BOARD OF DIRECTORS

14th MAY 2014

Agenda

Meeting Title: Board of Directors

Date: Wednesday 14th May Time: 2.00pm

Venue: Room 2, Education Centre, 1st Floor West Wing, 250 Euston Road Agenda item Attachment

1. Apologies for Absence and Declaration of Conflict of Interest

2. Minutes of the Meeting held on 12th March 2014

A

3.

Matters Arising Report B

4. Other urgent matters not appearing on the Matters Arising Report

5. Chairman’s Report

C

6. Chief Executive’s Report

D

7. Executive Board Report • Integrated Care presentation

E

8. Performance Report

F

9. Quality & Safety Committee Reports: March and April

G.1 & G.2

10. Human Resources Committee Report H

11. Finance & Contracting Committee Report I

12. Report of the Audit Committee meetings held on 25th March and 22nd April

J

13. Minutes of the Audit Committee meeting held on 28th January K

14. Minutes of the Audit Committee meeting held on 25th March L

15. Any Other Urgent Business

16. Date of Next Meeting

The next meeting will be held on Wednesday 11th June 2014 in the Education Centre, 1st Floor West Wing, 250 Euston Road.

A

Agenda Item 2

Minutes of the Meeting held on 12th March 2014

Board of Directors Minutes of the Meeting held on 12th March 2014 at 2.00pm

Present Richard Murley, Chairman Alasdair Breckenridge, Non-Executive Director Harry Bush, Non-Executive Director (Vice-Chairman) Rima Makarem, Non-Executive Director Kieran Murphy, Non-Executive Director John Tooke, Non-Executive Director Diana Walford, Non-Executive Director Richard Alexander, Finance Director Geoff Bellingan, Medical Director, Surgery & Cancer Board Katherine Fenton, Chief Nurse Jonathan Fielden, Medical Director, Medicine Board Mike Foster, Deputy Chief Executive Gill Gaskin, Medical Director, Specialist Hospitals Board Robert Naylor, Chief Executive (from item 10 onward)

In attendance Simon Knight, Director of Performance & Planning David Wherrett, Workforce Director Jocelyn Laws, Trust Administrator (Minutes)

Item Matters covered 3/1

Apologies for Absence and Declarations of Conflict of Interest Apologies were received from Tony Mundy and Tonia Ramsden. Professor Monty Mythen, who had been due to present a progress report on Research & Development, was also unable to attend. The presentation would be re-scheduled. No declarations of interest were made.

3/2

Minutes of the Meeting held on 12th February 2014 The minutes were agreed to be a correct record of the meeting.

3/3

Matters Arising Report The report was noted.

3/4 Other Matters Not Appearing on the Matters Arising Report There were no other matters arising.

3/5 3/5.1

Chairman’s Report The Chairman provided an oral report. Senior Staff Changes The Chairman announced that this would be the last Board meeting for both Mike Foster and David Wherrett. Mike Foster would be remaining in the Trust on a part-time basis to maintain his responsibilities in relation to contracting. David Wherrett was leaving to take up the post of Workforce Director at Cambridge University Hospitals Trust. The Chairman thanked both Mike and David for the significant contribution they had made over a number of years.

3/5.2

Staff Excellence Awards The second annual Celebrating Excellence awards ceremony had taken place on 27th February and was considered to have been a very successful event. Further details were provided in the Chief Executive’s report, including a full list of the winners.

3/5.3

Meeting with Commissioners The Chairman, Chief Executive and Mike Foster had attended a meeting with senior managers from Camden Clinical Commissioning Group. A variety of issues had been discussed and the Chairman felt it had been a positive meeting.

3/5.4

Shadowing in Outpatients At the end of February the Chairman had sat in on an outpatient clinic at Queen Square run by Professor John Duncan, Consultant Neurologist. The Chairman commented that it was humbling to witness the problems that patients had to live with and how Professor Duncan and his staff provided care and attention. It had also highlighted the difficulties in adhering to the 10 minute slots allocated to each patient.

3/5.5

UCL Institute of Child Health Event The Chairman (together with John Tooke) had attended the launch of the Institute of Child Health’s five-year academic strategy the previous day. The launch was also attended by representatives from Great Ormond Street Hospital and there had been encouraging discussions about further developing partnership working.

3/5.6 Meetings The Chairman advised that he had had a number of individual meetings with key people including Una O’Brien, Permanent Secretary at the Department of Health, Ruth Carnall and the new Chairman of the Whittington Hospital, Steve Hitchins. He had also met with the Head of Toshiba Medical Systems.

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3/6

It was agreed to alter the order of the agenda, pending the arrival of the Chief Executive who was attending a meeting of the Camden CCG Governing Body. Quality and Safety Committee Report John Tooke presented the report of the February meeting. He highlighted the concern at the lack of a solution to the issue of printed patient ID wristbands but it was noted that an implementation plan had been drawn up.

He also drew attention to the increase in the number of claims received and reported to the NHS Litigation Authority in 2013/14 (to date) compared with previous years. It was noted that the local Coroner’s office was making more robust use of Regulation 38. The Committee had requested comparative statistics on both claims and inquests in order to benchmark our performance against other Trusts that were under the same Coroner’s jurisdiction.

The outcome of the 2013 CQC survey on Maternity Services had been received and the Committee had been pleased to noted the improvement since the previous survey in 2010.

3/7 Finance and Contracting Committee Report Harry Bush presented the report which advised that at Month 10 the Income & Expenditure position was a £6.0m surplus after donation-related adjustments, which was £3.1m ahead of plan.

The Committee had considered the draft financial plan for 2014/15 – 2015/16 and noted that the position was likely to be much more challenging owing to the need to absorb activity growth within costs. There were a number of risks which would require mitigating action. The Executive Board would consider the financial plan again before it was submitted to Monitor.

The contracting update was noted. Negotiations with commissioners were continuing but this was also expected to be challenging, with a significant gap between our contract offer position and that of commissioners. However, discussions were more advanced than at the same time in previous years.

3/8 Entries in the Seal Register The report was noted

3/9

Register of Board Members’ Interests The annual review of the Register had been conducted during February and the updated Register was presented.

3/10 3/10.1

Chief Executive’s Report CQC Report and Governance Issues The report updated the Board on the project that had been set up to address concerns raised following the CQC inspection and overlapping performance issues

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as discussed previously by the Board. The project comprised nine workstreams and an attachment provided a high level summary of progress on each. A project board, chaired by the Chief Executive, was meeting weekly and each workstream, which had an agreed project plan, was led by an Executive Director. Some issues would be fairly simple to resolve, while others were more complex and would take time.

The Chief Executive advised that the Trust had responded to the CQC regarding the compliance actions and we would be able to demonstrate progress when they made a return visit.

In response to a question from Harry Bush about the security of medical records on wards, the Chief Executive acknowledged that it would require focused effort to modify individuals’ behaviour but the implementation of electronic health records would help.

3/10.2

Emergency Care Pathway The report provided details of improvements in the emergency pathway being achieved through changes in day-to-day operations and more strategic issues. These were being led by Jonathan Fielden. The Trust was on track to achieve the 95% 4 hour waiting time target for quarter 4 and we had eliminated doubling-up in majors cubicles since the expansion into the CRF space. The Chairman asked Jonathan Fielden to pass on the Board’s congratulations to the Emergency Department staff.

The longer-term strategic issues included the phased development of the Emergency Department, restructuring the medical workforce and ensuring appropriate use of the Urgent Treatment Centre to alleviate pressure on A&E services.

3/10.3

Monitor Risk Rating, Quarter 3 The Board noted that the Trust had been assigned a continuity of services risk rating (formerly Financial Risk Rating) of 3 in line with our plan, and a green governance risk rating, despite failure to meet certain targets.

3/10.4

Top 10 Objectives The final draft Top 10 Objectives were attached to the report. These had been produced following extensive consultation with Governors and others. It was acknowledged that some were very ambitious. The Chief Executive advised that the EB had discussed objective no.3 that morning (Deliver High Quality Patient Experience and Customer Service Excellence) and had felt that the three sub-objectives did not fully reflect our aims. Greater clarity was required to define what we intended to do and the bullet points would be changed to reflect this.

The Chairman said he had agreed with the Chief Executive that they, together with Rima Makarem, would consider how well the Trust had performed against the 2013/14 objectives and determine some clear indicators for measuring success against next year’s objectives, as well as identifying a responsible officer for each one. Performance would be reviewed after six months and again after 12 months.

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Diana Walford referred to objective 6 (Develop a Transformation Strategy based on Patient Pathways) and asked about the bullet point on standardising patient pathways across UCLH. The Chief Executive said this would enable electronic systems to flag up where patients were on the care pathway and provide greater transparency on what patients required within a timescale (for example diagnostic tests). Diana Walford welcomed this but felt it was extremely ambitious to aim to complete this in one year. The Chief Executive agreed this would have to be a longer-term objective and we would need to determine a methodology for measuring progress.

John Tooke asked for further information on reducing avoidable emergency admissions. Jonathan Fielden said this was partly about preventing inappropriate attendances but mostly about treating people in a different way so that admission was not required.

The Chairman said we must stretch ourselves to bring about further improvements while avoiding ‘initiative overload’ and being sensible about what could be achieved in a year. Geoff Bellingan said that a number of the sub-objectives were already in progress and we were aiming for incremental change.

The remaining two items (Celebrating Excellence and Executive Director Changes) had already been discussed.

3/11 3/11.1

Executive Board Report Clostridium difficile Reporting The report advised that the EB had agreed that, following concerns raised by the CQC, the Trust should report all cases of C.difficile rather than only those that met the criteria defined in guidance issued by Public Health England, as we had been doing for a number of months. This was likely to increase our year-end outturn by c.20 cases to approximately 95 cases against a threshold of 39. The Chief Executive said PHE had acknowledged that there was a need to change the way the target was set and that the key issue was the tolerance for testing, to ensure the best interests of patients was served.

3/11.2 Nursing and Midwifery Issues The progress report on strengthening the role of the matron was noted. Katherine Fenton commented that, as well as ensuring that matrons were equipped to fulfil their clinical leadership role to support improvements in the quality of care, we must have sufficient numbers of matrons in post. In response to a question from Kieran Murphy about whether it was feasible for matrons to spend 60% of their time on clinical leadership, Katherine Fenton said she believed this was achievable.

The report also advised the Board of a new approach to recruitment (‘strengths-based recruitment’) which complemented the existing techniques of competency and values assessment. Although to date strengths-based recruitment had been used for nursing posts, it could also be applied to other staff groups. Harry Bush asked whether we had assessed the impact and how we could be assured it was the correct approach. Katherine Fenton said we were developing a process of evaluation but also measuring how the wards were performing.

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3/11.3 Capital and Estates Issues The issues were noted.

3/11.4

Research and Development Update This was noted.

3/12

Performance Report Simon Knight presented the key issues. In January there had been one case of MRSA and three cases of C.difficile which was the lowest number for many months. This was potentially due to the introduction of HPV disinfection.

The performance on pressure ulcers in January had improved, with no grade three ulcers reported.

We had missed the 2 week cancer waiting time target. Many of the breaches were due to patients having cancelled their appointments owing to the holiday season. It was hoped we would be able to report compliance with this standard in February.

We had also been non-compliant with the 62 day target for first treatment which was again due to the number of late referrals received. Simon Knight said he was working with the Cancer Division to ensure, as far as possible, that breaches were unavoidable. Harry Bush commented that the current system for reallocations of breaches provided no incentive for referring trusts to improve their processes. Alasdair Breckenridge felt that clock stops should be introduced when patients were referred from one hospital to another, so that the tertiary centre was not penalised; however, the Chief Executive said this would not be in the best interest of patients.

The referral to treatment time (RTT) update was noted. The Trust was non-compliant for open pathways and admitted pathways, but compliant for closed non-admitted pathways. Simon Knight said this was a complex issue and he proposed sending a briefing note to Board members to explain how the situation had occurred.

Action: Director of Planning & Performance

The Chief Executive advised that the waiting lists had gown by 28% which made it more difficult to meet access targets, some of which conflicted with each other. He felt we should advise Monitor that the Trust was likely to fail the 18 week RTT target while we focused on clearing the backlog of long waits. We would need to significantly increase outpatient capacity, which could be done through weekend working and other means. However, the real difficulty would be in providing additional inpatient and theatre capacity, as well as identifying where patients were along the pathway.

In response to a question from Harry Bush, Gill Gaskin said the activity growth was due to a mixture of referrals for new treatments and an increase in market share.

Rima Makarem referred to the vacancy and temporary staff statistics and said there was a view that less ‘attractive’ wards and departments were disadvantaged by a central recruitment process, and that Pulse did not have sufficient staff to cover vacancies.

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David Wherrett and Katherine Fenton said the first point was a misconception and it was possible to undertake a targeted recruitment campaign for specific areas when required. David Wherrett added that the nurse bank was continuing to grow and if particular wards were finding it difficult to fill vacancies we could work with them.

With regard to performance on diagnostic waits (cystoscopy), Geoff Bellingan advised that specialist nurse recruitment was required to bring us back to compliance and this was being addressed. For endoscopy, we had opened a third Saturday list which meant an additional 6 sessions were available in the week. A further 30% increase in capacity was required but a plan to achieve this had been agreed.

The Chairman asked why outpatient utilisation the Medicine Board was only 78% against a target of 85%. Jonathan Fielden said this was partly a data quality issue but agreed it was not acceptable. The Medicine Board had investigated this and there were significant variances among consultants. He hoped an improvement in performance would be seen from next month.

Elective theatre utilisation was also below target; Geoff Bellingan advised that this was partly due to cancellations arising from winter pressures but also because of equipment downtime and planned closure for refurbishment. The Chief Executive said we should try to capture this in the metrics so that performance was more accurately recorded.

Action: Director of Planning & Performance

The Chairman stated that the staffing establishment had grown by 6% and we had increased capacity with the use of Evergreen and Jubilee Wards, but he felt this was not reflected in revenue growth. There was little evidence of improved productivity. The Chief Executive said that activity growth was at 9% but he agreed that the strategy was to undertake more work with the staff we had. The EB had discussed this issue that morning and had felt that the increase in staffing had led to quality improvements following the issue of the Francis and Berwick reports. However, it was agreed that an analysis of workforce productivity was required for discussion.

Action: Director of Planning & Performance

3/13 Any Other Urgent Business There was none.

3/14

Date of Next Meeting The next meeting would be held on Wednesday 14th May 2014.

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B

Agenda Item 3

Matters Arising Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 12th MARCH 2014

Minute no.

Issue Action

3/12 Performance report: Briefing note on background to current RTT situation

An appendix to the Chief Executive’s report provides a briefing and update on RTT. Action completed.

3/12 Performance report: Make metrics for theatre utilisation more meaningful

This issue is referred to in the Performance Report. Action completed.

3/12 Performance report: Analysis of Workforce productivity

This will be brought to the Board in July (SK)

Items from previous meetings brought forward

Date of Meeting

Minute no.

Issue Outcome

Feb 2013 2/5.1 The Francis Report – UCLH response

Board members will be aware that the Trust established a Task and Finish group comprising directors, senior managers and governors, to examine the recommendations arising from the Francis Inquiry into Mid-Staffordshire NHS FT and determine their relevance to UCLH. The group has been reporting to the Quality & Safety Committee and the Board has received updates on elements of the recommendations, such as assurances on care at ward level (‘Setting Safe Staffing Levels’). The Francis Report was also the topic of the joint Board and Governing Body meeting last June. The Francis group will shortly be holding its final meeting and will submit a report to the Board in June.

Items from previous meetings carried forward to future meetings

Date of Meeting

Minute no.

Issue Outcome

Dec 2013 12/6 Setting Safe Staffing Levels: Update on progress with roll-out of e-rostering tool

A progress report will be submitted to the Board in June (KF)

C

Agenda Item 5

Chairman’s Report

1

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

14 MAY 2014 1. VISIT BY MICHAEL D HIGGINS – PRESIDENT OF IRELAND

On 9 April, UCLH was honoured to be visited by President of Ireland, Michael D Higgins and his wife, Sabina, as part of their state visit to the UK. The President visited the Elderly Care Ward on T7, had a conversation with a number of our leading academic clinicians focused on the care of patients with dementia and was then introduced to a number of Irish members of staff. The visit was an excellent way of recognising the contribution of the significant Irish representation in UCLH’s workforce. I attach his letter of thanks as an appendix.

2. OBSERVING CLINICAL ACTIVITY

On 24 March I observed an epilepsy procedure in the neuro-theatres at NHNN, hosted by Dr Yogi Amin, Consultant Anaesthetist. It was useful to be able to observe the completion of the WHO checklist in practice as well of course to picking up some of the atmosphere and issues in a busy main theatre. On 29 April, I shadowed Karen Somerville, Clinical Nurse Specialist, in her Gynae/Oncology clinic in the UCH Macmillan Cancer Centre. I was able to learn more about the role of the Clinical Nurse Specialists and how they interact with the doctors in a clinic and also to understand the importance of having strong communication skills in this critical role.

3. BEREAVEMENT ROOM AND JUNIOR DOCTORS MESS

On 27 March, Mike Foster, Deputy CEO, and I visited the newly fitted out bereavement room and junior doctors mess. These two, entirely separate, facilities were created as part of a reconfiguration of space within UCH and the EGA lower ground floor. Each in its different way is a very important part of the Trust’s ability to improve patient and staff experience and each was previously an inadequate state. It was very good to see proper provision now being made in each case and I am very grateful to those who, at some inconvenience, allowed this to happen. I am particularly grateful to Mike Foster and Tom Hughes, Leased Building Manager, whose perseverance enabled the re-provision.

4. NHS CHANGE DAY PLEDGE

My pledge to the NHS Change Day was to join a governor walk-around. I duly did this on 27 March where I joined Dee Carter, Patient Governor, and a number of members of staff in walk-around to the Infection Division. We visited Ward T8 and also the facility in Mortimer Market.

5. SIR CYRIL CHANTLER

On 31 March, I attended a reception to mark the retirement of Sir Cyril Chantler as Chairman of UCLP. It was good to be able to mark the occasion as Sir Cyril has been an outstanding first leader of the partnership over the last few years.

6. FOUNDATION TRUST NETWORK INAUGURAL ANNUAL LECTURE

I attended a lecture by Alan Milburn hosted by the Foundation Trust Network on 1 April. Mr Milburn, the former Secretary of State for Health, gave a very thoughtful lecture to mark the 10th anniversary of the establishment of Foundation Trusts and some of his observations were widely reported in the media.

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7. ‘HARDWIRED FOR THE FUTURE’

On 3 April I was very pleased to be invited to chair a ‘Dragon’s Den’ session at the ‘‘#UCLH_Wired’ event. The purpose of the session was to award a grant to the most thoughtfully presented idea for a new app to improve patient care. We had a very difficult choice to make from three strong candidates but elected to award the grant to Wanda Aleksy, Medical Technical Officer from the RNTNEH who had an excellent app to help improve listening skills for children who had been fitted with cochlear implants.

8. VISIT TO CERN

On 14 April, Johanna Moss, Deputy Director of Strategic Development, and I visited CERN in Geneva to learn more about the background to Proton Beam technology and understand what new technologies are in the pipeline. We were also able to view the visible aspects of the large Hadron Collider and to meet members of the UCL team who work at CERN. It was particularly interesting to understand how CERN are starting to move from pure science to medical applications.

9. SPECIALIST HOSPITALS BOARD

On 25 April, the Chief Executive and I sat in on a meeting of the Specialist Hospitals Board chaired by Dr Gill Gaskin, Medical Director. In due course we look forward to similarly attending meetings of the other two medical boards.

