difficult to identify themes and trends. However, those identified for quarters 1 and 2 have already been reported and it is proposed that in the next report (quarter 4) a full year review will be reported as more reviews would have been undertaken.

To date the main areas highlighted are:

Inconsistency in allergy recording on different forms

Excellent, compassionate care

The requirement to draw up new treatment escalation plan when changes are required

Nurse to sign DNACPR form

When required fluid balance charts to be completed

TEP/DNACPR to be drawn up in a timely way once MDT agreed

5. Summary

This report outlines learning from deaths in April - December 2017. The challenges have included the introduction of a new initiative, that of SJRs, and associated training, and ensuring the data on the number of death reviews are consistent. We are addressing these challenges to ensure we have robust and clear processes for data validation.

Appendix A Learning from deaths reported in quarter three and updates on learning and actions from deaths reported in quarters one and two

Source Description Actions agreed and learning MSG review and date

Serious Incidents Q1

Serious incident Q1 (SI 476)

Post-stroke deterioration and collapse on ward leading to admission to ITU and eventual death.

A patient was discharged to the ward from ICU and was initially stable. The patient began to show signs of deterioration and whilst this was escalated it was not acted upon quickly enough to prevent arrest and subsequent death.

Reducing harm from unrecognised deterioration is one of our safety priorities and our work this year is focused on improving the use of vital signs and of the national early warning scoring (NEWS) system and escalating concerns using the communication tool ISBARD (Identification Situation, Background, Assessment Recommendation Decision).

The use of ISBARD as a communication tool has recently been launched and staff are being taught how to use it. We will check to ensure that staff do attend training and that it is making a difference. We will keep this under review and carry out an audit to see if the use of NEWS on the ward and checking patient records of patients that have been escalated to see if ISBARD has been documented as being used which will be reported in quarter 4.

There has been learning on the ward concerned and learning has been shared through the trust quality and safety bulletin and discussion at our patient safety committee. This is also scheduled for discussion at the next Deteriorating Patient Safety Group meeting.

Agreed death not likely to be due to problems in care (5/3/18),

5

Source Description Actions agreed and learning MSG review

Serious incident Q1 ( SI478)

Missed Femoral Hernia in the emergency department (ED):

A diagnosis of a femoral hernia was not considered as the possible explanation for the patient’s symptoms and so steps were not taken to further evaluate the patient for the possibility of a hernia complicated by bowel obstruction. As a result the patient was discharged but was ill overnight and was readmitted the next day.

We agreed to formalise consultant ward rounds in the Majors area of the Emergency Department (ED). This has now been done. In addition all patients diagnosed with, or suspected of, having a high risk surgical condition will be referred by the ED doctor to a registrar or more senior surgeon, rather than to a junior doctor on the surgical team.

Agreed death not likely to be due to problems in care (5/3/18),

Serious incident Q1 (SI 471)

Maternal death

A woman was admitted with bleeding and abdominal pain. Induction of labour was commenced and she delivered a stillbirth infant. Following the delivery the woman required immediate transfer to theatre. She continued to deteriorate despite interventions and had an arrest requiring cardiopulmonary resuscitation (CPR) from which she did not recover. The post-mortem report indicated that the cause of death was a rare complication from which the mortality rate is high, regardless of the management. The death was not deemed to have been preventable but some learning was identified.

Work has commenced on updating the guideline for obstetric haemorrhage and a robust approach to ensure that all blood test results (and other pathology results) are checked and reviewed within an appropriate time frame. This has been slightly delayed due to staffing changes.

The Clinical Director will also seek agreement and reinforce standards for timely review when consultants are called during non-resident on calls.

Agreed death not likely to be due to problems in care (5/3/18)



Serious incident Q2 (SI483) This death occurred in quarter one

Unexpected death from sub arachnoid bleed The patient was admitted following a fall and a knee fracture. He was found to be confused and a CT brain scan was undertaken which showed an acute subarachnoid haemorrhage. The patient suffered unexpected deterioration after the CT brain scan followed by a cardiac

This investigation could find no care or service delivery issues, and concluded that the event was unpredictable and unexpected.

The incident has been subsequently de-escalated as a serious incident.


6

but was entered onto the Strategic Executive Information System in quarter two.

arrest from which he did not recover. He was referred to the coroner who agreed the cause of death was subarachnoid haemorrhage secondary to ruptured intracranial aneurysm.

An investigation to determine if the bleed could have been picked up earlier found that the patient had no symptoms prior to the event, other than the confusion which led to the scan. His management was appropriate and in line with his clinical status and presentation. The sub-arachnoid haemorrhage was unexpected and it is unlikely that anything could have prevented this event.

Complaints Q2 These were reported in quarter two report and no further actions were identified


Source Description The learning and actions from the investigation

Serious incident Q3 SI491

Admission to neonatal Unit: A woman in her first pregnancy experienced an antepartum haemorrhage (APH) whilst in early labour and on arrival the fetal heart rate was pathological and significant bleeding was recognised. A decision was made for a category 1 emergency caesarean section; unfortunately the baby was born in poor condition and was transferred to the NNU however, her condition was severe and MRI examination revealed insurmountable multi organ damage and brain injury.

The learning from this incident is to inform teaching regarding haemorrhage – including telephone triage, assessment of blood loss via the telephone and in person, giving of appropriate advice and assessment of emergency / urgency.

Agreed death not likely to be due to problems in care ( 9/5/18)


Unexpected death A 77 year old man with history of adenocarcinoma of splenic flexure presented to UCH ED with a history of sudden onset of left iliac fossa pain and vomiting. He was diagnosed with small bowel obstruction and an NG tube inserted for the purpose of drainage. The tube did not drain and was not aspirated despite an earlier CT scan showing 1.5 litres of fluid present. The tube was on free drainage but

The main learning was that there is no written guidance for junior doctors or nursing staff on the management of nasogastric tube drainage in small bowel obstruction which means there is a lack of widespread knowledge of how to manage these tubes and when to be concerned and to escalate

Agreed not likely to be due to problems in care (9/5/18)

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there was no documentation of any further drainage attempts. He had a sudden attack of vomiting on the ward and had a cardiac arrest followed by a second arrest, after which he did not recover and sadly died. It is unclear whether any actions would have prevented the cardiac arrest, however if the lack of aspirate / no free drainage had been noted and escalated, potentially action could have prevented the copious vomit and aspiration.

The actions therefore include writing guidance and training staff on the management of acute bowl obstruction.

.



Delay in diagnosis of neutropenic fever. A 63 year old lady with a medical history of COPD, heart failure and lupus was admitted for debulking of a neuroendocrine tumour under Head and Neck oncology and was discharged post-procedure then readmitted 3 days later with suspected neutropenic fever and died the following day.

The clinicians in the ED did not treat the patient for suspected neutropenic fever for two hours despite the fact that she met the criteria for this diagnosis.

There was a delay in the review of the patient by the oncology team. Better communication between the oncology team and ED may have resulted in earlier review of the patient, however, may not necessarily have changed the outcome as the patient did deteriorate quickly after admission.

Teaching session for ED staff to be undertaken in relation to the policies: Suspicion of Neutropenia and Fever guidelines.” Flowcharts relating to these two policies to be printed and laminated and displayed to maintain awareness of the criteria for neutropaenic fever and the required actions. These also to be added to the induction pack for new staff.

The implementation of a document setting out responsibilities of oncology registrar on call overnight to be reviewed

An alternative assessment facility for known cancer patients (Cancer Assessment Unit) who require urgent assessment and do not need to be seen in the resuscitation room will be considered.

The Quality & Safety newsletter in April included a reminder to all acute admitting specialties of the importance of giving clear instructions to nursing staff including frequency of observations, fluid management, and triggers for calling a doctor.


8

Serious incident Q3 SI496 NB :This incident was reviewed for learning but death occurred in another hospital

Death from sepsis following previous treatment for cancer which included incidental irradiation of the spleen. A young man died in another hospital from septic shock and multi-organ failure in January 2018. His mother expressed concern about the lack of antibiotics following removal of his spleen at UCLH in May 2013. He presented with a large but localized Ewing Sarcoma arising from the left 11th rib. He was treated with chemotherapy, radiotherapy and surgery and was last seen at UCLH in October 2017 when he was well. The investigation showed that the patient’s spleen had not been removed but it was irradiated and the investigation reviewed the impact of this.

The investigation found that the care delivered by the consultant oncologist was entirely appropriate for the disease. There is not a policy in place which covers total body or splenic irradiation at the trust or nationally and whether patients undergoing such irradiation should be considered high risk and offered immunisation.

A working group has been established to write guidelines related to the implementation of the trust policy on Immunisation and antibiotic prophylaxis in patients with absent or dysfunctional spleen.

As there are no national guidelines, the professional body for clinical oncologists, the Royal College of Radiologists have been asked to consider developing national guidance.

Agreed death

not likely to be

due to problems

in care (11/6/18)


Complaints Q3 9 complaints following a death were closed in Q3, one of these met the criteria for review by MSG

Complaints Q3 17/1643

Concern discharge after first ED visit was premature. A complaint was received concerning the discharge of a patient after first ED visit which was considered premature. The patient was readmitted 5 days afterwards, then deteriorated despite ITU care and died.

The investigation showed that in hindsight it may have been better to keep the patient for another day but at the time the decision was considered clinically appropriate.

Meeting held with relatives to explain the decision made at the time and to address any other questions. Condolences and apology given


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Appendix B UCLH Mortality Surveillance quarterly monitoring report April to December 2017

Number of deaths to be reviewed /numbers reviewed/Death judged more likely than not to be due to problems in care by MSG:

Date stillbirths Neonatal deaths Childhood deaths (under 18) Maternal deaths

where the coding was elective admission(SJR)

following hospital acquired thrombosis

with a learning disability(All referred to LeDeR)

with severe mental illness/ whilst detained under the MHA

Mortality outlier notification

subject to serious incident investigation

where a complaint has been received

where bereaved families and carers, have raised a significant concern about the quality of care provision

in the community within 30 days of discharge

not under UCLH care at the time of death but where another organisation suggests that the trust should review the care provided to the patient in the past

.

2017-18 Q1

16/16/0 21/10/0 2/2/0 1/1/0 1/0/0 0 3/3/0 5/5/0 1/1/0 0/0/0

Q2 28/28/0 26/3/0 0/0/0 0/0/0 0/0/0 0 1/1/0 13/13/0 0/0/0 0/0/0

Q3 15/15/0 32/3/0 0/0/0 1/1/0 4/4/0 0 4/4/0 1/1/0 0/0/0 0/0/0

Q4

KEY

A/B/C A=Number of deaths to be reviewed B=numbers reviewed/ C=Death judged more likely than not to be due to problems in care by MSG

O

Agenda item 12

Research Report

BOARD OF DIRECTORS MEETING

11 JULY 2018

RESEARCH REPORT

1. Biomedical Research Centre (BRC) Update

1.1 NIHR BioResource In May I reported on the UCLH BRC proposal to establish and lead a dedicated Cerebrovascular Disease (Stroke) BioResource The National Institute for Health Research (NIHR) have asked for further clarification of some points and the National Bioresource lead will visit in the next few weeks to discuss further. It is not yet confirmed that our bid to host the stroke bioresource will be successful.

1.2 Appointment of new BRC lead for Healthcare engineering and Imaging The BRC will appoint a new Theme Lead for its Healthcare Engineering and Imaging Theme on July 4th. This follows the departure of Sebastian Ourselin to King’s. This BRC theme will benefit significantly from the fact that the Wellcome Trust has taken the decision that the Wellcome/EPSRC Centre for Surgical and Interventional Sciences will stay at UCL.