10. MEETING OF NCL/NEL CHAIRS

On 1 May, Dr Harry Bush, Vice Chairman and I attended what is becoming a regular meeting of some of the NCL/NEL Chairs and Vice-Chairs. These meetings are designed to improve links across the hospitals and discuss matters of common interest. On this occasion there were representatives from Barts Health, Royal Free Hospital and the Homerton Hospital.

11. PROFESSOR JANE DACRE

On 6 May, I met with Professor Jane Dacre, Director, UCL Medical School and President-Elect, Royal College of Physicians. We had a very useful discussion about a range of topics including medical education and how we can increase diversity at senior levels in UCLH and more widely across the NHS.

12. GOVERNOR PRE-ELECTION EVENT

On 12 May I am due to speak, along with Governor and Board colleagues at the pre-election event for UCLH members who are interested in becoming Governors. This is an excellent opportunity to communicate the important role which Governors play in the running of the Trust and in maintaining top quality care for our patients.

RICHARD MURLEY CHAIRMAN

D

Agenda Item 6

Chief Executive’s Report

1

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

14 MAY 2014

PART ONE 1. EMERGENCY DEPARTMENT PERFORMANCE

The Board will know that there has been a huge effort across the Trust, particularly in the Emergency Department, to achieve the 95% 4-hour target in the A&E Department. Concerns about the environment and overcrowding in the A&E Department were the most critical aspects of the CQC inspection last November. In this context, I am delighted to confirm that the Trust achieved the 95% target for the whole of 2013/14, with exemplary performance in Q4 (January-March) of 96.3%. The Q4 performance was in the upper quartile for London as a whole (with the London average being 92.0%). The Trust’s performance in the first quarter of 2014/15 currently stands @ 96.15%. This is despite a number of days on which we received in excess of 400 attendances with proportionately high numbers of admissions. I am sure that the Board will wish to join me in congratulating everyone involved in this excellent performance. The Board’s decision to expand the A&E Department into the Clinical Research Facility (CRF) has made a significant difference in improving the environment of the A&E Department. However it has caused concern for those previously occupying the CRF space. We have had detailed discussions with the CRF leadership to consider options for longer-term relocation to allow the A&E Department to expand into the remaining CRF space in due course. The project team dealing with this issue is currently finalising the options appraisal within a revised business case. The outcome of this depends upon the ability to relocate the CRF elsewhere in a timely and cost effective way. The preferred option is to relocate the CRF is into the 4th Floor of 170 Tottenham Court Road. Following recent discussions it appears that this can be achieved without major capital expenditure (previously estimated to be in the region of £10m) and possibly concluded before next winter. This business case will be brought to the Board by the Investment Committee at the earliest opportunity.

2. CQC AND GOVERNANCE PROJECT BOARD

Attached as Appendix A, is the project board performance report for April 2014. The Board will recollect that I established this project (covering nine specific sub-projects) following the CQC inspection last November and my concerns about failing a number of governance targets as outlined in my report to the Board last December. The attached report indicates that four of the nine projects are effectively completed, two are very close to completion, two are in progress and are on track and one is in progress but behind plan (the referral to treatment – waiting list targets). Originally I scheduled the project board, which I chair, to meet on a weekly basis until the end of April. At the last meeting the project board agreed that it did need to not continue to meet weekly as the majority are either completed or on track to be delivered. It was suggested that a lower level project board should meeting fortnightly, with adjusted membership, to provide exception reports to the Executive Board on continuing delivery. The exception is Project 2 – RTT inpatient and outpatient waiting times. This is addressed in more detail in the following item.

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I would like to thank everyone involved in the considerable time commitment in weekly meetings over the last four months. This has ensured a clear focus on these vulnerable targets and a greater level of assurance to the Board in response to those items raised following the CQC inspection.

3. REFERRAL TO TREATMENT (WAITING LIST) PERFORMANCE

It became clear at the end of last year that the outpatient and inpatient waiting lists were coming under severe pressure by the increase in GP referrals, despite the fact that we were significantly over-performing against CCG activity targets. This was particularly highlighted to the Board last December. This problem has been incorporated into the wider performance improvement project summarised above. The specific RTT sub-project was initially led by Mike Foster until the change in his contractual arrangements at the end of March. It has subsequently been led by Ed Donald who has been the overall Project Director for the nine sub-projects. The aim of the RTT project is to achieve a sustainable position by the end of the current financial year, recognising that it may take longer in some specialist areas. Although CCGs have planned to reduce the number of GP referrals to UCLH, this clearly has not been achieved. Overall waiting lists grew by 28.5% last year with the greatest increases being seen in the most specialist areas. There are currently about 41,000 patients in the overall waiting lists and unless we are able to significantly increase activity then I see little prospect of this declining. Although waiting list management appears to be straightforward, in reality this is not the case. For the majority of patients there are numerous steps in their waiting list journey, including outpatient appointments, various diagnostic procedures and tests, together with the possibility of subsequent inpatient admission. There are many analogies given to hospital waiting lists, such as traffic jams on the M1 and the filling of reservoirs but the essential problem is that when demand increases to a point that it exceeds capacity then inevitable backlogs will occur. The main options are either to reduce demand (which has consistently failed) or to increase productivity through our fixed resources. Based on current modelling, the capacity for outpatients has largely been identified through improving utilisation and extended working time. This suggests that long waits for an outpatient appointment can be resolved towards the end of this year. Identification of inpatient capacity is far more difficult, particularly for those waiting for specialist care, as the limiting factors may include the need to appoint additional staff and create additional theatre, ITU or inpatient capacity. There may be opportunities to outsource some of this work, but the specialist nature of many of these patients will limit private sector capacity to make this realistic. It is for a number of these reasons that we have embarked on a strategy to ‘transform’ the way in which a number of our services are provided. The likely transfer of cardiac services to Barts at the end of this financial year will create some capacity to expand elective inpatient beds and future capital investment in Phase 4 will provide longer-term opportunities. In the meantime, we need to make the best use of internal resources and external outsourcing as well as ensuring that we validate all the patients on our current waiting lists. The impact of the above is that our RTT performance is likely to decline before we see any improvement. This is an issue that we have already raised informally with Monitor who recognise that this is a widespread problem across the NHS and are pleased to see that we have such comprehensive plans to address the problem locally. The Board should also note that these problems have been exacerbated by the fact that our current IT systems were not designed to deal with the new complex RTT pathway rules. We are embarking on updates to our patient administration systems which should be completed by the end of this summer. This will make the overall position more transparent and support staff to manage increasingly complex patient pathways now required in the governance targets.

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I attached as Appendix B a brief paper which sets out more details in relation to the targets, analysis of our current performance and plans to achieve targets by the end of the year.

4. UPDATE ON THE TRUST’S VISIT TO SALFORD HOSPITALS NHS FOUNDATION TRUST

Directors will recollect that several members of the Board visited Salford Royal Hospital last year and returned with a list of initiatives for consideration. A number of these were already under consideration or embedded within our existing quality strategies. It was decided to ask the Executive Board to prioritise the list of initiatives to identify those with greatest potential. The top three initiatives were:

• Develop a ward accreditation scheme with an incentive to improve to enable earned autonomy

• A Board-to-Board meeting with the Institute for Healthcare Improvement, which sets the tone for a drive to improve quality.

• The creation of a single Quality Improvement office with IHI fellows and key staff having some level of quality improvement training.

The Executive Board considered these priorities at its recent meeting and considered a proposal to develop a ward accreditation scheme. The cost of this was estimated to be £500,000, with a request for an initial investment of £25,000 to explore feasibility (this smaller sum was approved). The question of a Board-to-Board meeting with the IHI was thought to be a suggestion which the Board itself should consider. The development of a single Quality Improvement office is a suggestion which should be considered by a small group possibly comprising Tony Mundy, Sandra Hallett, Tara Donnelly and Neil Griffiths when he takes up the Deputy CEO post.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

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Improving UCLH Project Board performance report April 2014

Sir Robert Naylor 30th April 2014

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Performance improvement since the establishment of the Project Board

Care Quality Commission Monitor access targets

18w admitted

18w non-admitted

18w incomplete A&E 4hour Cancer 62 day

Cancer 31 2nd tx

Cancer 31 1st tx

Cancer 2ww C.difficile

Chief Inspector of Hospitals report on the quality of care provided found that overall, services were safe, effective, caring and responsive to patients’ needs. The Trust responded to the CQC with its action plans by 10th February and has subsequently advised on the action being taken to improve.

improvements needed to A&E environment.

improvements needed for patient records on acute medical wards.

improvements needed for security of patient records.

improvements needed to ensure WHO checklist completed fully

The Trust can evidence significant improvement in relation to the CQC actions and 5 areas where access performance was below the required levels. The key risks going forwards are nursing documentation compliance, recovery of RTT 18 ww and 62 day cancer wait performance. Sustaining the performance improvement achieved since the establishment of the Project Board in the other sub-projects is a further risk.

2013/4 14/15

J F M A M

2013/4 14/15

Q1 Q2 Q3 Q4 Q1 Q2

The Trust maintained a Green governance rating in Q3 and Monitor have been advised about the action the Trust is taking to recover performance.

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Project Board Report April 2014 Progress

Progress - Project Milestones: Projects P1, P3, P4 and P8 have completed the 5 project milestones, in line with the project methodology set out in the March report to the Board of Directors. Project P5 cancer waits is close to delivery of the project milestones. Projects P6 nursing documentation and P7 security of records are in progress and on track. Project P2 RTT 18 ww’s is in progress but behind plan, primarily with the identification and booking of additional capacity. Delivery: Each of the completed projects have delivered their milestone key performance indicators (KPIs) agreed as part of their project scope. The action taken to improve standards and performance for all nine projects has been communicated on Insight, payslips and other channels. Copies are available on request. The CQC projects demonstrate significant improvement, evidenced by Trust and ‘independent’ audit results. These results have been triangulated with feedback from routine walk rounds plus the results of mock re-inspections and form the basis of the Project Boards assessment about progress and delivery. The access projects have supported sustainable delivery of the 4 hour A&E target, with performance amongst the best in London currently. The risk of failing to deliver the cancer 2 ww target was mitigated in Q4. C-difficile is meeting the target in April and there were no cases of MRSA. RTT 18 ww’s is forecast to achieve the targets Trust wide from the end of Q3 2014/15, subject to the final results of validation and the ability to identify additional waiting list capacity. Neurosurgery, neurology and specialist services at Queens Square are not forecast to achieve the admitted and incomplete pathway targets until the end of Q4, due to the difficulty in identifying additional specialist capacity to match to demand. 62 day cancer waits are not forecast to achieve the target until there is a change to the reallocation rules at a national level. The Trust continues to lobby for this on behalf of the Shelford group. Action is also being taken to improve the pathway for these patients to keep waits to a minimum where the Trust can control this. Finance: The Project Board has approved £1.2m of expenditure to date where non-recurrent investment has been needed to support delivery of a project or investment in training and education has been necessary to support changes to working practice and assure sustainability. Overall Status: Based on the progress and current project milestone delivery of each project, the overall project status is assessed as close to delivery. Whilst this represents good progress, it is recommended that the Project Board continues until the results of the CQC re-inspection expected in May 2014 are known, to maintain focus and grip. A recommendation on the future of the Project Board will be made in the next report to the Board of Directors, along with proposed governance arrangements going forwards.

Delivery

Finance

Overall

DOC ID Last M

odified 06/02/2014 20:21 GM

T Standard Time

Printed

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Lead Project milestones 1-5 completed

KPI targets Performance January 2014

Performance end April 2014

P1 – emergency access including A&E

JF 4 hour A&E wait 95% Fail Q3 Pass Q4 95.56% April

P2 – RTT 18 ww’s including outpatients

MF 90% Admitted 95% Non – Admitted 92% Incomplete

Fail Pass Fail

Fail Fail Fail

P3 – theatres and surgical flow

GB 100% WHO Checklist 67% Trust 100% Trust (OPERA audit results)

P4 – Control of infection

JF 5 C-difficile cases April 0 MRSA cases April

Fail Fail

3 0

P5 – cancer waiting targets

GB

2 week wait 62 days treatment 62 days screening

Fail Fail Fail

Pass Fail Pass

P6 – nursing documentation

KF 50% compliance

40% 90%

P7 – security of records

KF 85% compliance 50% 85%

P8 - DNAR JF 100% compliance 6% 100%

P9 – Other CQC projects

KF

• Dementia Friendly wards and training

• Improved patient information

• Implement NEWS

Could

Improve

• T7 completed & 1000 staff trained • In progress

• Rolled out

Summary sub-project performance report: January to end April 2014

Key: project stages completed project stages close to delivery project stages in progress and on track project stages in progress and behind plan

 CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS 

14 MAY 2014 – APPENDIX B 

 

Context UCLH has met its trust‐level RTT waiting times targets for the past few years, although we have experienced long waits in individual specialties. In December and January we missed the admitted complete and incomplete pathway targets with performance against the non‐admitted target very tight. InFebruary we missed all three headline targets. 

Target  December  January  February 

Incomplete – 92%  90%  89%  87.9% 

Admitted – 90%  88.9%  87.8%  87.3% 

Non‐Admitted – 95%  95.7%  95.0%  93.9% 

 

In early January we asked McKinsey to review our RTT performance position and provide an assessment of our infrastructure around RTT delivery. The McKinsey analysis related to our end December position and parts of this briefing is based on the McKinsey report. The key themes and general proportions of our performance position have not changed significantly since the end of December, although there has been some increase in our backlog position. 

At appendix 1 is a copy of the briefing that we have previously given to board members to help with their understanding of RTT terminology. 

Analysis of current performance  

Monthly RTT demand exceeds capacity, and this has led to a 28% increase in the overall waiting list in 2013 to around 41,000 patients. Our validation efforts to date have reduced the list size back to 35,792 patients as at March 31st.   However, two issues remain:  

1. There remains a large backlog (over 18 weeks) of 4941patients as at 31/03/2014. This includes an admitted (inpatient) backlog of around 1680, and a non‐admitted (outpatient and diagnostic) backlog of around 3261. Our waiting lists are now skewed towards having too many long waiting patients for us to sustainably achieve performance targets, indicating that we need to treat this backlog of patients as quickly as possible.  

 2. We also have a recurrent mismatch in our capacity to deal with the demand for our 

services. The growth in demand for our elective services is matched also by well‐known increases in non‐elective work. Significant growth in both streams is in the context of limited bed and theatre capacity across our sites. 

 

    

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A key feature of our areas with long waiting times is that they are often in very specialist areas, particularly in urology and neurosciences and RNTNEH, where we are providing services with regional and national catchment areas. In many instances there are very limited alternative providers available which leave our options for alternatives such as outsourcing limited. In particular, we have started conversations with NHS England on pressures at Queen Square which result from the issue of limited national capacity in super‐specialist services.  There are a number of divisions that are driving our non‐compliant position, most notably: 

• Neurosciences(30% of additional capacity needed) • Surgical specialties (19% of additional capacity needed ) • Royal National Throat Nose and Ear Hospital (12% of additional capacity needed) • Gastrointestinal services (8% additional capacity needed) • Heart Hospital (7% of additional capacity needed) 

 We are currently in the early stages of a validation of our waiting list to provide assurance as to the robustness of our data capture, processing and validation processes, a standard approach for any trust facing RTT pressures. This may lead to changes in the number of compliant or non‐compliant pathway numbers in our open pathway dataset, which will in turn have an impact on our assessment of the volumes of backlog pathways that we need to treat and the additional recurrent capacity we need to make available.  Patients who have waited for more than a year At the end of February we reported 89 patients as still waiting having already waited for at least a year for treatment. Of these patients, 84 were waiting for treatment at Queen Square, with the remainder waiting for treatment in Gastrointestinal and RNTNE.  At the end of April we forecast having 69 patients waiting longer than 52 weeks for treatment at Queen Square. 3 of these patients are not yet dated, although in line with a number of other long waiting patients at Queen Square these patients are choosing to wait for longer for their treatment. Our assessment of waiting times at Queen Square suggests that without commissioner support for expansion of national capacity in super‐specialist services, we will continue to have patients waiting longer than 52 weeks for the rest of the financial year. This is however a worst case scenario which we will work closely with commissioners to improve.  All patients waiting over 52 weeks at the end of February have been clinically reviewed. Breach formsare nowbeing completed for all patients over 52 weeks so that there is a clear audit trail from a clinical, administrative and patient choice perspective, along with an ability to understand and resolve the reason for the breaches. The results of these assessments will be shared with commissioners on a monthly basis at the Clinical Quality Review Group. To date we have not identified any patients where deterioration in their condition was directly applicable to their long wait, although patients with chronic conditions will have endured ongoing pain and symptoms (including seizures for patients with epilepsy and non‐epileptic attack disorder). This impact on patients will be a key message that we deliver to commissioners when asking them to consider the national capacity available for these super‐specialist services.  

    

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Recovery Plan  We will be pursuing the following six point plan (which relate closely to the McKinsey recommendations) to address our RTT performance position: 

• Urgently reduce the size of admitted backlog to a sustainable level of 300 patients by treating additional patients. 300 patients is equivalent to half a week of admitted RTT activity ‐ the nationally recommended sustainable level of backlog. This will require a one‐off increase in capacity to treat these patients in the backlog.  

• Reduce the non‐admitted backlog to 2,100 patients or fewer by treating additional patients through a temporary increase in clinic capacity. This will require a one‐off increase in capacity to treat these patients in the backlog.  

• Aim to minimise new tip‐ins to the backlog to prevent the backlog from growing: performance manage internally against a maximum of 100 admitted and 100 non‐admitted per month. This requires us to solve our recurrent capacity shortfall.  

• Increase recurrent capacity to eliminate the gap between clock starts and stops. As at end December we estimated that this would require a monthly increase in 166 admitted clock stops and 501 non‐admitted clock stops. We are working on assessing if this requires any additional capacity – or simply relates to incorrect recording of clock starts and stops and therefore will be dealt with through validation of the waiting list.  

• Rapidly complete validation of the waiting list, and then make sure we help all our administrative and clinical staff capture the data correctly at first time of asking wherever possible. 

• Review current waiting list reporting and algorithms: to ensure we are reporting efficiently and in line with national rules and standards. 

 Capacity Based on the current assessment and using UCLH‐specific assumptions we estimate that we need to see the following additional levels of activity.     One off Backlog Clearance   Admitted  Non‐Admitted Number of Patients  1720 3166 

       

           Monthly Additional Activity Recurrently    Admitted  Non‐Admitted Number of Patients  603 1230         Our clinical teams have done an initial assessment of how they might deliver the additional capacity needed.   

    

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However, we, in conjunction with other trusts and commissioners are finding capacity in London difficult to source. In particular we face the following key challenges in identifying the capacity that we need:  

• Very constrained bed and theatre capacity, particularly in the UCH Tower and at Queen Square. 

• Dependence on limited number of consultants and clinical support teams in some of our very specialist services, in particular at Queen Square. 

• Dependence on limited number of consultants in some of our very specialist services, in particular at RNTNEH. 

• Some pressures on outpatient capacity, although these are not as pronounced as for beds and theatres. 

• Some reluctance to pursue outsourcing as a source of additional capacity, principally in relation to specialist work and patient concerns. 

 There is also the risk that the cost of identifying capacity outside of the main UCLH sites could be at levels higher than we are planning for in our financial planning assumptions for 2014/15. 

 Validation of waiting lists  Much of our challenge in this area is one we share with many trust nationally on account of patient administration systems (PAS) not being designed to deal with RTT pathway rules. It is difficult for staff to construct RTT pathways accurately first time. While these errors do get corrected upon final reporting of our completed pathways position, we are now undertaking a full review of our open pathways to remove duplicate pathways and pathways that should have been stopped sooner.   However, there is clear room for improvement in staff knowledge in relation to management of waiting lists, principally around the linking pathways to the correct referrals and use of treatment status codes.   We are undertaking validation of all cases on the waiting list, with a specific focus in the first instance on patients waiting over ten weeks, with the priority being those patients waiting over 52 weeks and then working in descending order to ten weeks. Divisions have identified key staff to lead the validation work in their areas, and we have also recruited 12 staff to a central team to drive the effort. We expect the validation work to take around three months in total.   We are also validating cohorts of patients where we want to provide ourselves with greater assurance that clocks have not been stopped incorrectly or too soon.   Review of reporting algorithms We are also in the process of agreeing a number of technical changes to how we collate and report our RTT position. The principal changesare: 

• We will be adjusting our external reporting to correct an anomaly in how we report patient pauses on open pathways. We have relatively low numbers of patients with 

    

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pauses (around 400)and have analysed the impact of this change to be a performance reduction of 0.2% against the open pathways target. 

• We will be changing the way in which we track and report patient pathways where we don’t know the date that the clock started ticking. These largely relate to external organisations referring patients to us without the correct information attached, making it difficult for us to know exactly how long they have waited. We will now be recording and tracking these patients with the clock start assumed to be the date that UCLH received the referral (until we find out otherwise). These patients were not previously reported to the DH, and so the open pathway numbers will increase by up to 3,000 cases.  

 Better management of waiting lists We need to do more to support our staff in their understanding of RTT rulesand how to manage RTT pathways on our systems: 

• We have now updated key guidance and policy documents. • We have established RTT user groups • Weare investing in e‐learning packages that will enable us to provide sufficient 

training to staff, including annual refresher training. We will be considering making this training mandatory for key staff groups. All training will include tests on understanding of rules. 

• We have upgraded the system we use to manage validation of the waiting lists so that it guides users more intuitively through the work that they need to do. 

 We have conducted a review of practice at our three key contact centres (UCH, EDH, Queen Square) and made recommendations for improvements in how patient bookings as a whole are managed in the contact centres. We believe there are significant opportunities to improve the service we provide for referrers and patients through our contact centres, and that these improvements would also help us shorten waiting times.   We are consulting internally on implementation of more systematic and rigorous monitoring of waiting lists at divisional, board and trust level, with arrangements for formal weekly meetings in place by the end of April. Previously waiting list tracking has been done on an exception basis, and retrospectively rather than prospectively. Weekly meetings will retain accountability for delivery through the operational line but will also include greater support as well as oversight from central corporate teams.  Draft performance trajectories The following set out our initial view on the likely return to compliance at a divisional level for the admitted and non‐admitted targets. As we continue to develop more detailed capacity plans at specialty level these trajectories are likely to shift significantly. Given the challenges outlined thus far, performance is likely to deteriorate further before recovering. There is also a risk that it will take longer for some specialities to achieve the RTT targets than currently forecast, if capacity is not able to be identified and used due to the specialist nature of the services. Within each clinical area there are a number of factors that will impact on performance, and we will draw those out for you in more granular trajectories in future briefings.  

    

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  Project governance We have a weekly RTT project group meeting, currently chaired by Ed Donald (interim project director) until Neil Griffiths joins as the new deputy chief executive. This project group reports in turn to a project board chaired by Sir Robert Naylor. Thisproject board is tracking a range of projects relating to our CQC inspection and performance against key governance indicators.  We have recruited a consultancy called MBI Healthcare to support our project management,investigative and delivery work.   We have an extensive project plan that we are implementing. The project plan is still being revised as we consider new information coming out of our diagnostic and validation work. We are tracking our performance against a range of key performance and validation metrics on a weekly basis. Our reporting includes the following measures:  

• Admitted closed ‐ target 90%  • Non‐admitted closed ‐ target 95% • Open pathways ‐ target 92%  • Size of admitted backlog  • Size of non‐admitted backlog  • Number of tip‐ins admitted (pathways that breached in week) • No of Tip‐ins non‐admitted (Pathways that breached in week) • % of incompletes with a confirmed date 

    

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• Total Size of the incomplete waiting list • Number / % of patients waiting > 10 weeks whose pathway is not validated • Number of patients on the data quality exclusion list 

 Simon Knight Director of planning and performance  28th April 2014  

    

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Appendix 1: Board briefing on RTT from 2013 

18 weeks: Referral to Treatment summary of counting rules, targets and current performance 

The Referral to Treatment (RTT) standard measuresthe time from the date of the GP referral (clock start) to the time that the patient receives definitive treatment (clock stop). 

Admitted and non admitted pathways (RTT type) 

There are two types of pathways within RTT rules:  

• non admitted pathways: treatment provided in an outpatient setting; and  

• admitted pathways: treatment provided in an inpatient setting (day case or inpatient).  

 

Complete and incomplete pathways (RTT status) 

There are two statuses for both admitted and non‐admittedpathways: completed and incomplete pathways 

• complete pathways are those where the patient has received their first definitive treatment on the pathway, thereby stopping their clock. Completed pathways count towards performance in the month that the treatment was received / the clock stopped 

• incomplete (or open) pathways: patients who haven’t yet received definitive treatment, hence their clock is still ticking.  Incomplete / open pathways include both admitted and non‐admittedpathways combined since the definitive treatment pathway type is not known until the point of treatment. 

 

Target types 

There are three principal types of target for RTT performance: 

• % of incomplete pathways less than 18 weeks: This applies to incomplete pathways and looks at the number of pathways at month end that have been waiting for less than 18 weeks. The target is 92% (or more) of patients on open pathways have been waiting for less than 18 weeks. 

• % of complete admitted pathways less than 18 weeks: the percentage of patients whose admitted pathways were completed in less than 18 weeks for that period. The target for this is 90% of patients were treated in less than 18 weeks. 

• % of complete non‐admitted pathways less than 18 weeks:the percentage of patients whose non‐admitted pathways were completed in less than 18 weeks for that period. The target for this is 95% of patients were treated in less than 18 weeks. 

 

 

    

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Appendix 2: McKinsey Analysis December 2013 

 

 

    

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E

Agenda Item 7

Executive Board Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Executive Board Report to the Board of Directors, May 2014

1. Implementing Integrated Care Board Members will be aware that the development of integrated care is a

cornerstone of current NHS reforms. The focus on integrated care is the result of concern about service fragmentation for patients, and in particular a lack of coordination between primary, secondary and tertiary care. Achieving integrated care requires those involved with planning, financing and providing services to have a shared vision and to ensure that the patient’s perspective remains a central principle throughout.

The UCLH Integration Strategy (November 2012) outlined a number of key areas for delivery. These relate primarily to engagement with Clinical Commissioning Groups, GPs, other providers and patients, with a view to developing integrated care models for long-term conditions, for example heart failure. An Integration Division, led by Dr. Helen Taylor – a joint appointment with the Whittington Hospital - was established during 2013/14 within the Medicine Clinical Board. The role of the division is to support and facilitate integration within and across clinical divisions and support pathway development and projects between UCLH and partner organisations. These include, but are not limited to CCGs and other providers such as Royal Free London, Whittington Health, GPs and community and Mental Health providers. In addition, the division has operational responsibility for discharge services and the GP and Community Liaison programme. It will also be the home of our ‘Hospital@Home’ services, post-implementation.

The division has set out a number of strategic aims and a presentation will be given at the Board meeting on progress to date.

2. Nursing and Midwifery Issues The EB was advised that the Nursing & Midwifery Council has committed to introduce an effective system of revalidation for nurses by the end of 2015. This was one of the 290 recommendations arising from the Francis Report. Revalidation will require registered nurses and midwives to regularly demonstrate that they remain fit to practise and will help to protect patients. The three year Nursing & Midwifery Strategy is entering its final year. The Nursing &

Midwifery Board approved the 2014/15 Nursing & Midwifery objectives which support delivery of the strategy and are also mapped to the Trust’s Top 10 objectives.

A copy of the N&M objectives can be made available on request. 3. Pain Management – Update

The EB received a report which provided an update from the Making a Difference Together Campaign project to improve pain management. The report outlined the progress already made in developing an education package, improved patient information and initial work to improve both acute and chronic/complex inpatient services. It set out the further work necessary to deliver the aspiration for delivering an integrated, individualised approach to pain management across UCLH.

To date, progress has been made in developing an e-learning education package, targeted at nursing staff but available to all clinical staff. The package is being built by the Education Technology team and the aim is to go live on 19th May. To launch the educational tools and enable understanding of their impact on developing staff knowledge and skills on pain management, pain teams will be working with several wards during a 3 month pilot campaign commencing this month. A senior Clinical Practice Facilitator has recently been appointed, funded by the Making a Difference Together team for 6 months, to lead on the education campaign.

The current inpatient pilot, which introduced specialist psychology and physiotherapy support to the UCH Tower, has generated positive feedback and learning from patients and staff benefiting from the intervention. However, its small and incomplete nature has not enabled demonstration of financial viability as a service.

The EB therefore agreed that a proposal should be developed for submission to UCLH Charity to fund in depth research to demonstrate whether an integrated, first class pain service can improve clinical outcomes, reduce length of stay, and help avoid admissions. The Board will be kept advised of progress on this important issue. 4. National Surveys 2013 CQC Inpatient Survey The results of the CQC National Inpatient Survey 2013 have recently been received. The survey consists of 64 questions grouped into ten sections. Each question is scored on a scale 0 to 10 and compared with other trusts to determine if a trust is “about the same”, “better”, or “worse” than others. UCLH scored “about the same” as other trusts for 63 out of 64 questions, with one question rated green, meaning it was among the best performing trusts. This question related to patients receiving copies of letters sent between hospital doctors and GPs. The CQC survey report also identifies where the 2013 score is significantly higher or

lower than in 2012. No questions were identified as higher or lower than 2012 for UCLH. It can be seen from the table below that the positions and scores for London trusts, with the exception of Chelsea and Westminster, have also remained largely unchanged.

Peer London Teaching Hospital

Position against peers

Score out of 100

2012 Score & position

Guy’s & St Thomas 1 81.6 81.5(1) UCLH 2 79.5 79.6(2) Chelsea & Westminster 2 79.5 78.2(4) Kings College 4 78.0 78.5(3) St George’s 5 77.7 77.8(5) Imperial 6 77.5 77.6(6) Barts & The London 7 76.3 75.9(7) Royal Free 8 76.3 75.8(8)

There are no significant areas requiring urgent attention. However in order to improve our survey performance we need to refocus our effort on issues that have high importance to patients. Not all questions have the same value in terms of patient satisfaction and a strategy of targeting areas of high importance is proposed for the coming year. Actions are currently being developed through the Inpatient Steering Group, Patient Experience Committee and nursing forums. Leads will be identified

2

with responsibility for developing improvement proposals and implementation will be monitored via real time surveying. The Meridian Inpatient survey will be revised to support this. The full CQC Patient Survey Report has been circulated separately to Non Executive Directors. National Staff Survey The Board received the results of the 2013 staff survey in February 2014 and these were subsequently discussed at the March meeting of the Human Resources Committee. The report of that meeting is included with the Board papers.

In summary, UCLH performed very well in the national staff survey. However, areas of concern relate to staff working extra hours, experiencing harassment, bullying or abuse from other staff, discrimination at work and the percentage of staff who believe the Trust provides equal opportunities for career progression or promotion.

The Board asked to be advised on what the Trust UCLH planned to do to improve areas that compare less favourably with other acute hospital trusts. It should be noted that London hospitals, including UCLH, tend to score poorly for the questions relating to bullying, harassment and abuse from staff to staff, discrimination in the workplace (which includes discrimination from staff, patients and visitors) and equal opportunities for promotion and progression. This pattern is unchanged from previous years and is reflective of the diverse make-up of the workforce compared with other areas of the country. The Executive Board received a report outlining proposed actions to address these areas. The current approach is to build action plans from the bottom up. This is reflective of the spectrum of results across divisions and staff groups and the desire to ensure that actions are relevant and appropriate to local areas. From analysing local action plans, cross-cutting themes emerge which will inform organisation-wide actions which are complementary and will support and enable local improvement. The action plan is attached at appendix A. 5. Implementation of the Staff Friends and Family Test The EB received a report setting out the requirement to implement a Staff Friends and Family Test (SFFT) on a quarterly basis with immediate effect. The SFFT comprises two questions which staff will respond to using a five point scale between “extremely likely” and “extremely unlikely” (as well as a “don’t know” option). The questions are:

• How likely are you to recommend UCLH to friends and family if you needed care

or treatment? • How likely are you to recommend UCLH to friends and family as a place to

work? The EB supported to the implementation of quarterly surveys, one of which would be the wider annual staff survey, but expressed the view that the response rate was likely to fall over time if the survey was repeated frequently. It was therefore agreed that the three additional SFFTs should target a different sample of staff each time, rather than the whole workforce.

3

6. Multi Agency Safeguarding Hubs (MASH) Multi Agency Safeguarding Hubs (MASH) are being set up across London to assist in identifying and assessing risks to children’s wellbeing and welfare and to eliminate deficiencies in information sharing and communication among safeguarding partnerships. Several serious case reviews and inquiries (such as the Laming, Bichard and Baby P inquiries) have directly attributed the lack of good information sharing and communication to the subsequent death of an individual. In order to deliver the best safeguarding decisions which ensure timely, necessary and proportionate interventions, decision makers need to have the full information picture concerning an individual and their circumstances available to them. All information from various agencies needs to be available and accessible in one place. A MASH helps ensure this and aids communication among all safeguarding partners. The Executive Board considered a report which sought approval for UCLH sign-up to the MASH Information Sharing Agreement with the London Borough of Camden whereby Gill Gaskin, responsible executive for Safeguarding Children, would sign on behalf of the Trust. The Information Sharing Agreement has been reviewed by the Trust Caldicott

Guardian and the Trust’s Information Governance Group, neither of whom had concerns with the agreement.

7. Capital and Estates Issues On the recommendation of the Capital Investment Board the EB approved a number

of equipment items and schemes from the agreed capital programme. These include: • Image intensifier equipment that can be used for orthopaedic operations. It

requires no radiographer to operate thereby realising staff savings; • Patient self check-in kiosks for Specialist Hospitals sites that have not received

the equipment; • Purchase of automated controlled drug cabinets for the inpatient dispensary and

Macmillan Cancer Centre dispensary; • Investment in a Health informatics Collaboration sponsored by the National

Institute for Health Research. Land and property updates include assignment of a lease to Azzuri to use an area in the UCH basement, grant of a licence to UCL to share areas of the first floor at the Institute of Sport, Exercise and Health and extension to the TDL/Trust sub-lease of 60 Whitfield Street to be co-terminus with the head lease. A new sub-lease to the Trust has now been agreed until March 2018. Board members will be pleased to learn that all clinical services have now vacated the Rosenheim building in preparation for the construction of Phase 4. The Rosenheim Decant Programme Board has now been disbanded and the responsibility for the building has passed to the Rosenheim Demolition project team.

Board Members may recall being advised that the EB had agreed a simplified process for approving low value capital schemes (up to £100k and with a confirmed source of funding) in order to expedite the approval of such schemes. The Board was advised that this would necessitate a revision to the Scheme of Delegation. The revised section of the SoD is attached. Included with the revision is an explanation of

4

the capital approval process which the EB agreed. The EB also agreed changes to the waiver process and these are also attached at appendix B.

The Audit Committee have reviewed and endorsed these revisions. Once the

changes have been approved by the Board, the revised sections will be incorporated into the SoD which will be published on Insight.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

5

Executive Board Report to the Board of Directors Appendix A

Staff Survey Action Plan for 2014/15 – Cross-cutting themes to address bullying and harassment, discrimination & equal opportunities Theme Action Date 1. Leadership

behaviours aligned to UCLH values

A: Define leadership behaviours, aligned to our values, building on the Francis listening events & staff survey results, to be embedded in recruitment, appraisal, leadership development and other processes.

31 July 2014, embedded by 31

Dec 2014 2. Line

manager/leadership development

A: Ensure that line manager development programmes include mental health and stress awareness so that line managers are supported and are able to support employees to care for their own health

30 Sept 2014

3. Addressing bullying, harassment and discrimination locally within teams

A: Adopt the UCLH Living our Values engagement model developed by the clinical boards to address bullying and harassment hotspots, as identified by the staff survey data, entailing following 4 stages:

• Informal engagement with staff by the Workforce team to acknowledge the issue

• Use of a short survey tool to understand the underlying factors • Analysis of the results • Delivery of focus group discussions to share the findings and involve staff in

directly addressing the underlying factors.

With immediate effect, to be

completed by 30 Sept 2014

A: Develop a video to bring to life the key issues, positively demonstrating UCLH values

31 July 14

B: Review the ‘respecting each other ’e-learning programme to assure its relevance to the staff survey feedback

30 Sept 14

C: Work in partnership with the Royal College of Nursing as part of their ‘Is that discrimination’ project

Commence 2014 (3 year project)

4. Enhancing awareness of what bullying and harassment is (and isn’t), and developing the support options available for staff

D: Establish and promote a dedicated confidential Bullying and Harassment helpline to be staffed by the psychologists within Staff Psychology and Welfare

30 June 2014

A: Scope a mentorship programme for ‘rising stars’ (possibly in bands 6 and 7 in the first instance) in underrepresented groups, to help address under-representation above band 7 (and equivalent level within medical and dental leadership roles)

30 Sep 2014 5. Promoting equal opportunities for promotion and progression

B: All posts at Band 7 and above to be locally advertised within divisions/corporate functions, in addition to the central UCLH recruitment listing

1 June 2014

C: All acting-up opportunities to be subject to a (local) formal appointment process and are as a minimum advertised within the relevant division/corporate directorate A: Promote the NHS Employers Personal, Fair, Diverse brand and campaign and its underpinning principles

30 June 2014 6. Communication

B: Ensure that staff are aware of actions taken in response to this agenda via a ‘you said, we did’ campaign

31 Aug 2014

  

Executive Board report to the Board of DirectorsAppendix B

PROPOSED UPDATE TO SCHEME OF DELEGATION 3.5

Business Case approval: Revenue expenditure (five year value) Up to £500,000 £500,001 to £1,000,000 £1,000,001 to £5,000,000 over £5,000,000 In addition, significant novel or contentious projects may be considered by Investment Committee. Capital expenditure and disposals Up to £100,000 (if no ICT or building/infrastructure works) Up to £100,000 (if no ICT or building infrastructure works > £50,000) £100,000 to £500,000 (if no ICT) £500,000 to £1,000,000 (or if scheme requires ICT) Over £1,000,000

Executive Director Finance Director and Executive Director Executive Director, Finance Director and Chief Executive Board (via Investment Committee) See Appendix B for more detailed information Executive Director and Head of Finance Capital Works Committee Capital Investment Board Executive Board Board (via Investment Committee)

  

7.4 Waiving requirement for quotations and tenders subject to provisions of SFIs

Waiving of tender procedures for items where estimated expenditure is over £25,000 and not expected to exceed EU procurement thresholds.