1.3 The Research Hospital a. The Research Hospital was launched on 21st May in the presence of the Lord

O’Shaughnessy, the under-secretary of state for health. The launch was a successfulevent and attracted considerable national media interest.

b. A Research Hospital brochure was published at the time of the launch.c. The Head of Research Innovation was appointed in May (Daniel Herron PhD) who will

be the operational lead for the development of research aspects related to theimplementation of the Research Hospital

2. UCLH Clinical Research Update

2.1 Standard and centralised NHS tariff for research costs NHSE has proposed a single tariff for research costs based on the assumption that contract negotiations are a major factor delaying the set-up and commencement of clinical trials, especially those supported by industry. We have commented in the consultation process that this concept is too simplistic and research costs will vary according to the region and complexity of studies which is often not captured in simplistic standard templates. There is potential financial risk from this arrangement and consultations are ongoing via the Shelford group. There is also concern that centralisation of contracting will not necessarily speed up the process as local validation of costs will still need to be undertaken to assess the viability and financial risk of any study.

3. Contractual agreement with UCL Business and UCL and MOU with respect tocommercialisation

UCL Business is a UCL-owned spin-out company that provides technology transfer, licensing and IP support for the BRC and UCLH. Increasingly, we are seeing successful translation of discovery science from UCL into patient care at UCLH via advanced therapy trials. This often results in complex discussions around equity share in subsequent commercialisation agreements. A mechanism to resolve this was proposed and agreed in

an MOU between UCLH and UCL, agreeing a 50:50 share of equity. However, the agreement is open to different interpretations, especially with regard to the top-sliced UCLB costs. This is the subject on ongoing discussions.

P

Agenda item 13

Audit Committee report

Board of Directors Meeting

11 July 2018

AUDIT COMMITTEE REPORT

The Audit Committee (AC) met on 22 May to consider issues relating to the annual reporting process and

the other following issues. The Chairman attended the meeting.

1. Internal Audit (IA)

1.1 IA Assurance Reports 2017/18

The AC received and discussed two assurance reports on Drug Expenditure and Second Level

Regulators (Human Tissue Authority). Both received an amber/green rating of significant assurance with

minor improvements. There were no high priority recommendations.

1.2 Drug Expenditure

The review looked at the end-to-end process for recharging high cost drugs dispensed through both the

Trust’s pharmacy and Homecare, the Trust’s home delivery pharmacy provider. IA concluded that there

were robust processes in place to ensure that data was accurately collected. The AC was pleased to note

that consideration was being given to how the new EHRS prescribing system might be matched to drug

expenditure.

1.3 Second Level Regulators – HTA

UCLH, like other trusts, receives periodic inspections from the HTA relating to its licences. UCLH had an

HTA inspection in 2016; the inspection identified two minor shortfalls. The review looked at the information

used to confirm compliance with its licence and reviewed the most recent assessment. The AC noted that

there were clear governance processes for all the licences, reporting into the Quality and Safety

Committee. One area of weakness was that the self-assessment had not yet been completed as

expected; this was due to be completed at end of May. This had not impacted on the Trust’s ability to

confirm compliance with its governance statements.

1.4 Annual Report

The AC received and noted the Internal Audit Annual Report which set out the audit reviews completed by

KPMG. All year end reports had been completed with the exception of one relating to Digital Readiness

which will report in July. It also confirmed the final Head of Internal Audit (HOIA) Opinion 2017/18 which

had not changed since it was reported to the AC in April. There were no issues to be included in the

Annual Governance Statement.

2. Risk Report and Board Assurance Framework (BAF)

The Directors of Quality & Safety and Planning & Performance presented the BAF and a comprehensive

risk report updating the AC on the key risk issues considered by management. This was the first report

presented as a ‘live’ document which will be continuously reviewed and updated.

The BAF set out the priority areas for 2018/19. The AC noted that the BAF had been updated by the lead

responsible officer and would be presented to the Board.

On risks, the AC was pleased to note that its concern regarding how some of the entries on the risk

register were described was being tackled by the Risk Coordination Board. The RCB would take a phased

approach to reviewing the definition and description of entries to determine with risk leads whether the

entry was an issue (something that had already occurred) rather than a risk (something that might occur).

Progress will be reported to the AC at a future meeting.

The AC also noted that the Chair of the Audit Committee had asked that the risk report be simplified to

enable the AC members to better assure themselves on the design and management of the risk

management process; this was agreed by management.

3. Counter Fraud Annual Report 2017/18

The AC reviewed the Local Counter Fraud Specialist’s (LCFS) annual report which outlined the key

activities undertaken during 2017/18 including an analysis of the emerging fraud risks across the wider

NHS and a summary of casework undertaken at UCLH. It was noted that there had been increased

engagement with staff on issues such as cyber fraud. AC noted the good work of the team to create an

anti-fraud culture at UCLH.

4. General Data Protection Regulations (GDPR)

The Director of Digital Services presented an update to the AC on the implementation plan and key risks

to the delivery of GDPR. The AC noted that consent guidance had been put in place but asked for clarity

to ensure that this issue was properly understood by both patients and staff. It noted that training and

awareness sessions were in place and that policies were on track to be revised. The AC noted there was

still work to be done and that GDPR would be a topic for discussion at a Board seminar in June. The AC

would return to GDPR in July and consider how further assurance can be obtained on implementation

going forward.

5. Annual Report, Accounts, Quality Report and supporting documents

AC received, discussed and approved the final drafts of the following documents.

Annual Report 2017/18

Quality Report 2017/18

Annual Governance Statement (AGS)

Annual Accounts 2017/18 (financial statements)

A summary paper on changes to the accounts since the AC met on 24 April

External Auditors reports on the Accounts and findings on the Quality Account.

Deloitte presented the auditors’ report on the quality account highlighting the RTT and A&E four hour waits

audits and advised that they would be issuing a modified opinion following data testing in both audits. The

AC would follow up how well improvements were being delivered through its regular data quality review.

The AC was particularly concerned by the inability of A&E to provide 25% of the patient notes requested

by Deloitte for their audit – this had occurred in 2016/17 as well and needs further investigation.

The AC reviewed the final audited accounts discussing the valuation of assets and bad debt provision.

Deloitte advised that they would be issuing an unmodified audit opinion on the financial statements.

The AC recommended the annual report, annual accounts and quality report to the Board for approval on

22 May.

6. Trust Licence Statements

AC reviewed the assurance in place to confirm compliance with its Corporate Governance and General

Licence statements to operate as a foundation trust. Evidence included the HOIA opinion, and the AGS.