Waiving of tender procedures for items where estimated expenditure is less than £25,000

Finance Director

Director of Procurement or Deputy (when Director is unavailable)

Deputy Director of Procurement

Reporting of Tender Waiver: Where it is decided that competitive tendering is not applicable and should be waived the fact of the waiver and the reasons should be documented and reported by the Director of Procurement to the Audit Committee on a regular basis

  

Appendix – Details of New Proposed Capital Approval Process (see overleaf for definitions)

Category Decision by Criteria Process

Executive Director &

Head of Finance for

the area

Report to next CWC

< £100k

Must have a confirmed source of funding (R&R in prog, external funds) or be a DES case authorised by HOF

for board paying the loan

Excludes: ICT or any scheme requiring building/infrastructure works

Simplified application signed by Exec Dir and

HoF

To CIFD processing to obtain cost centre

Project Approval Letter Low risk Low value

CWC

Report to next CIB

< £100k

Must have a confirmed source of funding (R&R in prog, external funds) or be a DES case authorised by HOF

for board paying the loan

Excludes: ICT

Includes: build/infrastructure works or feasibility up to £50k

Authorised application to CIFD for entering on to

CAP

↓

CWC

↓

Project Approval Letter

Medium Risk

Medium Value

CIB

Report to next EB1

£100k to £500k

Must have a confirmed source of funding or a DES case demonstrated

for agreement

Includes: build/infrastructure works or feasibility >£50k

Excludes: ICT schemes

Schemes that CIB consider to be high risk may be referred to EB for

decision

SCAF and Investment Case via CAP

↓

CWC

↓

CIB

↓

Project Approval Letter

High risk High Value

< £1m EB

> £1m BoD (via IC)

> £500k

Any type of scheme

This route can be used whether or not source of funding is confirmed

SCAF and Investment Case via CAP

↓

CWC

↓

CIB

↓

EB

↓

Project Approval Letter

 

 

 

 

  

Definitions

BoD Board of Directors CAP Capital Application Process computer system, which contains details of

business cases and can provide some tracking of where a business case is within the overall process.

CIB Capital Investment Board CIFD Capital Investment & Facilities Directorate CWC Capital Works Committee DES Development & Expansion of Service - New Asset Investment covering the

development of new or expansion of existing services. The funding source is the UCLH Bank internal loan arrangement

EB Executive Board External Funds

Externally funded schemes are those that are funded through successfully securing resources external to the Trust, such as from charitable sources or public dividend capital awards

HoF Head of Finance IC Investment Committee ISQ Investment in Service Quality funding - Investment in service

improvements. Investment in Service Quality is generally funded from Trust surpluses and allocations are usually agreed annually by the Board of Directors as part of the planning process.

PAL Project Approval Letter - A letter issued to the relevant Board/Division/staff notifying of approval and the cost centre.

Prog Capital Programme R&R Replacement and Refresh – Retained depreciation on our existing assets

provides the funding for the replacement and refresh of existing assets, which will usually be used to maintain existing services.

SCAF Summary Capital Application Form - A document containing summarised information on the capital scheme and is registered before a business case is raised on the Capital Application Process computer system.

F

Agenda Item 8

Performance Report

Report to board of directors

Report Title Board of directors performance report Report from Simon Knight Prepared by Bindi Shah Previous papers Board of directors performance report Current issues

Action Month first raised

Infection

(Page 10)

There were no cases of MRSA for this month; the number of cases for the whole year is six. We recorded 9 clostridium difficile cases in March, Three cases were reported by surgery and cancer, two in surgical specialties and one in cancer. Please refer to page 10 for more detail.

June 2013

Pressure ulcers

(Page 11)

There were 15 hospital acquired pressure ulcers reported in total in February. There was one grade three pressure ulcer reported in surgery and cancer clinical board. A serious incident investigation is in progress for this.

June 2013

Cancer waits

(page 9)

The current performance for the 62 Day Cancer Wait is 72.7%, against a target of 85%. This is the position without maximum possible reallocations and is subject to change until the national Open Exeter reporting deadline for March. With all late referalls reallocated, our performance would have been reported as 84.3%. A total of 11 breaches were incurred (14 patients), of which 3.5 breaches (6 patients) were due to late referrals already beyond 50 weeks waiting. Three breaches (3 patients) were complex where the patient required non-cancer clinical intervention prior to cancer treatment. The remaining 4.5 breaches were avoidable as a Trust. Delays to these patients were due to capacity or scheduling constraints. Individual specialty teams are reviewing current capacity.

July 2013

RTT update

(page 8)

For March, we reported a non compliant position for all three measures. We also recorded 685 patients waiting over 36 weeks, 493 over 40 weeks and 93 patients waiting over 52 weeks. In total we incurred RTT penalties under the contract of £516k, the majority of which is for breaches within admitted pathways. The most significant penalties were £149k for NHNN admitted pathways, £56k for cardiac services admitted pathways and £56k for NHNN services non admitted pathways. This brings our year to date penalties to £3.2 million.

We did not meet the target for diagnostic waits within 6 weeks. The two main areas of concern for this indicator are endoscopy and cystoscopy. Endoscopy is expected to move back to a compliant position by May. To address the cystoscopy noncompliance we have 2 extra all day Saturday lists running in April. In May we will be delivering a further 2 sessions, which will have 10-12 patients each. We are aiming at returning to a compliant position by the end of June.

July 2013

There remains a significant risk associated with these targets over coming months. Timescales to reach a stable compliant position are likely to be around 6 months, depending on the speed of backlog clearance and the scale of additional capacity identified. We are implementing a detailed RTT project plan. The immediate priorities are still the validation of the entire incomplete waiting list (~40k patients) and for clinical boards and divisions to book the extra capacity needed to clear the backlog.

Statutory & Mandatory Training

(Page 16)

Staff who have changes applied to requirements within their Training Needs Analysis (TNAs) were written to during March in order to advise and direct towards training access. It is this change in TNAs which has resulted in a dip in compliance levels in recent months. Work continues in this area to improve take up with mandatory training. In addition, a data validation process is taking place with the subject matter experts and board workforce teams to address a very small proportion of mandatory training records that have been reporting incorrectly. This is affecting a maximum 3% of all records held. In addition the Boards are reinforcing the need for all staff to ensure their training is up to date via the Learning Management System portal.

March 2014

March 2014

Month 12 - March

Chief Executive Performance Report

Month 12 - March

1. Executive summaries

2. Finance 3. Delivery of QEP

4. Access

5. Patient Safety and Quality metrics

6. Workforce

7. Externally Reported Frameworks

Page Con

Chief Executive Performance Report Contents

Month 12 - March

Chief Executive Performance Report

Data quality score:

√√ high data quality

√ sufficient data quality

x not sufficient data quality

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% Elective variance 2.9% 0% 29.0% 11.7% -4.9% 1.2% -5.8% 4.7% -1.4% √√ Number of MRSA Bacteraemias 0 0 0 0 0 6 4 1 1 √√

% Daycase variance 9.8% 0% 7.6% 7.7% 12.9% 7.2% 17.8% 7.0% 5.7% √√ Number of clostridium difficile case9 3 3 3 3 99 31 37 30

√√

% Non-elective variance 20.3% 0% 16.2% 3.7% 25.6% 13.9% 20.9% 16.4% 10.7% √√ % Hand Hygiene Compliance 95.6% 100.0% 95.1% 97.5% 94.5% 95.5% 93.8% 96.1% 95.3% √√

Outpatient Variance 9.0% 0% 1.6% 21.0% 6.1% 7.6% 2.3% 16.8% 5.0% √√MRSA Screening - Percentage of

Inpatients Matched 87.2% 90.0% 88.0% 86.6% 87.1% 86.8% 88.9% 85.2% 87.0%√√

Trust theatre utilisation 78.5% 85% 79.7% 77.5% 78.9% 80.8% 77.2% √√All Pressure Ulcers Acquired at

UCLH 6 11 2 2 2 164 40 63 60√√

% Daily Discharges - Pre11 am 3.9% 2.3% 3.2% 4.9% 4.3% 2.5% 3.8% 5.2% √√ Inpatient falls with serious harm 0 0 0 0 0 4 4 0 0√√

Outpatient utilisation (attendances

per slot)91.6% 85% 80.2% 107.5% 88.9% 90.5% 79.7% 103.6% 88.5% √√

Percentage of Completed eVTE

Risk Assessments 95.4% 95.0% 94.5% 94.9% 96.3% 95.7% 94.8% 95.9% 96.0%√√

Complaints responded to within

target time 78.8% 85.0% 100.0% 78.9% 65.5% 79.0% 82.8% 79.9% 77.0%√√

% Non-admitted closed pathways

under 18 weeks93.5% 95.0% 92.4% 91.1% 94.5% 95.7% 95.4% 94.1% 96.2% √ Friends & Family Test Score

73 50 67 70 79 70 68 69 71√√

% Admitted closed pathways under

18 weeks86.3% 90.0% 99.6% 84.9% 85.0% 89.7% 99.3% 88.2% 89.3% √

% incomplete pathways < 18 weeks 87.9% 92.0% 96.0% 86.4% 87.3% 91.0% 96.5% 89.0% 90.8% √ Sickness absence rate (%) 3.7% 4.0% 3.2% 3.6% 3.8% 3.0% 2.8% 3.1% 3.1%√√

A&E attendances within 4 hours 97.1% 95.0% 97.1% 95.0% 95.0% √√Average time to recruit (request

pack - start date) 13.2 14.6 15.0 12.8 13.0 14.9 16.0 15.0 14.4√√

% Diagnostic waiting list within 6

weeks96.3% 99.0% 100.0% 95.6% 97.1% 97.7% 98.1% 97.5% 97.5% √√

% Statutory and mandatory training

compliance 78.7% 90.0% 79.2% 77.2% 77.7%√√

% Appraisals Complete - Tier 4 -

The remaining workforce (exc M&D

Workforce) 94.9% 90.0% 96.3% 96.1% 93.5%

√√

Cancer 62 Day GP referral to

treatment 78.4% 85.0% 80.4% 80.1% 71.7% 92.5% √√

Cancer 62 day referral from

screening to treatment100.0% 90.0% 100.0% 91.4% 92.6% 75.0% √√

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Cancer 31 Day Subsequent

Surgery Treatment100.0% 94.0% 100.0% 100.0% 96.0% 100.0% 96.2% 95.6% √√

HEADLINE FINANCIAL

PERFORMANCE (Overall Rating) 3

Cancer 31 Day Subsequent

Chemotherapy Treatment100.0% 98.0% 100.0% 99.7% 99.7% √√

1. Operational Performance (Debt

Service Cover) 2

Cancer 31 Day Subsequent:

Radiotherapy98.3% 94.0% 98.3% 99.2% 99.2% √√

2. Cash and Balance Sheet

Performance (Liquidity) 4

Cancer 31 Day Subsequent: Other 100.0% 98.0% 100.0% 94.7% 100.0% 94.1% 100.0% √√QEP

Cancer 31 days from diagnosis to

first treatment96.2% 96.0% 100.0% 98.9% 88.6% 97.7% 97.1% 98.5% 95.5% √√

Cancer GP referral to appointment 94.1% 93.0% 93.9% 94.6% 92.9% 93.5% 91.1% 93.4% 96.5% √√

Cancer 14 day wait from referral

(symptomatic breast)95.3% 93.0% 95.3% 93.2% 93.2% √√

Page 1

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

1.2 Executive summary: board performance

This month Year to date

Activity

Page 5

Infection

Page 16

This month Year to date

Month 12 - March

Efficiency

and

productivity

Page 13Quality and

safety

Pages 17 - 19

18 weeks and

other access

indicators

Page 14Workforce

Pages 20 - 21

Cancer

Page 15

Finance

Page 3

Page 2

2. Financial Performance2.1 Financial Performance Summary

Month 12 - March

Area of review Key Highlights

YTD Monitor Continuity of

Service Risk Rating (CoSRR)

Month 12

actual

Month 12

plan

Month 11

actual

HEADLINE

FINANCIAL

PERFORMANCE

(Overall Rating)

The M12 YTD income & expenditure position, reported before donation adjustments (i.e. income & depreciation

relating to donated assets) & exceptional items, is £2.6 million ahead of plan (+£4.6m actual versus +£2.0m plan)

(YTD overall rating = 3).

The bottom-line I&E position is a surplus of £18.3 million. This includes exceptional items of £14.3m, made up as

follows:

o Net impairment reversals of £16.0m, which have arisen as a result of the year-end revaluation of Trust

properties, &

o Impairment costs of £1.7m, resulting from an exercise undertaken to disaggregate the fixed asset register.

When exceptional items are excluded the bottom-line position is a surplus of £4.1 million.

NHS clinical income is £46.5 million ahead of the M12 YTD plan. This can be further analysed as follows:

o Income from patient activity is £34.5 million ahead of plan (+£7.5m in-month)

o Drugs, devices & pass-through income is £11.9 million ahead of plan (+£0.1m in-month).

At M12, a further £2.0m has been released from the Trust’s £5m board contingency (the budget has now been fully

released). All of the Trust’s £3m income contingency has also been released ( of which £1.8m was used to fund

50% relief on lost income resulting from the unbundling of Nuclear Medicine).

3 3 3

1. Operational

Performance

(Debt Service

Cover)

At M12, the Trust’s YTD revenue available for debt service is £4.1m ahead of plan (£67.6m actual versus £63.5m

plan). YTD positions are as follows:

o Medicine is £0.1m ahead of plan (-£0.3m in-month),

o Specialist Hospitals is £1.2 million behind plan (+£0.4m in-month),

o Surgery & Cancer is £3.8 million behind plan (balanced in-month),

o The remaining Corporate budgets within EBITDA (including R&D & Education) are £9.0 million ahead of plan,

o Interest income is balanced against plan.

At M12, YTD revenue of £67.6m is able to cover 1.42 times the Trust’s debt service (YTD rating = 2).

2 2 2

2. Cash &

Balance

Sheet

Performance

(Liquidity)

The liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 31 days of the

Trust’s operating expenses (YTD rating = 4).

At 31st March 2014 the Trust’s cash balance was £129.9 million, £15.2 million behind the planned cash position

of £145.1 million.

The Trust’s cash position at the end of April was £135m (£20m ahead of plan).

Of the current capital programme totalling £86.5 million, 73% (or £63.3 million) is approved & in progress.

M12 YTD capital expenditure of £28.0m is £4.8m greater than plan (of £23.2m).

4 4 4

Area of review Key Highlights

YTD Monitor Continuity of

Service Risk Rating (CoSRR)

Month 12

actual

Month 12

plan

Month 11

actual

HEADLINE

FINANCIAL

PERFORMANCE

(Overall Rating)

The M12 YTD income & expenditure position, reported before donation adjustments (i.e. income & depreciation

relating to donated assets) & exceptional items, is £2.6 million ahead of plan (+£4.6m actual versus +£2.0m plan)

(YTD overall rating = 3).

The bottom-line I&E position is a surplus of £18.3 million. This includes exceptional items of £14.3m, made up as

follows:

o Net impairment reversals of £16.0m, which have arisen as a result of the year-end revaluation of Trust

properties, &

o Impairment costs of £1.7m, resulting from an exercise undertaken to disaggregate the fixed asset register.

When exceptional items are excluded the bottom-line position is a surplus of £4.1 million.

NHS clinical income is £46.5 million ahead of the M12 YTD plan. This can be further analysed as follows:

o Income from patient activity is £34.5 million ahead of plan (+£7.5m in-month)

o Drugs, devices & pass-through income is £11.9 million ahead of plan (+£0.1m in-month).

At M12, a further £2.0m has been released from the Trust’s £5m board contingency (the budget has now been fully

released). All of the Trust’s £3m income contingency has also been released ( of which £1.8m was used to fund

50% relief on lost income resulting from the unbundling of Nuclear Medicine).

3 3 3

1. Operational

Performance

(Debt Service

Cover)

At M12, the Trust’s YTD revenue available for debt service is £4.1m ahead of plan (£67.6m actual versus £63.5m

plan). YTD positions are as follows:

o Medicine is £0.1m ahead of plan (-£0.3m in-month),

o Specialist Hospitals is £1.2 million behind plan (+£0.4m in-month),

o Surgery & Cancer is £3.8 million behind plan (balanced in-month),

o The remaining Corporate budgets within EBITDA (including R&D & Education) are £9.0 million ahead of plan,

o Interest income is balanced against plan.

At M12, YTD revenue of £67.6m is able to cover 1.42 times the Trust’s debt service (YTD rating = 2).

2 2 2

2. Cash &

Balance

Sheet

Performance

(Liquidity)

The liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 31 days of the

Trust’s operating expenses (YTD rating = 4).

At 31st March 2014 the Trust’s cash balance was £129.9 million, £15.2 million behind the planned cash position

of £145.1 million.

The Trust’s cash position at the end of April was £135m (£20m ahead of plan).

Of the current capital programme totalling £86.5 million, 73% (or £63.3 million) is approved & in progress.

M12 YTD capital expenditure of £28.0m is £4.8m greater than plan (of £23.2m).

4 4 4

Page 3

2. Financial Performance2.2 Service lines summary

Month 12 - March

Page 4

Month 12 - March

2. Financial Performance2.3 Clinical income summary

Page 5

2. Financial Performance2.4 Clinical income summary - commentary

Month 12 - March

Notes

■ At Trust level, day case, non-elective & outpatient activity was ahead of plan in the month, with elective activity below plan:

o Outpatients over performed significantly across the Trust - particularly at Specialist Hospitals

o Day cases were strongly ahead of plan in-month again - with the exception of RNTNEH, which continues to underperform

o Non-elective emergency income continues to benefit from the agreement with NHSE & is now offsetting the financial underperformance on electives but bringing increasing

pressures on waiting times & numbers.

■ Drugs, devices & pass-through income was ahead of plan in month with a corresponding increase in drug costs.

■ Potential contractual penalties & planned commissioner intentions impact (not devolved to divisions) are accrued corporately. Final 13/14 commissioner intentions & prices have been

agreed with commissioners & were implemented retrospectively for M8 reporting.

■ C.diff penalties have not been devolved to clinical divisions.

■ Accruals against “other activity” income reflecting local risk assessments of non-payment for activity charged at incorrect prices or to wrong commissioner have been reversed & added

to the year-end credit note provisions as part of the usual quarter end review of commissioner risks.

■ Referral-to-treat (RTT) penalties of -£4.6m YTD have been devolved to divisions, partially offset by +£2.6m benefit from settlement of 12/13 contract payments vs. position accrued at

year-end (including release of provisions) & +£2.0m of RTT penalty reinvestment

■ CQUINs are being reported based on an updated forecast of 95% completion.

■ The M12 YTD variance of +£10.3m on the corporate line – as shown on p11 – is made up as follows:

o YTD release of the income contingency (+£1.2m)

o 50% of the additional YTD trust-wide paediatrics specialist top-up income & other negotiated price changes (+£1.0m)

o The settlement of 2012/13 PCT invoices not allocated to clinical boards (+£0.3m)

o Impact of agreed CIs held corporately vs. plan (+£0.7m variance)

o Reinvestment of penalties + HCAS + WAI receipts vs.. planned +£3.6m

o Risk accruals reclassified to non-clinical income £+5.8m

o The emergency threshold marginal rate applied at divisional level differs from the overall Trust liability – the difference is shown corporately (-£2.3m).

Page 6

3.1 Financial analysis

3. Delivery of QEP

Month 12 - March

Commentary

■ The M12 QEP position shows that the Trust is £0.8m adverse in-month & £0.5m

adverse against plan for the 2013/14 financial year. The 13/14 outturn position is

savings of £36.0m for the year (99% of target), which is £0.8m worse than the

M11-based forecast (£36.8m).

■ Medicine Board is reporting a £0.1m adverse in-month position & is £0.5m

adverse against plan for the year. The board’s outturn performance is as its M11-

based forecast.

■ Specialist Hospitals Board is reporting a £0.3m adverse in-month position & is

£0.4m adverse against plan for the year. The in-month variance is due to

underachievement of schemes across most strands in Queen Square (-£0.2m) &

workforce schemes in Women's Health (-£0.1m). The remaining divisions were

broadly on plan in-month. The board’s outturn performance is £0.1m worse than

its M11-based forecast.

■ Surgery & Cancer Board is on plan in-month & is £0.4m adverse against plan for

the year. The board’s outturn performance is as its M11-based forecast.

■ Corporate areas are reporting a £0.5m in-month adverse variance, but are £0.7m

favourable for the year-end, broadly as a result of the Interserve FM interim fee

scheme (+£1.0m FY variance). The outturn performance is £0.5m worse than the

M11-based forecast – this is due to M12 under performance (-£0.5m) on the PDC

dividend scheme, where it was previously anticipated that there would be a

greater collection of outstanding CCG debt in March.

■ The Trust's equivalent annual savings forecast is £36.6m, which is £0.1m above

the target of £36.5m.

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Tower elective theatre utilisation - total

elective time utilised85% 80.0% 79.7% 80.9%

Trust theatre utilisation 85% 78.5% 79.7% 77.5%

Outpatient utilisation (attendances per

slot)85% 91.6% 80.2% 107.5% 88.9%

% Daily Discharges - Pre11 am

% Daily Bed Demand - 3pm

DNA Rate 8% 11.2% 13.0% 11.5% 10.7%

Page 7

3. Delivery of QEP3.4 Efficiency and productivity

This month

Month 12 - March

Trust theatre utilistation (which includes NHNN, Heart Hospital, and RNTNE theatres) has improved from 76.9% last month to 78.5% in March. Changes have been made to sessional recording in OPERA to remove some of the previously highlighted misreporting, primarily at Queen Square. The result of these changes will be seen in April's performance figures. Elective theatre utilisation for the tower (80.0%) remains below the threshold of 85%. This is a similar level of performance to February. The DNA rate for the trust (11.2%) is above the 8% threshold. All boards are above the threshold and medicine, at 13.0%, is showing as red for this metric. Various actions in the medicine clinical board are being addressed to improve the DNA rate, including greater use of text reminders, telephone reminders and some additional work on data quality issues.

65%

70%

75%

80%

85%

90%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Percentage trust theatre utilisation - All Services

Trust theatre utilisation

10.8%

10.9%

11.0%

11.1%

11.2%

11.3%

11.4%

11.5%

11.6%

11.7%

84%

85%

86%

87%

88%

89%

90%

91%

92%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Percentage utilisation of reportable outpatient clinics and DNA rate - All Services

Outpatient utilisation (attendances per slot) DNA Rate

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% Non-admitted closed pathways

under 18 weeks95% 93.5% 92.4% 91.1% 94.5%

% Admitted closed pathways under

18 weeks90% 86.3% 99.6% 84.9% 85.0%

% incomplete pathways < 18 weeks 92% 87.9% 96.0% 86.4% 87.3%

18 week pathways >36 weeks (open) 0 685 5 169 511

% Diagnostic waiting list within 6

weeks99% 96.3% 100.0% 95.6% 97.1%

% Last Minute Cancellations to

Elective Surgery0.8% 0.2% 0.0% 0.1% 0.4%

A&E attendances within 4 hours 95% 97.1% 97.1%

Page 8

4. Access4.1 Access Targets - Referral to treatment

This month

Month 12 - March

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

A&E attendances within 4 hours

A&E attendances within 4 hours Target

For March, we reported a non compliant position for all three measures. We also recorded 685 patients waiting over 36 weeks, 493 over 40 weeks and 93 patients waiting over 52 weeks. In total we incurred RTT penalties under the contract of £516k, the majority of which is for breaches within admitted pathways. The most significant penalties were £149k for NHNN admitted pathways, £56k for cardiac services admitted pathways and £56k for NHNN services non admitted pathways. This brings our year to date penalties to £3.2 million. We did not meet the target for diagnostic waits within 6 weeks. The two main areas of concern for this indicator are endoscopy and cystoscopy. Endoscopy is expected to move back to a compliant position by May. To address the cystoscopy noncompliance we have 2 extra all day Saturday lists running in April. In May we will be delivering a further 2 sessions, which will have 10-12 patients each. We are aiming at returning to a compliant position by the end of June. There remains a significant risk associated with these targets over coming months. Timescales to reach a stable compliant position are likely to be around 6 months, depending on the speed of backlog clearance and the scale of additional capacity identified. We are implementing a detailed RTT project plan. The immediate priorities are still the validation of the entire incomplete waiting list (~40k patients) and for clinical boards and divisions to book the extra capacity needed to clear the backlog. Both in March and for the whole year we achieved the standard for 95 per cent of Emergency Department patients to be seen within four hours. The emergency department saw nearly 6500 more patients than last year – a total of 125,848 – and ended in a better position than last year, coming fifth in London. There are still days when the department see close to or in excess of 400 patients.

70%

75%

80%

85%

90%

95%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Referral to treatment % completed and incomplete pathways under 18 weeks

% incomplete pathways < 18 weeks % Non-admitted closed pathways under 18 weeks

% Admitted closed pathways under 18 weeks

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Two week wait from referral to date first seen93% 94.1% 93.9% 94.6% 92.9%

Two week wait from referral to date first

seen: breast symptoms93% 95.3% 95.3%

31-day wait from diagnosis to first treatment96% 96.2% 100.0% 98.9% 88.6%

31-day wait for second or subsequent

treatment: surgery94.0% 100.0% 100.0% 100.0%

31-day wait for second or subsequent

treatment: drug treatments98% 100.0% 100.0%

31-day wait for second or subsequent

treatment: Radiotherapy94% 98.3% 98.3%

31-day wait for second or subsequent

treatment: other98% 100.0% 100.0%

62-day wait for first treatment from urgent GP

referral to treatment85% 72.7% 80.0% 60.6% 87.0%

62-day wait for first treatment from consultant

screening service referral90% 100.0% 100.0%

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

Page 9

This month

4. Access4.2 Access Targets – Cancer

Month 12 - March

The current performance for the 62 Day Cancer Wait is 72.7%, against a target of 85%. This is the position without maximum possible reallocations and is subject to change until the national Open Exeter reporting deadline for March. With all late referalls reallocated, our performance would have been reported as 84.3%. A total of 11 breaches were incurred (14 patients), of which 3.5 breaches (6 patients) were due to late referrals already beyond 50 weeks waiting. Three breaches (3 patients) were complex where the patient required non-cancer clinical intervention prior to cancer treatment. The remaining 4.5 breaches were avoidable as a Trust. Delays to these patients were due to capacity or scheduling constraints. Individual specialty teams are reviewing current capacity. We continue to pursue, along with other cancer centres and Shelford Group providers, the implementation of fairer breach reallocation rules nationally. For all other Cancer Wait targets we were compliant in March. There is a trust wide cancer programme focusing on two week waits, initially prioritising standardisation of administrative processes.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Cancer 62 day referral targets

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

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

70%

75%

80%

85%

90%

95%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Cancer 2 week referral targets

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

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Number of MRSA Bacteraemias (Trust

Attributable) (Ward)0 0 0 0 0

Number of clostridium difficile cases

(Trust Attributable) (Ward)3 9 3 3 3

Number of MSSA Bacteraemias (Trust

Attributable) (Ward)2 1 0 1 0

% Hand Hygiene Compliance 100.0% 95.6% 95.1% 97.5% 94.5%

MRSA Screening - Percentage of

Inpatients Matched New90% 87.2% 88.0% 86.6% 87.1%

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

Page 10

5. Quality5.1 Infection

This month

Month 12 - March

There were no cases of MRSA for this month; the number of cases for the whole year is six. We recorded 9 clostridium difficile cases in March, Three cases were reported by surgery and cancer, two in surgical specialties and one in cancer. Root cause analysis is underway for all three cases. Clinell dispensers have now been implemented on the ward. Staff awareness of the importance of stool charts has also been raised. The nurse in charge completes a review of side rooms each day and reports to Infection Control. Three cases were reported by the Medicine Board, two in critical care, one in infection. Specialist Hospitals also reported three cases, one at Queen Square, one at the heart hospital and one in paediatrics At the heart hospital, weekly infection control meetings are taking place with strict management of hand hygeine on all wards as well as infection control champions on each ward working with teams on education and management Root cause analysis is being done on the one MSSA case reported in March.

0

1

2

3

4

5

6

7

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

MRSA bacteraemia / infections - All Services

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

0

20

40

60

80

100

120

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Clostridium difficile infections post 48 hrs - All Services

CDiff Actuals Monthly CDiff Threshold Monthly CDiff Actuals YTD CDiff Threshold YTD

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Inpatient falls with serious harm 0 0 0 0 0

Falls per 1000 beddays 1.5 3.5 6.1 2.6 3.1

All Pressure Ulcers Acquired at UCLH 11 6 2 2 2

Number of Grade 3 Pressure Ulcers

Acquired at UCLH0 2 1 1 0

Number of Grade 4 Pressure Ulcers

Acquired at UCLH0 0 0 0 0

The trust threshold is an aggregate of individual clinical board thresholds

Page 11

5. Quality5.2 Safety

This month

Month 12 - March

There were six hospital acquired pressure ulcers reported in total in March. There were two grade three pressure ulcers reported, one in medicine and one in surgery and cancer. Root cause analysis is underway for the one in surgical specialties. Due to the complexity of the conditions of the patient in critical care, the ward team had to make a clinical decision about the priorities of the care of the patient and therefore, decided to allow a grade two ulcer to turn into a grade three. Some of the key issues highlighted for acquiring pressure ulcers were poor mobility and nutrition, inconsistent SKINN documentation. Actions identfied were checking of daily documentation by ward sisters, further tissue viability training on wards, and one to one discussions with staff and training or improvement notices given. .

0

0.5

1

1.5

2

2.5

3

3.5

4

0

20

40

60

80

100

120

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

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

Inpatient falls with harm Patient falls Falls per 1000 beddays

0

5

10

15

20

25

30

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

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

Grade 4 Grade 3 Grade 2

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Preventable dose omissions 1.3% 3.1% 3.4% 3.1% 3.0%

Percentage of Completed eVTE Risk

Assessments95.0% 95.2% 96.0% 96.4% 94.7%

Hospital Acquired Thromboses

% Harm free care 95.0% 95.7% 92.9% 95.4% 97.6%

The trust threshold is an aggregate of individual clinical board thresholds

Page 12

5. Quality5.3 Safety

This month

Month 12 - March

We were not compliant for the target for dose omissions in March at 3.1% against the threshold of 1.3%. The medicine board remained non compliant at 3.4%, Surgery and Cancer were also non compliant at 3.1%, as were Specialist Hospitals at 3.0%. Further investigations have establisehd that majority of the dose omissions on wards were due to a failure to document the omission. Reasons for omitting doses were not recorded and ofetn drug charts were left balnk. At Queen Square, action plans have been requested for individual areas as well as champions to be identified at ward level. Dose omissions will be addressed at the ward sisters meeting for further discussion. In Paediatrics, a member of ward staff will be accompanying the pharmacist at the monthly audit to identify and resolve problems in real-time. Weekly spot audits will take place between matrons and pharmacists to identify specific issues. Drug charts wil also be checked at the end of each shift to ensure completeness. The medicine clinical board was non compliant in meeting the harm free care indicator, at 92.9%, The majority of these harms were those recorded as being present on admission.

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Dose Omissions - All Services

Preventable dose omissions Target

To be developed

92%

93%

94%

95%

96%

97%

98%

99%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

VTE Risk assessment - All Services

Percentage of Completed eVTE Risk Assessments Target

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Emergency readmissions within 30

days (with PbR exclusions)6.4% 18.8% 6.0% 2.5%

Percentage of Complete Vital Signs

Observations100.0% 93.5% 88.3% 94.5% 93.8%

Local SHMI - Relative Risk - (1 yr

rolling data)0.53 0.49 0.58 0.54

Never Events

The trust threshold is an aggregate of individual clinical board thresholds

Page 13

5. Quality5.4 Outcomes

This month

Month 12 - March

All three boards were non compliant against the threshold for completed vital signs observations. In Surgery and Cancer, this was due to agency staff and new members of staff

not completing the pain score. In the medicine clinical board, there is focus on recording vital signs observations as part of a broader programme on improving nursing documentation. All staff are now having one to one training on the new NEWS observation charts that have been introduced.

75%

80%

85%

90%

95%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Complete Vital Signs - All Services

Percentage of Complete Vital Signs Observations Target

To be developed

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Emergency readmissions - All Services

Emergency readmissions within 30 days (with PbR exclusions)

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Complaints responded to within target

time85.0% 78.8% 100.0% 78.9% 65.5%

Friends & Family Test (IP survey) 50 73 67.2 70.0 78.5

Number of PDA responses (IP survey) 1402 857 171 355 331

Page 14

5. Quality5.5 Patient Experience

This month

Month 12 - March

We were worse than target for complaints responses in March. In women's health, the complaints team are providing ad-hoc training to try to reduce the number of edits and reduce the time to complete responses. At the RNTNE and the Heart Hospital, new processes have been introduced to deal with complaints quicker and new staff joining this month will be tasked to ensure compaints have been responded in time. In GI, complex cases have led to delays in some areas and complainants have been made aware of the delay. The number of PDA responses to our inpatient survey has decreased in March with all three boards failing to meet their target. At the Heart Hospital, ward managers have been made aware of the low number of responses and this will be brought up in each safety huddle every day, reminding staff to use the IPad prior to discharge. The discharge team will also be asked if they can remind the patient to complete the surveys before leaving the hospital. In GI, a broken IPad meant that patients were unable to complete surveys on the wards. All staff are being reminded during the safety brief to make sure all patients are offered a chance to complete the survey. The Medicine board has requested more IPads to ensure completion of surveys.

0

200

400

600

800

1000

1200

1400

1600

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Patient experience - Number of PDA responses

Number of PDA responses (IP survey) Target

0

10

20

30

40

50

60

70

80

90

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Patient experience - Complaints received

Number of Patient Complaints Complaints responded to within target time Target

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% Agency staff spend of temporary

staff spendNA 34.3% 40.4% 20.4% 31.4% 50.1%

% Bank nursing and midwifery temp

staffing usageNA 87.8% 84.5% 93.9% 86.5% 31.7%

% Vacancy rate 5% 9.2% 3.6% 10.7% 10.8% 8.9%

% Staff turnover (excluding

honoraries, bank, junior doctors,

executive and non executive posts)

12.0% 13.5% 13.7% 13.3% 12.5% 19.3%

Staff in post WTE NA 7639.7 1600.4 1945.7 3452.7 640.9

The trust threshold is an aggregate of individual clinical board thresholds

Page 15

6. Workforce 6.1 Performance indicators

Month 12 - March

This month Staff In Post (WTE): has increased by 355 WTE between Month 1 and Month 12. Vacancy Rate: has decreased by 3.0%, from 13.7% in Month 2 to 9.2% in Month 12. As a result of the Recruit 500 campaign, the vacancy rate for front-line registered nurses and midwifes was 8% for month 12. Staff Turnover: has decreased from 14.0% in Month 1 to 13.5% in Month 12. Temp Staffing: demand for temporary staff increased to 1,252 WTE in Month 12, an increase of 95 WTE on Month 12 last year. 84% of total shifts in Month 12 were filled by Bank staff. Work continues to eliminate the use of non-specialist agency workers by the end of March 2014.

6,5

08

6,5

04

6,8

38

6,8

71

6,9

40

6,9

44

6,9

78

7,0

52

7,0

52

7,0

80

7,1

25

7,1

21

7,2

85

7,3

40

7,3

38

7,3

72

7,3

80

7,3

85

7,4

30

7,4

72

7,4

92

7,5

56

7,5

92

7,6

40

0

0

325

325

371

37

1

371

371

371

371

371

371

371

371

371

371

371

37

1

371

371

371

371

371

371

5000

5500

6000

6500

7000

7500

8000

8500

Staff in post WTE (ESR) April 2012 - March 2014

TUPE Staff Staff in post WTE

62

9

69

6

65

4

65

8

78

9

76

8

83

2

84

6

75

7

90

2

87

2

96

2

87

0

90

3

86

6

94

1

90

7

89

8

95

3

90

7

79

2

92

0

92

0

10

47

10

9

10

6

13

0

66

15

6

12

3

15

9

19

8

15

2 18

9

17

4

17

5

17

3

16

9

17

9

18

1

14

8

17

0

19

4

18

7

16

1 18

8

19

3 20

5

0

200

400

600

800

1000

1200

1400

WTE Temporary Staff Usage (All staff groups) Previous 24 months, Source: Pulse

Agency WTE Bank WTE

Tru

st

thre

sh

old

Tru

st a

ctu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Co

rpo

rate

Fu

nctio

ns

Sickness absence rate (%) 4.0% 3.7% 3.2% 3.6% 3.8% 3.9%

% Appraisals Complete - Tier 4 - The

remaining workforce (exc M&D

Workforce)

90.0% 94.9% 96.3% 96.1% 93.5% 96.1%

% Statutory and mandatory training

compliance90.0% 78.7% 79.2% 77.2% 77.7% 91.1%

Average time to recruit (request pack -

start date)14.6 13.2 15.0 12.8 13.0 12.4

Page 16

6. Workforce 6.2 Performance indicators

This month

Month 12 - March

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

Statutory & Mandatory Training:

Staff who have changes applied to requirements within their Training Needs Analysis (TNAs) were written to during March in order to advise and direct towards training access. It is this change in TNAs which has resulted in a dip in compliance levels in recent months. Work continues in this area to improve take up with mandatory training.

In addition, a data validation process is taking place with the subject matter experts and board workforce teams to address a very small proportion of mandatory training records that have been reporting incorrectly. This is affecting a maximum 3% of all records held. In addition the Boards are reinforcing the need for all staff to ensure their training is up to date via the Learning Management System portal.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Trust Appraisal completion rate - All Services

Tier 4 (Overall) Tier 1 Tier 2 Tier 3

The Annual Appraisals Cycle By end of April - Tier 1 - All direct reports to the Chief Executive

By end of June - Tier 2 - All Staff reporting to a Director who has been appraised by the Chief Executive including all DCDs

By end of July - Tier 3 - All remaining AFC staff at Band 8C and above including all DCDs

By end of October - Tier 4 - Remaining of the workforce

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

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

% Sickness Absence Rate Reported 1 month in arrears

2010/11 2011/12 2012/13 2013/14

Estimated riskThresholds Weighting Mar 14 Q1 Q2 Q3 Q4 Comments

0 1.0 0 2 2 1 1YTD Threshold and Q1/Q2 actual performance figures.

See page 10 for detail.

39 1.0 9 19 19 20 20YTD Threshold and Q1/Q2 actual performance figures.

See page 10 for detail.

90% 1.0 86.3% 91.7% 90.6% 88.9% 86.3%See page 8 for detail

95% 1.0 93.5% 97.0% 96.3% 95.6% 93.5%See page 8 for detail

92% 1.0 87.9% 92.2% 92.3% 89.9% 87.2%See page 8 for detail.

85% 72.7% 87.0% 86.3% 80.6% 77.7%See page 15 for detail. To note, our submission to Monitor includes breach

reallocations not shown in the internal and Open Exeter positions.