The AC recommended that the Board certify compliance with its Licence at a meeting on 22 May.

7. External Audit Policy

AC reviewed the external audit policy which sets out how the Trust might engage its external auditors for

non-audit services. No non-audit services were provided by Deloitte in 2017/18.

No changes were made to the policy, which is available to Board members on request.

The AC recommends the Board approve a one-year extension to the policy.

The Council of Governors will be advised of the extension.

8. Annual Report of the Work of the Audit Committee

Outside of the meeting Audit Committee members reviewed an Annual Report of its work covering the

work of the AC for the financial year 2017/18 – it is attached to this report.

The Board is asked to receive this report and consider if it has assurance in regard to the work of

the Audit Committee.

The report will also be provided to the Council of Governors.

Rima Makarem

Audit Committee Chair

June 2018

P1

Audit Committee Annual report

Audit Committee Annual Report

Report of the work of the Audit Committee

during 2017/18

Introduction I am pleased to present our audit committee annual report for the year ending March 2018. Throughout the year the committee has continued to provide assurance to the board on governance and systems of internal control. This report provides an insight into the audit committee’s activities and sets out how the committee met its key priorities. In addition to the regular accounting activities, the committee followed up work with the UCLH digital services team on information governance, monitoring in particular the Trust’s preparations for the introduction of the new EU General Data Protection Regulations (GDPR) which came into force in May 2018. We also had committee workshops into GDPR, the Electronic Health Records System, and Cyber Security to gain a deeper understanding of the subjects. Next year we will review all three issues on a regular basis. The committee also spent time discussing areas of governance where we felt improvements could be made. This year, there was particular focus on debt management. We received regular reports which have allowed us to better understand the overall picture across UCLH and are satisfied with the approach management are taking to reduce the aged debt position. We will continue to receive reports and updates in the coming year. We have also conducted our annual performance evaluation. We concluded that the committee was effective and able to fulfil its role in accordance with its terms of reference. These can be found on the UCLH website on the audit committee page. click here I have been very well supported by the strong teamwork of the audit committee and I wish to thank all the members of the committee and those who have supported its work for their commitment. I am grateful to all for their contributions. The importance of an effective committee remains critical as we look forward to 2018/19, in the context of continuing financial pressure, working in partnership to deliver new models of healthcare, and using new technology to help us do this.

Rima Makarem Non-Executive Director Chair, Audit Committee

https://www.uclh.nhs.uk/aboutus/whoweare/bod/Pages/AuditCommittee.aspx

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Contents

Role of the Audit Committee Page 4

Meetings and Membership Page 4

Board Governance Arrangements Page 5

Business of the Committee Page 5

Risk Management Assurance and Governance Page 5

Internal Audit Page 6

Counter Fraud Page 7

Other Reports Page 7

External Audit, Review of Financial Statements and Annual Reports

Page 7

Non Audit Work Page 8

Evaluation and Briefing Page 8

Looking forward to 2017/18 Page 8

Conclusion Page 9

Appendix A – UCLH Internal Audits 2017/18 Page 10

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Report of the work of the Audit Committee during 2017/18

1. Role of the Audit Committee

1.1 The audit committee’s (committee) main role is to provide independent assurance to the board of directors (board) on the effectiveness of UCLH’s internal control and governance arrangements. It follows the best practice guidance set out in the NHS Audit Committee Handbook1. The committee’s responsibilities are described in its terms of reference; these were reviewed at a meeting in September 2017.

2. Meetings and Membership

2.1 The committee was chaired throughout the year by Dr Rima Makarem who has significant experience as a chair of audit committees. There were seven meetings held during 2017/18: 25 April 2017, 23 May, 25 July, 29 Sept, 28 Nov, 30 Jan 2018 and 20 March.

2.2 Two further meetings were held on 24 April and 22 May 2018 to discuss the external audit review of the quality account and financial statements, and to review and approve the financial statements, the annual report, the quality report and the annual governance statement for 2017/18.

2.3. During the year the membership of the committee changed; Diana Walford stood down from the board and the committee in November 2017 when her term as a non-executive director came to an end.

2.4. From December 2017 the committee had three members. Membership details and attendance at committee meetings is recorded below.

Table 1: Member’s attendance in 2017/18 and time on the committee

2.5. Brief CVs of all members including any declared interests can be found on the UCLH website. Harry Bush has recent and relevant financial experience to enable him to express views about financial management and governance.

2.6. The internal and external auditors, local counter fraud service (LCFS) provider, the finance director and deputy finance director, and the director of corporate services regularly attend meetings to assist the committee with its duties. Other senior staff are invited to attend to provide assurance on specific items.

2.7. The committee also held private sessions with both the external audit partner and the head of internal audit during the year.

1 Health Financial Management Association (HFMA) Governance and Audit Committee

Name Meetings (out of a possible seven)

Term as a member

Dr. Rima Makarem 7/7 Member from July 2013 and Chair from January 2014

Dr. Harry Bush 6/7 Member from December 2011

Althea Efunshile 5/7 Member from January 2017

Dr. Diana Walford 4/4 Member from February 2012 until November 2017

5

3. Board Governance arrangements

3.1. In 2017/18 there were four other board committees: finance and contracting; investment; quality and safety (QSC); and workforce, all with a monitoring and oversight role. Audit committee members are familiar with the work of these other committees, attending all of them between them. This is particularly notable when it considers clinical risk issues. The QSC oversees all aspects of clinical governance including clinical audit, and provides assurance to the board on safety and on the annual quality account. The committee may cross-refer clinical matters to the QSC, who then report back on their discussions. This year it asked the QSC to consider how it might encourage clinical staff to better engage in clinical audit to take advantage of the medical journal publishing licences the Trust had secured. This was addressed in the clinical audit report.

3.2. In 2018/19 the Board will rationalise its committee structure to engage all board members more fully in its decision-making by discussing key agenda items at Board level and not in sub-committees.

4. Business of the Committee

4.1. The committee has an annual reporting workplan, approved at its July meeting, to schedule its work throughout the year, and an action log to track committee actions. The workplan is based on the terms of reference and takes account of the Trust’s corporate objectives and both the corporate assurance framework and risk register. In 2016/17 it agreed that the review and assurance of insurance arrangements and EHRS project delivery should be added to the workplan.

4.2 The following sections provide an overview of the business conducted during the year to help demonstrate how an effective committee can bring benefits. A summary of its work is also published for information in the UCLH annual report each year.

5. Risk Management, Assurance and Governance

5.1. Effective risk management is essential to the delivery of the UCLH strategic objectives. The principal UCLH risks and how these are managed is set out in more detail in the 2017/18 annual report. The committee has continued to review the ongoing operation and management of the risk and assurance framework.

5.2. The Board Assurance Framework (BAF) focuses on the achievement of the UCLH strategic objectives. Last year it was agreed it would be considered by the committee as a ‘live’ document which is continuously reviewed and updated by management.

5.3 The committee reviewed the BAF three times during the year to ensure the main risks had been identified, any new risks arising were appropriately addressed, and there were no significant gaps. It was assured that the process undertaken to manage, monitor and update the BAF was appropriate and the relevant lead directors were taking responsibility for their area. In year the committee sought more information on the broader impact after Brexit, this was also sought by the council of governors. The BAF was updated.

5.4 The committee reviewed a regular risk report from the risk co-ordination board, the executive committee with oversight of risk. As well as reviewing the Trust’s principal red and high amber risks the committee also reviewed the total number of risks on the register and sought assurance that the number of longstanding risks was being appropriately managed. It was satisfied that a process was being put in place to deal with risks that had not recently been reviewed.

6

5.5. Preparing the Annual Governance Statement (AGS) is an important part of the governance process. The AGS explains the process and procedures of internal control in place to enable the Trust to carry out its functions effectively. The committee determined that the AGS was consistent with its view of internal control and recommended it to the Board in May 2018.

5.6. To support the recommendation the committee received regular reports on the control framework and the internal assurance processes throughout the year. These included:

- A compliance statement on how the requirements of the AGS had been met.

- Regular reports on finance metrics which included debt management and information on how well the Trust met the better payment practice code.

- Regular reports on data quality assurance across a range of national and local indicators such as Referral to Treatment (RTT)2, diagnostics, and cancer waiting times.

- Reports on information governance which included the information governance toolkit assessment score of 83% (80% in 2016/17), which also advised that there were no data breaches during the year.

5.7. The Trust’s principal strategic and operational risks are identified in the AGS and are set out in the 2017/18 annual report. In summary the risks relate to financial sustainability and our ability to meet two national indicators i.e. the emergency four hour wait target and the 62 cancer waiting time standard. These were all known risks included within the BAF and risk register.

6. Internal Audit

6.1. KPMG was appointed as internal auditors for three years from 2016/17. In April 2018 the committee approved a risk-based work programme for the coming year. It received a report from the internal auditors at each of its subsequent meetings which summarised the audit reports issued since the previous meeting.

6.2. Each report included an opinion and a management action plan to address any weaknesses. At the committee’s request senior managers are invited to attend to present their plans to address any recommendations. In addition a regular report on recommendations is presented to the executive team to ensure any delays can be monitored. The 2017/18 reports are listed in Appendix A. A summary with comparative figures from last year is shown in the table below. This year we were again pleased to note that there were no red opinions, although there were more amber/red opinions.

Assurance Reports

2016/17 2017/18

number percent number percent

Green: Significant assurance 1 7 0 0

Green / Amber: Significant assurance with minor improvement opportunities 12 86 13 64

Amber / Red: Partial assurance with improvements required 1 7 4 29

Red: No assurance - - - -

Not yet completed - - 1 7

Total reports 14 100 14 100

2 Referral to Treatment - the right to access certain services commissioned by NHS bodies within

maximum waiting times,

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6.3. The Committee also reviewed the internal audit annual report including the Head of Internal Audit’s (HOIA) opinion. The opinion was one of ‘significant assurance with minor improvement opportunities’ which was subsequently included in the AGS.

7. Counter Fraud

7.1. RSM Risk Assurance Services LLP, the Trust’s LCFS provider has continued to help strengthen anti-fraud and bribery arrangements through the delivery of a range of agreed activities approved in an annual fraud workplan in May 2017. The committee received regular updates on fraud activities and a counter-fraud annual report.

7.2. This year, LCFS gave more time to the investigation and detection of fraud, working with the Trust to ensure appropriate sanction is applied. This included raising awareness of fraud experienced at the Trust and within the NHS to create an anti-fraud culture.

7.3. The LCFS annual report also gave an analysis of emerging fraud risks across the wider NHS and confirmed that the work being undertaken at UCLH met the requirements of NHS Counter Fraud Authority standards.

8. Other reports

8.1. The following reports were also received by the committee:

- A regular report on clinical audit; this advised that the quality of clinical audits had improved and, although more slowly than expected, work to build quality improvement objectives into the audit programme was ongoing.

- A regular report on the raising concerns (whistleblowing) process; this year the committee was pleased to note that an independent guardian service had been fully implemented. This enables staff to raise issues confidentially and seek guidance from a trained mediator or counsellor.

- A requested report on fire safety following the Grenfell Tower Fire. The committee was satisfied that the system of fire detection, evacuation and control to identify and manage fire risks was given priority at UCLH.

- A report setting out the Trust’s credit control strategy. This aims to identify at the earliest stage the patient’s status for billing purposes and is being developed alongside a private patient strategy. The objective to improve compliance in this area was welcomed by the committee.

- A review of Licence statements which set out how the Trust complies with its obligations as a foundation trust. Evidence to support the statement included the AGS and HOIA opinion.

- Biannual waivers reports showing the number of requests made to waive the process for awarding a contract or service; these showed the number was broadly consistent with the previous year.

- The committee also referred some issues to other committees for more consideration including asking the workforce committee to consider the Trust’s approach to budget training.

9. External Audit, Review of Financial Statements and Annual Reports

9.1 The external audit service is provided by Deloitte LLP, who were appointed by the council of governors for three years commencing with the 2016/17 audit, with an option to extend for a further two years.