90% 100.0% 100.0% 92.9% 71.4% 87.5%See page 9 for detail

94% 100.0% 98.3% 94.8% 97.3% 99.0%See page 9 for detail

98% 100.0% 100.0% 100.0% 100.0% 100.0%See page 9 for detail

94% 98.3% 100.0% 100.0% 99.3% 98.2%See page 9 for detail

96% 0.5 96.2% 98.5% 97.7% 96.5% 97.7% See page 9 for detail

93% 94.1% 93.3% 93.5% 94.7% 93.2%See page 9 for detail

93% 95.3% 89.3% 90.5% 95.4% 96.2%See page 9 for detail

95% 1.0 97.1% 95.1% 96.0% 92.3% 96.3%See page 8 for detail

Green Green Green Green TBC

Page 17

Month 12 - March

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

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

Overall governance rating / Monitor RAF assessment

7. Externally Reported Frameworks 7.1 Monitor Indicators – Compliance Framework

Indicators

Incidence of MRSA year to date

62 day wait for first treatment from urgent GP referral

1.0

62 day wait for first treatment from consultant screening service referral

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

Incidence of Clostridium difficile year to date

Maximum time of 18 weeks from point of referral to treatment - admitted

Maximum time of 18 weeks from point of referral to treatment - non-admitted

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

Page 18

Month 12 - March

7. Externally Reported Frameworks 7.2 CQUIN and financial penalty summary

Estimated

Annual value

available

Financial Plan

assumptionsQuarter 1

actual

Quarter 2

risk

Quarter 3

Risk

Quarter 4

Risk Total

£776,417 £ -

£776,417 £ -

£899,023 £ -

£899,023 £ -

£817,202 £ -

£1,225,802 £ -

£1,225,802 £ -

£1,634,403 £ -

£817,202

£817,202 £ -

£1,103,450 £ -

£613,028 £ -

£1,226,055 £ -

£1,471,266 £ -

£14,302,291 £0 £0 £0 £0 £0

Financial Plan

assumptions

£30,000 £30,000 £15,000 £30,000 £ 105,000

£1,000,000 £125,000 £352,500 £460,000 £380,000 £ 1,317,500

£2,000 £2,750 £1,500 £2,750 £ 9,000

£436,274 £604,543 £797,726 £1,323,949 £ 3,162,492

£0 £15,000 £175,000 £1,250,000 £ 1,440,000

£0 £593,274 £1,004,793 £1,449,226 £2,986,699 £6,033,992

Financial Plan

assumptions

£345,800 £ 335,205 £ 327,534 £ 336,180 £ 1,344,719

£154,700 £ 154,842 £ 213,045 £ 174,196 £ 696,783

£1,839,000 £425,000 £425,000 £ 425,000 £ 425,000 £ 1,700,000

£8,400 £7,600 £ 37,600 £ 18,000 £ 71,600

£7,299 £ 7,299

£1,000 £1,750 £500 £1,500 £ 4,750

£4,379,000 £942,199 £924,397 £1,003,679 £954,876 £ 3,825,151

£1,535,473 £1,929,190 £2,452,905 £3,941,575 £9,859,143

Shaded cells are estimates of risk

Risk of forfeited CQUIN income

Integrated care (MDT)

Alcohol misuse

Friends & Family Test

Dementia

Rare cancer CNS impact

Specialist audit workshop

Cardiac surgery

Neurosurgery - shunt procedures

Nati

on

al VTE

Reducing pressure ulcers

Dashboards

Smoking cessation

NH

SE

BMT

Total CQUIN Incentive payment risk

Financial Penalties

C. Difficile

Lo

cal

COPD Discharge bundle

£2,540,000

"Never" events

Mixed sex accommodation breach

LAS 30 & 60 Minute handover breaches

MRSA

RTT penalties

MSSA

RTT 52+ penalties

Total penaties

Non-reimbursed activity - Contact metrics

Overall penalty / risk / non-reimbursement

Total non-reimbursed penalties

Emergency readmissions (internal)

Emergency readmissions (external)

First / follow up ratios (full year projection)

There have been signif icant improvements during 2013/14 in

reducing pressure ulcers with threshold numbers for quartes 1-3 being achieved. Quarter 4 is currently slightly above the internal trajectory to achieve the threshold level of 33.

The level of LAS breaches remains an estimate at this time as there are many cases being reviewed and challenged by the A&E

department

There is agreement with commissioners that penalties will be reinvested to support improved performance. Final decisions about allocation of bids will take place after the report from McKinsey.

1. Referrals and activity

2. Access

3. Patient safety and quality metrics

4. Top 10 objectives

5. Externally reported frameworks

6. Data quality report

Page 19

Quarterly review slidesContents

Month 12 - March

Page 20

Month 12 - March

Quarterly Review1. Referrals and activity

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Number of referrals to UCLH by working day (RNTNE included from Apr-12)

GP Refs Non GP Refs Total Refs

0

50,000

100,000

150,000

200,000

250,000

300,000

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

All Outpatient Attendances (RNTNE included from Apr-12)

Total Attendances

0

5000

10000

15000

20000

25000

30000

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Daycase and Elective Inpatients (RNTNE included from Apr-12)

Total DC & ELIP

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Non Elective Inpatients (RNTNE included from Apr-12)

Non Elective

Page 21

Quarterly Review2. Access Targets

Month 12 - March

70%

75%

80%

85%

90%

95%

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

62 day from GP referral target (without reallocations)

Performance Threshold

26000

27000

28000

29000

30000

31000

32000

33000

90%

91%

92%

93%

94%

95%

96%

97%

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

A&E 4 hour wait target

A&E Performance Threshold A & E Attendances

0%

20%

40%

60%

80%

100%

120%

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

62 day screening target

Performance Threshold

76%

78%

80%

82%

84%

86%

88%

90%

92%

94%

96%

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Switchboard performance

Calls answered within 30 secons Threshold

No Data

Page 22

Quarterly Review3.1 Infections

Month 12 - March

0

1

2

3

4

5

6

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

MRSA - All Trust reported cases to HPA (including community acquired)

UCLH All MRSA (incl community acquired) MRSA Peer average

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

MRSA cases per 10000 bed days UCLH Vs London Peers

UCLH MRSA bed rate London peers MRSA bed rate

Linear (UCLH MRSA bed rate) Linear (London peers MRSA bed rate)

0

5

10

15

20

25

30

35

40

45

50

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

C. Difficile - All Trust reported cases to HPA (including community acquired)

UCLH All C-diff (incl community acquired) C diff Peer average

0

1

2

3

4

5

6

7

8

9

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

C. Difficile cases per 10000 bed days UCLH Vs London Peers

UCLH Cdiff bed rate London peers Cdiff bed rate

Linear (UCLH Cdiff bed rate) Linear (London peers Cdiff bed rate)

Page 23

Month 12 - March

Quarterly Review3.2 Other Quality issues

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Last minute cancellations to elective surgery

Cancellations to Elective Surgery Threshold

0

500

1,000

1,500

2,000

2,500

3,000

3,500

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Number of Incidents

0

50

100

150

200

250

300

2011-12 Q4 2012-13 Q1 2012-13 Q2 2012-13 Q3 2012-13 Q4 2013-14 Q1 2013-14 Q2 2013-14 Q3 2013-14 Q4

Inpatient Falls

Falls with no harm Falls with harm (w/o serious harm) Falls with serious harm

Page 24

Quarterly review4.1 Top 10 Objectives (1)

Month 12 - March

Full Good Partial None

Reduce pressure ulcers, falls, blood clots and

preventable dose omissions 

Improve clinical communication through the

ward safety checklist and intentional

rounding

Improve performance on hospital mortality

Reduce avoidable readmissions  

Generate specific outcome measures for

specialties 

Continue to improve patient experience    

Improve the appointment, booking and

transport services we offer to patients

Transform pain management and palliative

care across UCLH

Deliver the integrated care programme  

Achieve income, expenditure and cash

targets

Develop strong, robust relationships with

new GP and specialist commissioners

Objectives

2013/14

TargetsAchievement /Progress

Improve patient safety

Reduce hospital-acquired infections        

Deliver excellent clinical outcomes

Deliver high-quality patient experience

Integrate care more effectively with partnersImprove the timeliness and quality of all

communications with GPsEnsure that wherever possible we have the

correct GP details and NHS number for

 

Achieve sustainable financial healthDevelop service line management and

patient-level costing

Page 25

Quarterly review4.2 Top 10 Objectives (2)

Month 12 - March

Full Good Partial None

Deliver QEP savings in 2013/14

Improve support service efficiency

(including radiology and pathology)

Embed the new experimental medicine

strategy of the Biomedical Research Centre

Deliver a positive experience for all staff

groups going through educational

programmes at UCLH

Contribute to the re-accreditation of

UCLPartners as an academic health science

centre

Continue to improve the experience of staff

working at UCLH

Reduce waits for planned care to make UCLH

the provider of choice

Deliver A&E waiting times and targets

Meet the cancer waiting time targets

Progress out strategic service plan priorities

Progress plans for Proton Beam Therapy

and phase 4 and 5 development

Refresh and implement a transformative ICT

strategy 

Deliver the Quality, Efficiency and Productivity (QEP) Programme

Develop 3 year productivity and efficiency

savings

Deliver waiting times in line with contract

Progress strategic development

Objectives

2013/14

TargetsAchievement /Progress

Deliver actions to develop excellent

leadership across UCLH

Develop R&D and education

Enable staff to maximise their potentialEnsure all staff benefit from appraisal and

mandatory training

Page 26

Quarterly review5.1 New CQC Risk Summary May 2014

Month 12 - March

Page 27

Quarterly review5.2 Dr Foster Summary of key indicators supporting the CQC reporting indicators

Month 12 - March

Page 28

Month 12 - March

Quarterly review6.1 Data quality reporting

90%

91%

92%

93%

94%

95%

96%

97%

98%

Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13

Ethnic coding completeness

In-patient Out-patient A&E

50%

60%

70%

80%

90%

100%

Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13

NHS Number completeness

In-patient Out-patient A&E

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13

GP Practice Validity

In-patient Out-patient A&E

3

3.5

4

4.5

5

5.5

6

Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13

Depth of Clinical Coding

In-patient Day case

Gi

Agenda Item 9

Quality & Safety Committee Report March

Quality & Safety committee March 2014 summary to the May Board of Directors 1. Information technology 1.1 Printed patient identity wrist bands The director of ICT updated QSC on the problems implementing printed bands which have been caused by printer compatibility. Testing of the print runs should be complete by the end of March and it is anticipated that patients will have printed bands from the end of May 14. The director of ICT is to look at identifying additional resource to speed up implementation. 1.2 E-prescribing The director of ICT reported that UCLH has successfully bid to NHS England for Safer hospitals; Safer wards technology funds to restart the e-prescribing project following the original provider going into receivership. The undertaking to NHS England is implementation in 12-15 months, it is hoped it will be available across the trust in 12 months. 1.3 Vital signs recording A trial of automated vital signs recording is in process in ITU. A mobile application is being written to audit compliance with vital signs recording. 2. Vital signs compliance Action has been taken to implement the national early warning score (NEWS) alongside a revised patient observation standard and audit and performance management processes, in response to the findings of the recent CQC inspection. The key actions include: a new observation chart, including NEWS, an education programme including e-learning,a new standard for patient observations which requires observations to be of a higher standard (previous standard was that each patient should have two full sets of observations in a 24 hour period), a re-designed audit process, with audits being collected via an App rather than being paper based. This will ensure that non-compliance with data collection can be monitored in real time and action taken, audit data will be fed into the ward care thermometer, so that ward performance in relation to observations can be viewed alongside other performance data and a new performance management system, that increases scrutiny where wards have low compliance with the patient observation standard is being developed and will be rolled out once the NEWS system is fully implemented. 3. Prescribing Concerns about prescribing practices were identified following an audit against the legal requirements and trust standards for prescribing in October 2013. A number of measures to mitigate the risks to patients whilst awaiting implementation of e-prescribing, such as mandated use of name stamps and daily checking of prescription charts on the ward round are to be implemented. 4. Trauma care 4.1 The key outcome measures for the years 2010-13 for UCH indicate neitherunexpected deaths nor unexpected survivors. The impression for the NHNN is improvement over time. 4.2 Trauma data submitted appears to be improving at UCH and the approach is to be rolled out at the NHNN. The objective is for data completeness and accreditation to be consistently above 90%, matching that of the Major Trauma Centres. 4.3 Various actions have been taken to ensure that all patients who meet the hospital trauma call criteria do trigger a call – particularly those in whom clinicians may underestimate trauma severity (intoxicated patients and the elderly). 4.4 The proportion of trauma patients seen by senior doctorsas a whole is comparable to that at other Trauma Units nationally, albeit proportionately fewer are seen by a Consultant at UCH. 100% patients warranting a hospital trauma call were seen by a Consultant and / or Registrar). 4.5 A computerised tomography(CT) scanner in the ED (as part of the ED redevelopment) is expected to address the problem of CT scanning for head injured patients; in the meantime several mitigating actions are being taken, and their effect will be monitored.

5. Clinical Research Governance Following one pharmaceutical company’s decision to halt recruitment of all trials it sponsored at UCLH, a root cause analysis (RCA) was undertaken. The RCA determined that patient safety was not compromised but study conduct fell well below the sponsor’s expectations. Lessons to be learnt have been circulated to clinical trials teams at UCLH. The committee reviewed all incidents in research studies reported since 2010. Incidents concerning medicines received the largest number of reports and a small working party has been set up to review what can be learnt from these incidents. Assurance was provided that the joint research office are active in reviewing the streamlining of the UCL/UCLH relationship. 6. Clinical Effectiveness The outcomes of five new interventional procedures has been reviewed by the trust and one new application has been received. QSC received the annual reports of the Use of Medicines committee and the annual Organ Donation plan, which was commended by the lead patient governor. 7. Clinical Audit & Quality Improvement 7.1 The new clinical audit policy has been published. Compliance with the previous version was patchy and improvement is already evident. 7.2 The 2013-14 corporate Clinical Audit programme has been delivered. The 2014-15 programme is under consultation. 7.3 The National Dementia Audit specifies three key performance indicators, in people with dementia, which should be reviewed by the Board: readmissions, delayed discharge/transfer and in-hospital falls. Consideration is being given to including these in the trust performance report. 7.4 Audit of compliance with NICE CG83, rehabilitation after critical illness has identified that improvements are needed in discharge from the ITU,HDU and from the ward to home. It is planned that this will be driven at divisional level, led by the Critical Care delivery group. 8. Nutrition & Hydration 8.1 The food group are evaluating the factors that lead to the variance in patient satisfaction with the Steamplicity food delivery system across sites and problem solving is in progress. 8.2 The Nutrition Screening tool (NST) has now been in place for nearly a year and though compliance is still higher than that of the previous tool (MUST Score) there are still improvements to be made. 8.3 A main focus in 2014-15 will be on addressing the management of ‘fasting’ patients. The work will include the review of the current guidelines and the roll out of a training programme to all clinicians. 8.4 Nurse led mealtimes is a second focus for 2014-15 with the objective being to have all inpatient areas adopt the model by the end of quarter two. 9. Infection control and prevention There have been no significant infection outbreaks. There were no cases of MRSA and four cases of MSSA bacteraemia in February. Root cause analyses (RCAs) are in progress. One case was community acquired but a blood culture was taken after 48 hours. There were seven cases of E.colibacteraemia. A recent review indicated that these were rarely related to urinary catheterisation. All previously non-reportable C.difficilecases have now been reported, the total for the year 2013-14 is 92 cases. There were ten cases in February. The new C.difficile target for 2014-5 is 57 cases.

10. Francis report The task group has met on a number of occasions to progress actions to achieve the recommendations in the Francis report. Actions that have been closed include: • Honesty and Candour – Further “Being Open”training is being made available to staff to

include end of life care discussions, advanced duty of candour and Do not attempt resuscitation decisions.

• Closing the loop within Incident Reporting- An additional question about whether the incident handler has communicated with the reporter has been added to DATIX

11. Controlled Drugs (CD) 11.1 An analysis of CD incidents reported during the quarter identified a continued high number of CD related incidents in October (32) following September high number (32). This number fell to lower levels in November and December. 11.2 The most frequent categories of CD incident reported across all three months was CD management (55%) followed by administration (39%). 11.3 The majority of the CD management incidents relate to minor deviations from policy and practice or discrepancies in CD drug quantities that are resolved upon investigation. The substantial majority of CD incidents involved no patient harm (85%). Of the remainder patient harm was minimal for 5 incidents and short term for 4 incidents. 12. Trust Quality & Safety performance The Quality & Safety performance book for January 2014 was received by QSC 13. Care Quality Commission compliance monitoring The board is asked to approve the adoption of CQC compliance walk rounds and / or mock visits, to replace current compliance monitoring, as referred to the March board, by QSC. Further detail is provided at appendix A.

Professor Tony Mundy Corporate Medical Director March 2014

Appendix A Care Quality commission (CQC) compliance monitoring

• The focus of the CQC steering Group (CQCCSG) over the last quarter has changed in the light of the preparation for and outcome of the November 2013 CQC visit. Work to develop a more practical visit based approach to promoting and monitoring compliance with the CQC requirements has been undertaken.

• A shortened assessment tool to both promote and assess compliance on a visit / walk round basis is being developed and further work with Internal Audit (IA) to ensure that IA play a complementary role which adds to, strengthens and challenges the Trust’s future approach is being undertaken.

• Assessments will be carefully coordinated and/or combined with other walk rounds in place to ensure staff are not overburdened, and to avoid duplication of work.

Planned outcomes of walk rounds-

• Immediate feedback to the ward via a staff huddle of top three ‘best practice tips’ to

share/be proud of and top three ‘should improve’ points • Immediate email feedback to the divisional management team for action planning • Action plans to be delivered by divisional management/governance teams, monitored by

the MD /clinical board • Internal audit to provide independent tracking of divisional action plans, for board

assurance • Progress against action plans to be captured by the CQC compliance steering group

and reported in the quarterly report to QSC and the board, for assurance

• The board is asked to approve the adoption of Walk rounds and / or mock assessments along the lines of the November 2013 CQC inspection of UCH & EGA, to replace current compliance monitoring and MD 6 monthly sign-off of provider compliance assessments (PCAs).

Gii

Agenda Item 9

Quality & Safety Committee Report April

Quality & Safety Committee Summary to the Board of Directors 13th May 2014 1. Patient Reported Outcome Measures (PROMs) UCLH has undertaken an extensive review to understand, validate, and act on available PROMS data from 2011-2012, for patients who undergo hip and knee surgery at the Trust. A number of issues in relation to interpretation of the data, published by the Health & Social Care Information centre (HSCIC), have been identified, such as inability to match up patient identifiable data where the NHS number is not known, and case mix adjustment. However, the pathway at UCLH has improved. Oxford scores and EQ5D are obtained on all patients before they go on the waiting list. This identifies those whose potential gain is more limited so that it can help the patient decide whether surgery is appropriate for them or not. Preoperative education has been improved significantly. The perioperative pathway in terms of analgesia has also been improved, as has the appointment of a ‘readmission avoidance’ nurse to ensure perioperative care is streamlined. The latest release of data from HSCIC indicates that we are performing well for hip and knee replacements. 2. Statutory duty of Candour Following of publication of the Francis Report there have been two key developments in relation to a ‘Duty of Candour’. The DoH is consulting on proposals to introduce a new statutory CQC registration requirement, and the introduction of the principles of ‘Being open’ into a contractual Duty of Candour clause in the NHS Standard Contract. The aim of Duty of Candour is to ensure that patients and their families are told about patient safety incidents that affect them, receive appropriate apologies, are kept informed of investigations and are supported to deal with the consequences. The proposals extend the duty of openness for serious incidents to include ‘moderate harm’ which will increase the number of cases to which it applies from 10 per month to 100 at UCLH. 3. Clinical Audit Annual report for 2013-14 The medical directors (MDs) reported a significant drive to improve audit and linking of divisional objectives to the Trust objectives. The clinical audit & quality improvement committee chair is working with the MDs on standardisation and will report back on each clinical boards’ action plan to improve. 4. The Audit Committee (AC) The audit committee raised with the QSC an issue regarding a potential risk to patient safety relating to the management of water quality issues, specifically Pseudomonas and Legionella. QSC was asked to ensure that appropriate action was in place to deal with the patient safety risk. An update report was requested from the microbiology department to provide clarity that the Trust was taking appropriate steps to identify, manage and mitigate these risks through the testing and treatment regime. The committee received a report on the Quality Account, relating to the data quality of audit of vital signs. Data quality was impacted because there were a number of wards that did not return data. There was concern that the data could give an inaccurate view of the overall Trust position. The Chief Nurse reported that the audit standard has been improved and she would provide QSC with the detail of the new audit standard, when it will be implemented and our compliance against it.