8

9.2. The external auditors provided their annual workplan and the committee received regular progress reports and briefings throughout the year. Reports highlighted changes to accounting policy and recommendations for improvements in internal controls. Assurance was received from management that recommendations would be implemented. Further details about the plan and the audit fees can be found in the 2017/18 annual report and accounts.

9.3. The committee reviewed the annual financial statements which were prepared in accordance with IFRS. The external auditors undertook a full and thorough audit of the financial statements for 2017/18 resulting in an unmodified opinion.

9.4. The committee also reviewed both the annual report and quality report. Both provided a narrative on the Trust’s achievements for the year and on the delivery of its strategic objectives and quality indicators. The external auditors finding on the quality report included a modified opinion in respect of RTT and A&E data sampling. Data quality assurance was added to the committee’s workplan in 2016/17 and will continue to be monitored in the coming year.

9.4 The committee recommended the 2017/18 annual accounts, annual report and quality report to the board on 22 May 2018 for approval.

10. Non Audit Work

10.1 The committee reviewed the engagement of the external auditors’ policy which governs the use of non-audit services. No non-audit work was provided during 2017/18.

11. Evaluation and Briefings

11.1 The committee carried out a self-assessment of its performance; the results of the review for 2017/18 were very positive. The committee was able to provide assurance to the board that it functioned well. Two issues emerged where further action will be taken to make the committee more effective; these were timely distribution of papers, and training. Distribution of papers will be more timely and a programme of training events will be developed and offered to members

11.2 Committee members held three workshops during the year: on the Trust’s Electronic Health Record System, cyber-security, and GDPR, to better understand the risks and complexities of those issues. Members also attended an annual session on risk management and assurance jointly with other board members which focused on risk register challenges and assurance that the right risks were on the risk register. The internal and external auditors also provide regular audit, governance and legal briefings for the committee.

12. Looking forward to 2018/19

12.1 The Committee will give priority to the following areas:

- Information governance including: GDPR and cyber security arrangements.

- Risk and assurance: including how well risks are being updated and managed.

- Fraud and compliance activities: including post implementation review of the roll out of the standards of business conduct policy.

12.2. It will also gain a more in-depth understanding of EHRS, in particular how well the project is being delivered through cultural and process change management, and keep under review the effectiveness of its own working arrangements.

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13. Conclusion

13.1 The Committee feels that the information in this report and the reports provided to the board throughout 2017/18 demonstrate how it adds value to the overall governance of UCLH. It has held management to account in particular for the implementation of improved internal control on data quality and financial policy. In completing its work it places considerable reliance on the work of both internal and external audit as well as local counter-fraud services, and is able to conclude that the UCLH’s systems are generally sound.

13.2 In making this statement, the committee thanks Tim Jaggard, Finance Director and his team for their support. It also thanks Mairi Bell, Chief Accountant, for her administrative support, and Tonia Ramsden, Director of Corporate Services, for her continued advice. It also acknowledges the support given by both internal and external audit, and local counter-fraud services.

13.3 The Committee recommends this annual report of the audit committee to the board for approval.

Rima Makarem Chair, Audit Committee June 2018

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Appendix A

UCLH Internal Audit Reports 2017/18 Assurance Opinion

Core financial controls green amber

Local risk registers green amber

Data quality green amber

Improving care rounds amber red

Imaging activity data green amber

Sickness management green amber

Drug expenditure – high cost drugs green amber

Safeguarding green amber

Information governance tool kit green amber

Interserve facilities management amber red

Compliance with the well-led framework amber red

Managing partnerships (Camden integrated MSK service) amber red

Self-certification (second level – e.g. Blood and transplant and HTA)

green amber

Digital readiness To be presented in July 2018

Green Significant assurance Green Amber Significant assurance with minor improvement opportunities Amber Red Partial assurance with improvements required Red No assurance

University College London Hospitals NHS Foundation Trust Trust Headquarters 2nd Floor Central 250 Euston Road London NW1 2PG

Tel No 020 344 79976 Email address: [email protected] Web address www.uclh.nhs.uk

mailto:[email protected]

http://www.uclh.nhs.uk/

Q

Agenda item 14

Audit Committee minutes

1

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Tuesday 24th April 2018

Present: Audit Committee Members Rima Makarem Non-Executive Director and Chair (RM) Harry Bush Non-Executive Director (HB) Althea Efunshile Non-Executive Director (AE) Non-Members Guy Dentith Deputy Director of Finance (GD) Tim Jaggard Finance Director (TJ) Tonia Ramsden Director of Corporate Services (TR) Craig Wisdom Deloitte, External Audit (CW) Neil Thomas KPMG, Internal Audit (NT) David Walker Chair of Clinical Audit Committee (DW), For Item 4.1 Cathy Mooney Director of Quality and Safety (CM), For Items 4.1, 4.3, 6.6 Maria Adiseshiah Deputy Director for Quality (MA), For Items 4.3, 6.6 Cassie Zachariou Head of Communications (CZ), For Item 6.1 Rachel Maybank Associate Director of Communications (RMy), For Item 6.1 Jayne Foley Head of Information Governance (JF), For Item 4.2 Deborah Dillon Information Governance Manager (DD), For Item 4.2 Vicky Clarke Deputy Finance Director (VC), For Item 6.5 Mairi Bell Chief Accountant; Minutes

Matters Covered

1. Apologies for Absence

Apologies received from Gemma Higginson

2. Minutes of the Meeting held on 20th March

The minutes were agreed subject to minor corrections 3. Matters Arising AC agreed to close the following MA as complete: MA 410, 414, 425, 428, 429, 430

2

Matters Covered

4 Other Reports 4.1 Clinical Audit DW attended to give the annual update to AC on the work of the Clinical Audit Committee. DW reported that clinical audit was in good health, with 8 meetings held during the year and 4 reports presented to QSC with no major complications arising. DW added that the Trust was 100% compliant with national audit requirements. DW noted that divisional sign off for audits could be slow, with admin delays occurring. CM commented that the move towards quality improvement was encouraging. DW replied that the audit process was focussed on reporting the numbers, with quality improvement focussed on transforming and checking. DW added that quality improvement projects tended to be long and were often inconsistent with committee attention spans. DW also noted that the number of metrics requiring to be reported was increasing. DW noted that the Institute lead on quality improvement had been invited to attend clinical audit meetings. CM suggested that data extraction would be much easier with EPIC, noting it was time consuming to extract data. DW noted that the EPIC group was represented at the clinical audit meetings. RM observed that despite discussion about quality improvement, there was not much evidence of this in the reports and asked if quality had improved. RM added that this was a big organisation to move and that persistence would be required to see improvements in quality. DW agreed with this approach, noting that the work continued to be positively focussed, but highlighted that there was still important work to do to finish getting basic reporting in order. RM asked about the BMJ funded publications, with 5 referenced in the write up out of a possible 14. DW replied that while a lot of interest had been registered, this hadn’t resulted in completed projects, and that the intention was to try to make this a more open ended process to maximise potential benefits. 4.2 GDPR UPDATE JF and DD attended to present the regular update on GDPR. JF introduced DD to the committee as the new interim Head of Information Governance, noting DD was very experienced in the area and had been contracted from the IT service provider. DD updated on GDPR status, noting there was 4 weeks to go. DD added that 100% compliance was not anticipated, but that essentials were in place. DD highlighted Data Inventory Management and understanding data streams and data assets as the priority areas in the remaining weeks. RM expressed surprise that this was not finished as it had been previously raised. JF responded that this was reviewed as part of the IG toolkit, but that a more detailed review was required now. AE asked what the expanded process would reveal. DD replied that this would show the data flows of the organisation, where data came in and out, and how it was stored. DD added that there

3

Matters Covered

was often no clear process covering how long data would be stored. DD also highlighted the different requirements for patient and employee data. RM asked if GDPR was a part of the EPIC setup. JF confirmed that work was being carried out around EPIC, with an interoperability group in place looking to utilise inventories. RM asked if this was working together or duplication. JF confirmed this was working together. HB asked how the organisation took account of why data was held. DD replied that the organisation would consider statute of limitations and legal guidance among other inputs. HB referred to the Windrush issue, noting that previous employers may be a useful source of information in such a case. DD noted that this could involve searching paper records in large storage areas, and often the required information would be unlikely to be found anyway. TR suggested the organisation could look to strip down the information held to a minimum, e.g. start and finish dates. JF advised there were NHS retention guidelines in place. TR added that the organisation had to be able to answer why the information was being held. DD noted that a trigger date for review could be held on the file. DD updated the committee that comms work was being increased, with a notice on the Trust website, a weekly GDPR newsletter and a planned posted campaign in Trust buildings. DD noted that training sessions were now taking off, with HR sessions first to be set up. DD added that cheat sheets were also being developed for key areas, with progress measured against these. DD also added that specific processing notices for child data would be written. RM asked how these processing notices would be handed out. DD replied that there would be a notice on the website, outlining UCLH’s approach to data. TR suggested linking up with the patient involvement team. TJ commented on the communications with medical staff, noting that this had proven to be a hard to reach group of staff, who did not appear to be well briefed about GDPR. TR suggested targeting specific groups like this, and also perhaps producing an FAQ document for the group. DD noted that awareness work had previously worked well in dealing with groups like this. TR observed that this work was focussed on routine activities , and what could and couldn’t be done, for example, using non nhs.net emails. DD confirmed an emergency situation response would be in place. 4.3 Well Led Framework Review CM attended to present an update on the well-led framework. CM noted that there were two main aims to this, to get the organisation ready for CQC and to prepare a statement for the Annual Report. CM noted that there were 80 actions to condense to produce the annual report statement. CM asked the committee to consider if the summary captured the key points, and if the wording was ok. RM suggested clarifying the meaning of ‘wonder ward’.

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Matters Covered

HB noted that the list appeared quite repetitive and suggested some grouping or reorganisation. AE suggested focussing more on the results of the Friends and Family Test, and also asked about actions on quality and diversity from the Appendix. CM replied that there were no identified actions on this and the report had been rated as green. AE replied that this felt generous. 4.4 Constitution Review TR presented a paper proposing updates to the Trust constitution, noting that the changes were self-explanatory, and that this was to be presented to the Council of governors for a second time. TR noted that key discussion would be around proposed changes to the length of time in post for governors. TJ asked how this compared to other FTs. TR confirmed that most were shorter, but that the arrangements were often ambiguous, although some had fixed the term to a specific duration. TR added that there was no guidance in the model constitution. TR noted that governors and the Board needed to agree the proposed changes, with half of the council voting and half of the Board voting needing to agree. TR further added that as this was not a change to the role of the governors, it would not need to go to members for approval. RM suggested that the governors’ process should mirror that of non executive directors. TR replied that this was the aim of the proposed changes. HB commented that 9 consecutive years was too long, and would not represent good governance. RM suggested that this should be restricted by a break, with 9 years as the maximum total time. RM asked about Board size and whether the number of executive directors should be reduced by 1 in line with the number of non-executive directors (NEDs). TJ noted that since the departure of NG voting membership for executive directors had reduced by 1, and suggested that a proposal to increase the NEDs would be easier, noting more breadth of experience would be helpful to the Board. TR noted that the current setup was outwith the code, as one NED was not sufficiently independent as a clinician in the Trust. 5. Internal Audit 5.1 Internal Audit Progress Report NT presented the Internal Audit progress report. RM noted that the IFM recruitment review had been updated with actions, but asked about Trust responsibility. TJ confirmed that the action needed UCLH ownership identified. RM suggested HR should attend and give an update on this audit. HB asked about the applicable policy, and whether vaccination was offered or required. TR replied this would depend on the policies under which transfer from UCLH to the FM operator had taken place. HB asked about the policy for internal staff. TJ suggested HR should update on this directly.