5. Infection prevention and control 5.1 Surgical site infection (SSI) Higher numbers of SSI in the gastro-intestinal service (GI) and at the Heart Hospital have been investigated. Higher SSI rates previously reported for the GI service may be related to a change in case mix i.e. more surgery which is already contaminated and therefore has higher rates of infection. At the Heart hospital a dedicated graft harvester is to be recruited to reduce groin infections in patients

requiring saphenous vein grafting. Compliance with the WHO safer surgery check-list was also reviewed. A specialist clinical lead is to be appointed for theatres and there are plans in place to improve training.

5.2 Early detection, management and control of carbapenemase-producing Enterobacteriaceae (CRE) The implications of the Acute trust toolkit for the early detection, management and control of CRE published by Public Health England in December 2013 were considered by the QSC. Three options are to be proposed to the executive board, which have implications for compliance with the national guidance, the availability of side rooms and additional cost. 5.3 Infection Prevention and Control scorecard March 2014

• There were 9 cases of C.difficile in March 2014 and 99 cases for the year 2013-14. • There were no cases of MRSA bacteraemia in March 2014, and a total of 6 for the year 2013-

14, against a zero threshold. • There was one case of MSSA bacteraemia bringing the total in 2013-4 to 33 cases against a

Trust objective of 27 cases. • There were 7 cases of E.coli Bacteraemia. A recent review indicated that these were rarely

related to urinary catheterisation • There was an outbreak of Norovirus in March. Although difficult to manage on an open ward the

staff worked well to keep the outbreak under control.

6. Quality Account The draft Quality Account for 2013-14 is under consultation. 7. Care Quality Commission compliance The Trust is adopting new ‘Improving Care’ walk rounds which will be conducted along the lines of the CQC inspections to prepare the Trust for visits and ensure ongoing improvement. The walk rounds will include governers, students and junior doctors as well as senior nurses, doctors and specialists. 8. Trust Quality & Safety performance A patient safety group for Falls has been reinstated; it will look at contributory factors and draw up a strategy to improve safety. A new audit standard and audit is being implemented to address compliance with vital signs. 9. Clinical Record keeping The Trust is to consider mandating the use of name stamps and signature lists maintained by departments to enable easy identification of staff to improve the quality of record keeping. 10. Patient Safety & Risk The steering group reported that a dedicated training facility for resuscitation training remains a concern. 11. Inpatient survey 2013 UCLH scored ‘about the same’ as other trusts for the survey questions, and remains ranked second amongst the London hospitals for patient experience. Professor Tony Mundy Corporate Medical Director April 2014

H

Agenda Item 10

Human Resources Committee Report

Board of Directors – May 2014 Summary Report from the Human Resource Committee (HRC)

1. Strategic Issues

The Committee met on 18th March 2014. Each Committee meeting begins with a discussion on strategic workforce issues. At March’s meeting this was the 2013 Staff Survey Results.

1.1 2013 Staff Survey Results

The Committee discussed the 2013 Staff Survey results. Overall 3,300 staff responded to the survey (48%), which is marginally lower than last year. Key results include:

• UCLH had improved on 29 of the 91 questions asked of staff. Performance had

deteriorated on 2 questions. The remainder of the question responses remained unchanged.

• 83% of staff would recommend UCLH as a place to receive treatment (consistent with last year’s result) and 73% of staff (up from 71% last year) would recommend UCLH as a place to work. 84% of staff agreed that care of patients is UCLH’s top priority and that UCLH acts on concerns raised by patients. These results place UCLH in the top 20% of trusts in the NHS.

• UCLH performs well in metrics that look at staff engagement – 72% of staff report

that they feel able to contribute to improvements at work and feel motivated and engaged with their work. Staff report that there is good communication between senior managers and staff.

• UCLH had high scores for those metrics relating to staff appraisals – 93% of staff

say they were appraised last year, a 10% increase on the 2012 result. UCLH had the highest score across the NHS for the number of staff agreeing that they had a well-structured appraisal. This demonstrates that significant progress can be made when there is a targeted action plan.

• The number of staff experiencing physical violence from patients has reduced,

falling to 10%. All physical violence incidents are reviewed by the Health and Safety Committee to see what lessons can be learned and all staff involved are offered support. This is another area where a targeted action plan has led to improvement.

 • 97.1% of staff were aware of the Trust’s values and behaviours (up from 89.4% in

2012) and 69.5% of staff said that the values and behaviours had influenced them in their work (up from 69.2% in 2012).

• Bullying, harassment and abuse from other staff is still a concern for too many staff

and a significant number of staff do not believe that we offer equal opportunities for career progression or promotion.

NHS England has published the results for all trusts – UCLH is compared against other acute trusts. The UCLH position for 2013 maintains the improved performance in 2011 and 2012 against the 28 key findings.

Nationally, UCLH has significantly improved (against acute trusts across England) in 3 key findings (the number of staff reporting they had an appraisal; reporting a well-structured appraisal; experiencing physical violence from other staff) and significantly deteriorated in one key finding (the number of staff having equality and diversity training in the past year). It should be noted that the UCLH training needs analysis requires staff to undertake equality and diversity training once only. The national results include an overall indicator for staff engagement as there is evidence that a high staff engagement score correlates closely with high levels of patient satisfaction. Staff engagement includes staff ability to contribute to improvement at work, staff recommendation of the Trust as a place to work or receive treatment and staff motivation at work. The UCLH score of 3.91 (out of 5) is in the top 20% for all acute trusts. UCLH has the 4th highest staff engagement score in the Shelford community, and the second highest staff engagement score in UCLP acute trusts.

The key findings for which UCLH is in the top 20% of all acute trusts are staff satisfied with the quality of work and patient care they are able to deliver; staff agreeing their role makes a difference to patients; staff being appraised; staff having a well-structured

appraisal; staff experiencing physical violence from patients; staff feeling pressure to attend work when feeling unwell; staff reporting good communication between senior management and staff; staff feeling able to contribute to improvements at work; work pressure felt by staff; the fairness and effectiveness of incident reporting procedures and staff recommendation of the Trust as a place to work or receive treatment. The key findings for which UCLH is in the bottom 20% of all acute trusts remain the availability of hand washing materials, the number of staff experiencing bullying, harassment and abuse from other staff, the number of staff working extra hours (both paid and unpaid), the number of staff believing UCLH provides equal opportunities for career progression and promotion and the number of staff experiencing discrimination at work. The local action plans developed in 2013 addressed some of the challenging results reported in 2012/13. The staff survey results for 2013 show that some of these initiatives have had a positive impact with improved scores for team working, communication and recommending the Trust as a place to work. Boards and divisions are reviewing the current local action plans in the light of the survey results and developing new local action plans for 2014/15 to ensure that UCLH’s performance is further enhanced. However, in order for UCLH to make a significant improvement to its results, there needs to be an increased focus on equality, reducing discrimination, bullying and harassment and improving the availability of hand washing materials.

2. Workforce Director’s Report 2.1 2014/15 Key Performance Indicators (KPI’s) for Workforce

The senior workforce team have recently agreed nine key performance objectives (detailed in the table below) which will support the 2014/15 strategic workforce stream to deliver improvement in nine key performance indicators.

Objective Target Date 1 To deliver a 95% compliance rate for completed appraisals of

staff by 31st October 2014 CEO Direct Reports -30th April 2014 Director reports - 31st May Bands 7 and above - 31st July 2014 Bands 1-6 – 31st October 2014

2 To have agreed and implemented job plans for all medical consultants To have agreed and implemented job plans for all nurse consultants

Medical & dental consultants - 31st July 2014 Nurse consultants – 31st

October 2014

3 To deliver the eRostering system to all rostered areas To deliver the time and attendance functionality to all non-rostered staff To deliver the Ipoint (bank) interface Trust wide To produce a delivery plan for real time acuity functionality

30th April 2014 August 2014 September 2014 June 2014

4 To deliver a sickness rate of 0.5% below the NHS average for London acute hospital trusts

31st March 2015

5 To deliver a 90% statutory and mandatory compliance rate To maintain a 90% compliance rate from November 2014 to March 2015

31st November 2014 31st March 2015

6 To deliver a Trust wide vacancy rate of 8% To deliver a front-line nursing and midwifery vacancy rate of 5%

31st March 2015 31st March 2015

7 To ensure all workforce policies remain in date and fit for purpose during 2014/15

30th September 2014

8 To safely deliver 0% non-specialist agency Trust wide 31st March 2015

9 To reduce turnover by 2% by March 2015 To reduce by 25% the number of leavers during their first year of service (currently 27% - target 20%) by March 2015

31st March 2015

The HRC endorsed the nine key performance objectives and asked to be kept informed of progress.

2.2 Workforce Performance Report

The Committee discussed the latest Workforce Performance report. The following issues were discussed at the Committee:

Item Issues/Action/Recommendation:

Vacancy Levels

As at the end of February, the vacancy rate for all qualified and unqualified frontline nursing and midwifery posts is 10.3%, compared to 10.9% in December 2013 and 12.5% in June 2013. The vacancy rate for qualified posts is 8.6% (down from 9.2% in December and 10.7% in June) and 17.6% for assistants (down from 20.3% in December and 21.4% in June).

Agency Usage

Total temporary staffing usage in January decreased slightly (15 wte) compared to the same time last year. Work continues to eliminate the use of non‐specialist agency workers. Agency has been ‘switched off’ in all N&M areas except ITU, Theatres, NNU and A&E and strict measures are being put in place to reduce temporary staffing overall in N&M by limiting authorised usage.

Recruitment Services

For new starters in January, we saw a small increase (2 days) in the overall time to hire from EC1 received to start date to 14.1 weeks (still below the KPI of 14.6 weeks).

Sickness Absence

The sickness absence rate in Month 10 was 3.7% which is an increase of 1.2% from the same period last year. In recent months the Trust has increased the robustness of sickness absence reporting via ESR Manager Self Service and e-rostering. The Employee Relations team continue to monitor sickness rates and contact relevant managers when an employee reaches one of the trigger points as defined in the Trust’s Sickness Absence Policy.

Performance Appraisals

Overall, total to date, the Trust has achieved a 96% appraisal rate.

Statutory and Mandatory Training

Subject matter expert scrutiny following the de-bucketing of posts within ESR has uncovered a number of issues in the application of the Training Needs Analysis within the Learning Management System (LMS). Post-level review has been undertaken and applied to the TNA in the LMS resulting in 1002 posts having changes applied to their requirements. Staff who have changes applied to their requirements are being written to during March in order to advice and direct towards training access. It is this change primarily which has resulted in a dip in compliance levels in January data. Work continues in this area in order to improve take up with mandatory training.

Job Planning The current percentage of NHS job plans received thus far is 81% which breaks down by Board as follows: Medicine 93.2% Surgery & Cancer 72.8% Specialist Hospitals 82.4% Four divisions have achieved 100% returns for NHS job plans: Emergency and Acute Medicine, Pathology, Infection and Paediatrics.

4. Next Meeting of the Committee

The next meeting of the HRC is scheduled for 20th May 2014. All Board members are welcome to attend the HRC meetings.

Jeremy Over Acting Workforce Director For Richard Murley Chairman & HRC Chair April 2014

I

Agenda Item 11

Finance & Contracting Committee Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST FINANCE & CONTRACTING COMMITTEE REPORT TO THE BOARD OF DIRECTORS

1. Introduction 1.1 This report updates the Board of Directors on the issues, considered at the meeting of

the Finance and Contracting Committee (FCC) on 7thMay 2014, relating to the financial performance and contracting position of the Trust as at 31st March 2014.

A brief update is also provided on issues discussed at the FCC meeting of 2nd April 2014, which have not been previously reported to the Board of Directors

1.2 The Board of Directors is asked to: • Note the financial performance for the full twelve months of the 2013/14

financial year, and associated financial issues, • Endorse the declaration, which was submitted as part of the Quarter 4 financial

return to Monitor, that the Trust will retain a continuity of service risk rating (CoSRR) of at least 3 for the next 12-month period,

• Note the contracting update, and • Note the issues discussed at the previous FCC meeting of 2nd April 2014.

2. Finance Director’s Report 2.1 The Trust’s full year income and expenditure position, when reported prior to donation-

related adjustments, was a surplus of £4.6m (£2.6m ahead of plan). The Finance Director mentioned that this position, whilst lower than reported last year, included a £3m depreciation timing adjustment that had followed from a detailed analysis of the Trust’s asset register (see paragraph 8.9 below). The Finance Director pointed out, however, that the majority of this year's adverse impact will flow back favourably into future years.

Table 1– 2013/14 M12 financial position

2.2 The overall income and expenditure position, as reported in the unaudited draft accounts, as shown in table 1 above, was a surplus of £18.3m. This position included the impact of:

a) Donation adjustments, i.e. charitable income and donated asset depreciation (-£0.5m), and b) Exceptional items (£14.3m) relating to net impairment reversals of £16.0m which had arisen as a result of the year-end revaluation of Trust properties

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(finalised following discussions with the District Valuer), & net impairment costs of £1.7m, resulting from a recent exercise undertaken to disaggregate the fixed asset register- also see paragraph 8.9 below.

2.3 As usual for a quarter-end, a detailed assessment of balance sheet provisions and central budgets had been undertaken, which resulted in some further in-month changes to the financial position, including the release of the remaining £2m from the £5m Board contingency.

2.4 The month 12 results, as reported in the Trust’s Quarter 4 financial return to Monitor, represent a CoSRR of 3.

3. Clinical Board Performance 3.1 The Committee congratulated Medicine Board on exceeding their 2013/14 plan target,

with a year-end favourable variance of £0.1m mostly driven by activity income above plan of £4.3m (5.3%), combined with unplanned commissioner investment of winter pressure funding and reinvestment of performance penalties offsetting overspends within Medical Specialties and Emergency Services.

The Medical Director for the Medicine Board informed the Committee that there had been some significant additional investment in Medical Specialities in 2013/14, particularly in the care of the elderly services, and he was confident that this would not only generate an improved level of financial contribution for the division in 2014/15 but would also have other non-financial benefits, e.g. lower length of stay and improving the patient experience.

3.2 The Committee was also pleased to see that Surgery and Cancer Board recorded their fourth on-plan month. Whilst the board ended the year £3.8m behind plan, this had arisen mainly from the adverse performance in the first half of the financial year. The Committee also noted that the underlying neutral run-rate achieved in recent months should ensure the clinical board carried forward a significantly improved financial position, compared to recent years, into 2014/15.

3.3 The Medical Director for Specialist Hospitals informed the Committee that whilst the Queen Square division reported a £4.7m year-end shortfall against plan, strong financial performance in the other divisions meant that the board's overall year-end position was a £1.2m adverse variance.

The Medical Director outlined some of the reasons for the poor financial performance at Queen Square highlighting the impact of unachieved QEP, nursing pay overspends (some of which resulted from the introduction of a new nursing rota system in 2013/14)and the imposition of referral-to-treat (RTT) financial penalties.

The Chief Executive informed the Committee that reducing UCLH’s exposure to RTT penalties was one of the key priorities for the Trust in 2014/15. The Committee noted that an update on work being done to reduce RTT penalties, alongside the implementation of CQC-related actions, would be presented separately to the Board.

The Committee also asked if the Medical Director for Specialist Hospitals could bring back an update on progress that had been made by Queen Square in delivery against the short term actions identified by the division as part of its recovery plan, taken to the August 2013 FCC meeting, to improve financial performance.

4. Efficiency and QEP 4.1. The year-end QEP position showed that the Trust delivered savings of £36.0m, an

achievement of over 98% of the planned target (£36.5m).Overall, the full-year impact of 2013/14savings plans was projected to yield £36.6m of efficiencies – an overachievement of £0.1m.

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5. Balance Sheet and Cash

5.1 The Trust’s cash balance at 31st March 2014 was £130m, which was £15m behind plan. This shortfall against plan reflected the difficulty the Trust had experienced in 2013/14 in collecting over-performance payments from CCGs.

The cash balance at 30th April 2014 was £135m, which was £20m higher than plan, reflecting the continued, concerted efforts by the finance and contracting teams to ensure that outstanding debt was collected.

6. Quarter 4 Finance Declaration to Monitor 6.1. The Committee noted that the financial and governance narrative, which formed part of

the Trust’s Quarter 4 report to Monitor, as submitted on 30th April 2014, showed that the Trust was unable to confirm the statement that the Board is satisfied that plans in place are sufficient to ensure: on-going compliance with all existing targets (after the application of thresholds) as set out in appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards, due to:

• The Trust's failure to achieve the referral to treatment times for admitted and non-admitted closed pathways and incomplete pathways during Quarter 4, and

• The Trust's failure to achieve the 62 day wait for first treatment for cancer patients referred within 2 weeks

6.2 The Committee also noted that the narrative highlighted twof urther issues associated with targets and indicators concerning delivery against: Clostridium difficile, and 62 day wait for treatment following referral from screening service.

6.3 Given the absence of the Board of Directors meeting in April, the April FCC had instead agreed the Quarter 4 finance declaration that the Trust anticipated remaining at a CoSRR of 3 or higher for the 12 months ending 31stMarch 2015. In support of the finance declaration, the Committee noted that the 2014/15 financial plan had shown a risk rating of 3 for all four quarters of 2014/15. There was also significant income and expenditure ‘headroom’ available to the Trust, driven by a high level of liquidity. In order for the risk rating to reduce to a 2 at Quarter 4 2014/15 the Trust’s financial position would need to deteriorate by c. £25m, with an even greater level of deterioration needed in the other three quarters of the financial year.

6.4 The Committee noted that the finance declaration was also predicated on a number of assumptions as included within the following wording: “The declaration is signed subject to the following risks and concerns:

• It may not be possible to reach a reasonable agreement around levels of both activity and payment with commissioners as part of 2014/15 discussions,

• Regular cash payments relating to the commissioner contract values may not be received,

• Project Diamond funding may potentially be reduced or removed, and • Winter pressures in 2014/15 may result in increased costs that are not funded.

The Trust’s signing of the declaration is contingent upon these risks not materialising. The Trust would also like to note that at this stage in the financial year that the Trust’s efficiency programme for 2014/15 has not yet been fully identified. Achievement of this programme will be a critical factor underpinning the planned surplus.”

6.5 The Board of Directors is asked to provide their formal endorsement of the finance.

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• NHS England, where there currently remained a significant financial difference between the respective positions.