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5.2 MSK Report NT presented the completed report on the MSK programme, noting that this had received and Amber-Red rating of partial assurance with improvements required. NT reminded AC that the report had focussed on the strength of processes and contract management and had not considered the impact of the scheme on health outcomes. NT noted that the management process for controls was quite sound, but there were two red areas which were fundamental. RM asked if the set up was adequate for integrated services, or if there were obvious gaps. NT noted that managers were used to managing budgets and tracking activity, but that a different approach was required for this contract. NT noted that nothing was missing from a contracting perspective. NT added that the contract had been considered from data and tracking sides. RM asked about quality and whether a contractor not performing well would be performance managed. NT replied that this was the focus of a recommendation made to improve KPIs, which were poorly defined. RM further asked if the patient focussed structure of the contract had come through in the audit work. NT replied that this had not been part of the objectives, but anecdotally it had appeared to be the case. NT added that the service could be ringfenced in a way that had been previously impossible. RM noted that this pilot programme needed to start being reviewed and recommended it be discussed at a future Board seminar. ACTION Recommend MSK style contracts for Board seminar ACTION clarify Trust ownership for IFM actions ACTION HR to give an update on IFM audit 5.3 Draft Internal Audit Annual Plan 2018/19 NT presented the final 2018/19 Internal Audit plan, updated following discussion at the March AC meeting. AE asked about the proposed review of overseas visitors, and if the Windrush situation could have an impact here. NT replied that the wider situation on this supported the continued inclusion of overseas visitors in the plan for the year, and this review would also allow a focus on ward-level practical arrangements. NT suggested there would be an opportunity to include this type of scenario within the scope of the proposed audit. TJ added that the audit would be designed to avoid duplication of any work already being undertaken by DHSC, and would consider how best to deploy the patient facing team and how to train front line staff.

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Matters Covered

RM commented on the governance review and whether it would look at Board effectiveness. TR noted that the full well-led review would be commissioned, and the process for this was at the procurement stage. RM asked if the discharge review would focus on process or documentation. HB observed the scope of this sounded very narrow. NT replied that this had deliberately been kept narrow, as other reviews such as recruitment had expanded very widely. RM noted that efficiency of process would be more useful to know than about the documentation in place. NT replied that this type of review had been done at another Trust, but there was no guarantee systemic unblockers would be identified. RM asked why recruitment had been expanded. NT replied this had been at the request of the Trust, to cover both non-medical and medical staff groups. TJ added that the Trust was keen to explore ways to improve the process in general. NT noted that this would be limited by days available in the audit plan, but should be able to be accommodated. RM asked if change management was included in the digital readiness scope. NT confirmed that it was. RM confirmed that the audit plan for 2018/19 was approved. 6. Annual Report and Accounts 6.1 Annual Report CZ and RMy attended to present the draft Annual Report, highlighting updates since the previous presentation to March AC. CZ noted that feedback provided by HB and AE previously had been incorporated into the draft. RM suggested a page turn review with comments provided directly to CZ. CZ noted that the performance section needed the most work to finalise it, and suggested recirculating outside of the meeting if significant changes were made. CZ asked if previous changes made could now be fixed in the document. HB replied that they could with further changes tracked from this point, and a focus on exceptional changes. 6.2 Draft Accounts and Commentary GD presented the draft accounts and associated commentary, highlighting the key statements. GD confirmed that the draft accounts had been submitted to NHSI. GD noted the exceptional items affecting the bottom line, including disposal profits, incentive and bonus STF and the impact of year end valuation movements. GD noted that the Trust had received late notification of bonus STF of £6.7m following submission of the AC papers, but that this had been incorporated in to the accounts submitted to NHSI.

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Matters Covered

GD highlighted some significant movements in the Balance Sheet, with an increase in property, plant and equipment assets of £120m driven by significant capital works done in year, year end property revaluations and sale of the first part of the EDH site. RM asked about the Section 106 provisions. GD replied that all of the original 5 had now been resolved, with a final settlement on the MHRC provision agreed with LB Camden in year following legal advice. HB asked about impairment of assets under construction. GD confirmed impairment would be recorded when the asset became operational. HB asked about the high value of assets under construction. GD replied that this represented spend on both Phase 4 and Phase 5 sites, as well as EHRS, along with smaller projects. HB asked about the apparent low value of the EDH site. GD replied that the assets were valued on a Modern Equivalent Asset basis, using an alternative site basis. CW confirmed that large disposal profits were also seen in other Trusts. HB queried the figures on PFI. TJ suggested reviewing the wording on contingent rent, and CW suggested this could be done with a footnote. 6.3 Draft Annual Governance Statement GD presented the draft Annual Governance Statement (AGS), noting that the format of the report was largely prescribed by NHSI. GD noted that there were no incidences of information loss or never events to disclose, but added that there was no definitive definition from NHSI on control failings. GD added that the report had been reviewed by SDT. RM suggested a page turn review of the AGS and comments were provided directly to GD for updating. CW noted that the final AGS would need to be updated to reflect the final quality accounts. 6.4 Draft Remuneration Report GD presented the draft remuneration report, highlighting the fair pay multiple. TJ queried the pension figure for GB and suggested this be reviewed. 6.5 Revenue Recognition and Bad Debt Provision VC attended to present the annual report on revenue recognition and bad debt provision. VC highlighted an overall reduction of £4.5m in the provision, noting that this had been driven by reductions in outstanding commissioning challenges, with no prior year challenges left to resolve at year end. VC added that the general provision had increased due to an increase in ageing of debt, particularly for other NHS providers. VC noted that specific work in resolving some of these debts was underway with counterparties. TJ added that the provisioning methodology was consistent with prior years, agreeing

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Matters Covered

that non-commissioning NHS debt was the most problematic area, and that commissioning cash was easier to collect, with some payments on account agreed in year. CW noted that the provision had historically felt quite prudent. 6.6 Draft Quality Account CM and MA presented the draft quality accounts. CM thanked HB for detailed comments provided in advance of the meeting. RM suggested the committee do a page turn review feeding comments directly back to CM and MA. AC specifically discussed the presentation of transport complaints, noting as significant increase in this area. CM noted that this was not recorded by other Trusts. HB suggested reorganising the section. AC also discussed specific presentation of chart Q4, cancer centre waiting times and the choice of reporting period for ED performance. 7. Audit Committee Work Programme 2017-18 The work programme was noted. Date of Next Meeting 9am, Tuesday 22nd May 2018, Chairman/CEO Meeting Room, 2nd floor Central, 250 Euston Road