7. Contracting Update

7.1 The Committee was pleased to note that the Trust had now agreed2014/15 contract baseline values and main contractual terms and conditions with the North East London CCGs. The Chief Executive informed the Committee that the Trust’s contracts team was in the process of finalising the contract documentation, with the aim of being in a position to shortly move to signature.

The Committee noted that the early conclusion of the contract negotiations would allow both parties to focus on contract management, and in particular develop an improved joint understanding of the drivers behind in year activity flows and variations.

7.2. The Chief Executive informed the Committee that the Trust had yet to reach agreement on 2014/15 contract values with NHS England, and whilst progress was continuing to be made in negotiations there remained a number of material differences both in activity volume assumptions and on pricing issues driven by the emerging financial pressures on NHSE.

8. Summary of issues discussed at the FCC meeting of 2nd April 2014

8.1 This section summarises the discussion at the previous FCC meeting, which due to the absence of a formal Board meeting in April has not yet been reported to the Board.

8.2 The Committee reviewed the proposed final version of the two-year financial plan for the Trust, together with the draft financial narrative. The Finance Director confirmed that the broad framework of the plan (surplus/contingencies) had not changed since the previous iteration presented to FCC, however more work had been done, since then, to address the level of risk in the plan, including:

• “Star chamber” sessions with clinical boards over the course of March, which had resulted in a reduction in the overall 2014/15QEP gap from £43.4m to a final figure of £38.4m, and

• The identification of further schemes to address the 2014/15QEP target.

8.3 Medical Directors provided updates on the work being done within their boards to identify new QEP-related schemes for 2014/15. The Committee noted that whilst £23.7m of “risk-assessed” 2014/15 QEP schemes had now been identified, clinical boards and corporate directorates remained focussed on ensuring that the target was delivered in full.

8.4 As part of a discussion on the costs, within the two-year plan, associated with undertaking clinical activity growth, the Chairman asked for a proposal outlining a more robust analysis, and monitoring, of productivity in the Trust, to be brought back to the Committee.

8.5 The Committee agreed that the presented financial plan, incorporating a QEP target of £38.4m in 2014/15, should form the basis for the two-year operating plan submission to due to be submitted to Monitor on 4th April 2014. In addition, the Committee also agreed the financial narrative, included within the Operational Plan Document submission, subject to the inclusion of:

• Further information on liquidity, particularly relating to the implications of the Trust’s strategic developments over the next two years, and

• A caveat to recognise the higher level of uncertainty associated with the figures included within the second year of plan.

8.6 The Director of Performance and Planning provided an update on 2014/15 commissioning negotiations with:

• North East London CCGs, which were continuing to progress well, and

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8.7 TheLondon focussed diabetes service. The Committee

8.8 f £4.5m, which was

8.9

b)

r Harry Bush Richard Alexander hair of FCC Finance Director th

Committee also engaged in a brief discussion on work taking place within North to provide an integrated patient

noted that the Medical Director for Medicine would be providing a presentation on the clinical integration programme at UCLHt o the May Board meeting.

The Committee noted that the Trust’s month 11 year-to-date income and expenditure position, before charitable donation adjustments, was a surplus o£3.3m better than the planned position.

The Finance Director informed the Committee that month 11 financial performance had been better than expected, and as a result there had not been the need to release any further contingency. £2m of contingency therefore remained available in month 12.

The Finance Director drew the Committee’s attention to two issues with financial implications fort he 2013/14 year-end position and 2014/15 plan:

a) The Trust had received draft District Valuer (DV) valuation figures for 31st March 2014, which indicated an increase in the value of the Trust’s land and, in particular, buildings. The implications of this, in terms of a higher level of PDC dividend charge (in both financial years) and increased depreciation costs (in 2014/15 only), were significant. Following a review of the Trust’s fixed asset register the Trust was disaggregating assets on the balance sheet which were previously grouped together, in order to comply with the relevant accounting guidance. The result of this disaggregation exercise was that a number of assets had been assessed to have a considerably shorter useful economic life (therefore depreciate faster), and a number of asset impairments had been identified as required. The financial impact of this was a £3.1m negative movement on the 2013/14 I&E position as a result of the accelerated depreciation charge and a further £1.7m reduction in the value of assets on the balance sheet due to the impairment.

DC8 May 2014

J

Agenda Item 12

Report of the Audit Committee Meetings held on 25th March & 22nd April

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UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST Report to Board of Directors – 14 May 2014

MAIN POINTS FROM THE AUDIT COMMITTEE The Audit Committee (AC) met on 25 March and 22 April 2014 to consider the following important matters:

1 Internal Audit (IA) 1.1. Assurance and advisory reports AC received and reviewed nine assurance and three advisory reports with varied findings. One of the reports was red rated; more than one report had high priority recommendations. The reports and ratings were:

Divisional Business Planning amber/green Purchasing and procurement review - Eastman Dental Hospital amber/green Quality Accounts – data quality amber/green Private patients and Overseas patients red Contract Register and Compliance with Standing Instructions amber/red Trust exit procedures advisory Patient Level Information and Costing System green Specialised Commissioning Review advisory Income – Payment by Results green Accounts Receivable green Payroll amber/green Information Governance: IG Toolkit advisory

AC noted all the reports including that management accepted the recommendations and had in place action plans, with dates to deliver the actions, to implement gaps in the controls identified. Discussion focused on the following reports.

1.2. Private patients and Overseas patients IA focused on whether the trust systems enable it to recover all income relating to private and overseas visitors. The review looked at how well job plans were completed, if all the appropriate documentation is held on file for consultants who undertake private practice; and whether activity undertaken within UCLH is appropriately identified and billed. It excluded work undertaken by HCA.

AC noted the potential implications of non-compliance and that the Executive Board (EB) had considered the report. AC was advised that the job planning process was being tightened up for 2014/15 to improve recording of private patient sessions and to support the appraisal and annual declaration of interest process. Also, a working group would be set up to oversee delivery of the actions including the six high priority recommendations; this would be chaired by the Finance Director.

1.3. Quality Accounts – data quality The review focused on whether data collected for five patient safety/quality indicators (falls, pressure ulcers, dose omissions, cardiac arrests and vital signs) enabled the Trust to accurately monitor performance in those areas. Overall the findings indicated that the metrics were suitably designed with one particular area of concern raised about vital signs data. However, AC were concerned to note that the vital signs data was not always returned by every ward therefore the calculation ( based on the number of returns) could give an inaccurate picture of the overall Trust position and whether each ward was interpreting the question in the same way. AC asked that the report be referred to the QSC to discuss highlighting the vital signs issue to them in particular.

1.4. Payroll IA looked at a number of issues including the leaver process and travel and expenses claims. The former involved many staff. AC noted that the potential for financial loss had been minimised since a previous audit although a number of overpayments still occurred. The Finance Director advised that all overpayments were followed up and

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much of it was recovered. He also said the Workforce Directorate are putting in place new exit procedures to support managers who deal with staff leaving the Trust. This would be a one-stop shop approach including cancellation of ID Cards, collection of any technology e.g. mobile phones as well as informing payroll.

On travel and expenses claims AC noted that the findings included incomplete documentation. The report advised that payroll undertook retrospective reviews of claims. AC asked management to consider if the checking process for claims could be strengthened.

1.5. Accounts Receivable AC noted that a review of aged debt had been undertaken. The majority of outstanding debt at November 2013 was NHS debt (either CCGs or NHSE) much of which had now been collected. The Finance Director advised that steps had been taken to limit the extent of a debt building up from a non-NHS organisation more quickly than previously. This action was taken following an audit in 2012. AC noted that the current finance system (at time of audit) did not allow for credit limits to be set for organisations; these were now in place.

AC noted the status of unimplemented recommendations from past audits.

2. AC discussed the IA Strategy for 2014 – 2017 and the annual plan 2014/15 prepared by Baker Tilly. Both had been prepared following the IA Risk Universe work undertaken in 2013/14. The plan includes annual audits for high risk areas and provides support on the achievement of the objectives. AC approved the plan which has been reviewed and approved by the EB.

3. AC received and noted the draft Head of Internal Audit Opinion 2013/14 of

‘significant assurance’. It advised of the issues to be included in the (AGS) which included two red opinion audits. The draft opinion was given at both meetings and is not expected to change.

4. Following a review of the IA Service Baker Tilly were reappointed as the internal audit

provider for the 2014/15 year.

5. Assurance Issues AC reviewed the Annual Governance Statement (AGS) and a report on the Trust’s

Provider Licence both of which included supporting evidence on the processes of assurance. AC felt that the information provided assurance relating to risk management and internal control measures and approved the format of the AGS. This would be presented in final form to AC and the Board in May.

6. Draft Clinical Audit and Quality Reports 2013/14 Sandra Hallett, Director of Quality and Safety presented a report on progress made to

improve clinical audit since 2012 and the draft annual clinical audit report. AC noted that the quality and type of audits had been strengthened and more clinicians were engaged in audit. The next step was to establish more consistency in audits trustwide. AC felt that clinical audit could be further strengthened by including a number of re-audits and was advised that a programme of repeat audits was in place. IA would also identify which clinical audits were being re-audited in the 2014/15 plan and report these to the QSC. Clinical audit will be one of the topic sessions the AC will cover in 2014/15 to assist them with their work.

Regarding the draft quality report, Sandra Hallett advised that the report had been reviewed by the QSC who had referred it to the AC for review. The report by provided a table of clinical audits to demonstrate that elements of the clinical audit plan, referred to in the annual clinical audit report, are derived from the clinical quality priorities. Comments had been invited on the quality report from external organisations; Camden OSC would not be providing comment this year.

- 3 –

7. Annual Accounts and Report 2013/14 AC received the draft unaudited Accounts and received a report from management on the revaluation of the Estate. The unaudited Accounts were subsequently submitted to Monitor. The draft commentary on all the key accounting judgements made by management were reviewed; these will be reviewed again when the final accounts are presented at the May meeting.

AC reviewed draft financial accounting policies and noted that the proposed Consolidation of Charity Accounts did not apply to UCLH; Deloitte confirmed this view.

AC discussed and made some suggested changes to the draft Annual Report noting that new guidance had recently been received and some sections would need to be revised. The final version will be presented at the May meeting.

8. Risk Report

AC reviewed an early draft of the risk report for the fourth quarter (end March 2014) and noted that this was subject to executive review and challenge and may change. AC noted that two new red risks had been added to the register and two risks had been removed AC focussed discussion on how risks were described and the mitigation in place to manage risks including the arrangements for managing the RTT targets. The chair of AC advised that risk management and strategy would be a topic session in 2014/15 as would ICT.

9. Counter Fraud AC reviewed the Local Counter Fraud Specialist’s (LCFS) annual report which outlined the key work undertaken in 2013/14 including the programme of work to raise awareness of fraud across the Trust and a summary of casework. It was noted that there had been increased engagement with staff and fraud was covered at induction.

LCFS also presented an annual workplan for 2014/15 and agreed to produce a ‘heat map’, an audit universe for fraud, with the Q1 report. The map would focus on areas of risk both in and outside the Trust. AC approved the plan.

10. Other matters

AC considered a recommendation from the EB to revise the Scheme of Delegation (SoD). The need for the change arose from an EB committee review which suggested that the capital approval process should be revised to enable low value schemes to be approved at Clinical Board level. AC proposed a useful amendment which was incorporated into the revision and were assured that the new arrangements would maintain appropriate financial governance. The AC also supported a revision relating to the thresholds for authorisation of waivers.

Deloitte reported on their Q3 Audit and the continuing work. Included in the report was a briefing on the risks and challenges of introducing new EPR/PAS system which reinforced the need for clinical engagement. AC also received an early draft of the management letter of representation which it was agreed would be circulated to the EB.

AC discussed regular papers on waivers, losses and special payments. AC reviewed the going concern statement which it noted must be prepared according to the concept of a going concern in the public sector. AC supported the statement

Finally, the AC members reviewed and discussed a report of its effectiveness and noted that overall it operated well. Some improvements were discussed including a plan to hold four topic sessions in 2014/15 to give members a more detailed briefing on a number of issues the AC considers.

Rima Makarem Audit Committee Chair

K

Agenda Item 13

Minutes of the Audit Committee Meeting held on 28th January

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Tuesday, 28thJanuary 2014

Present: Audit Committee Members RimaMakarem Non-Executive Director and Chair (RM) Diana Walford Non-Executive Director (DW) Kieran Murphy Non-Executive Director (KM) Non-Members Richard Alexander Finance Director (RA) Mike Foster Deputy Chief Executive (MF) Jonathan Gooding Deloitte (JG) for item 3 Nick Atkinson Baker Tilly (NA) Clive Makombera Baker Tilly (CM) Mike Peasley Interim Chief Accountant (MP) Pia Larson Interim Director of Procurement (for item 3) Tracey Wain Deputy DirectorCapital Planning & Strategic Estates Development (for

item 3) Adam Cook Head of Facilities Management and Commercial Services (for item 3) David Wherrett Director of Workforce (for item 6) Simon Blazer Head of Finance (Income) (for item 3) Item Matters Covered Action 1. Apologies for Absence Harry Bush, Tonia Ramsden 2. Minutes of the Meeting held on 28thNovember 2013

The minutes were agreed following clarification from RA that SFI’s and SoD’s review was not ready, there will be an update to the Scheme of Delegation in March with a full update of SFI’s and SoD’s in the new financial year.

3. Matters Arising

Ci Fixed assets. RA explained that the Fixed Assets Register (FAR) accuracy is acceptable from a financial accounting point of view but it is not acceptable as a means of identifying assets. The disaggregation process has completed the first phase of identifying as far as possible individual assets within the FAR and as a result there is a better process in place for recording new assets. The financial effect of

1

Item Matters Covered Action

disaggregating the recorded assets is being worked through which will include a recalculation of depreciation as a result of any changes to assets previously incorrectly categorised. The financial impact will be quantified by financial year end. Cii Private Patients monitoring. Simon Blazer outlined the process for recording NHS and private patients for billing purposes and set out the 5 stages in the process that operate separately from each other as a manual process with checks during the process, recognizing that the current in-house developed billing system is no longer fit for purpose. RM asked when a new system might be available and what functionality will it contain. S Blazer responded that the plan is to have a new system in the new financial year but the timing of that has been affected by the implementation of the new accounting system. RA added that a Private Patient system will be implemented in the new financial year recognising that the trust needs a single process to pull together all the strands of information to provide a streamlined system. A review of the current process had identified an underbilling of £2m. DW asked what system would be used. RA responded that the new accounting system does have a billing module and there are third party systems also available, the options are open. It must be recognised that it is not necessarily an IT problem but a culture change required in the process, the challenge is to get the right balance between control and information recording. RM asked how the trust would safeguard against non-payment. S Blazer responded that insurance funded patients are asked for a letter of guarantee from their insurer, package deal patients are required to pay up front and that other private patients are required to pay 115% of the estimated costs at the commencement of treatment. TM asked what proportion of PP is insurance. S Blazer responded that he did not have that information to hand but it can be provided if it is required. RM asked if there could be an update regarding how the trust proposed to tackle standardization and a defined timescale. ACTION: Update about how it is proposed the standardisation of the process is to be tackled and a defined timescale.

RA

2

Item Matters Covered Action

Ciii Estate infrastructure risk T Wain explained that a non-invasive estate condition survey has been carried out to inform the issue of the adequacy of the backlog maintenance programme. The outcome has supported the continued focus on the replace and refresh impetus but will be a challenge to fund £6m cost identified in the new financial year. RM asked a question raised by HB, can a reassurance be given that the trust has the skills and the people to carry out this work. D Cook responded that there has been an intensive team review to ensure the delivery of the service is aligned with the needs of the trust, ensuring compliance monitoring and an understanding of the needs for building maintenance. RM asked how much faith the trust has in the current service provider. D Cook responded that the service provider has strengthened their service team and that their contract includes service provision to the PFI and non-PFI buildings. DW commented that recent sampling indicated that there is still a problem with water quality and bacteria in the water supply. What is the regime for testing and treating the water supply. ACTION: update to be presented to the next meeting. RM asked how the trust decides priorities given that some buildings are quite old and some properties are going to be disposed. T Wain responded that a risk assessment is carried out that considers the impact of that risk and the funding available through the Cross Trust Capitalisation Panel. However, it is possible that not all risks have been identified, it is a balancing act. RA added that this is the reality of funding in relation to what is included in tariff and what is not, especially if costs are higher than funding. An example of the Trust’s investment in its estate is seen in the investment in the RNTNE since it came into the trust when it was in a relatively poor state. Finance System Implementation update RA outlined the reasons for the delay in the implementation of the Finance System to the 1st April 2014. This was due mainly to problems with data migration and project planning issues impacting on a successful implementation in the current year.

MF

3

Item Matters Covered Action 4.

RM asked on behalf of HB whether the delay to the financial system was hiding a risk in the absence of the new system. RA responded that a paper will be presented to the next meeting on the resources required to complete the implementation and the governance arrangements now that a new level of project management has been introduced. This has been done to identify the critical path of the project to ensure a successful implementation in the new year. RA added that the deferment was as a result of concerns relating to the data migration impacting on the completion of the implementation in the current financial year. ACTION: paper setting out the resources identified and the governance arrangements for the new accounting system. Waivers to SO’s and SFI’s P Larsen commented that the value of waivers is higher than last year but remains comparable to previous years. The two major waivers included in the report were the Capita and BMI contracts. Capita The Capita contract is a tri-partite arrangement and a further partner could not be easily brought in. RA added that it was believed to be important that one contractor managed both the IT and software provision. DW asked if the trust was in a difficult position with only having one contractor. RA responded that situation was mitigated largely because Capita have a large volume of NHS contracts. BMI RM asked how much the choice is affected by consultants’ private practice. P Larsen responded that it is a boundary problem and she does not believe it is an issue. SFI’s and SoD’s are to be reviewed in relation to approval limits and who can approve waivers. However, there are valid reasons why waivers are used. RM asked if an update can be provided when SFI’s and SoD’s are reviewed and the proportional value of waivers of non-pay. KM asked if the remaining 208 waivers was represented by the

RA

4

Item Matters Covered Action 5.

remaining waivers value. P Larsen responded that it did, equating to an average of £20,000 per waiver. RM asked about the procurement dashboard from the deep dive review. PLarsen responded that there is a paper to EB the next day and FCC the following week arising from the deep dive review recently carried out. ACTION: update on review of authorisation levels, in relation to waivers, in the SFI’s and SoD’s. Internal Audit Sickness absence update NA outlined the key reasons for a red rating; it is a combination of data quality, concern about the system ability to collect information and the failure to follow-up non receipt, culture problem in the organisation in relation to sickness absence recording and that information is not retained. It was acknowledged that the Trust is moving to an e-rostering system which makes linking absence reporting to shift covering easier. RA added that the Directors review concluded that e-rostering is the most appropriate mechanism to address this issue. RM asked if there was a differential in reporting where e-rostering was in use. D Wherrett responded that the audit was done during the implementation of e-rostering, the February 2014 migration should give visibility to non-compliance, but this does need to be reinforced by policy. DW asked if there was a mechanism to remind managers where there is no data. D Wherrett responded that replacing a paper based process with a reporting tool would allow review of data and enable a reminder issuing process to be established. NA added that in the planning for the next audit they will be looking at the figures and compare them to other trusts. Currently, UCLH has the lowest sickness rates but is this because of the issue of data quality. NA added it is important to note that a manual reporting and escalation process exists to check the system is working properly rather than rely on data. DW asked if managers are chased where they are not entering data. D Wherrett responded that the reporting of absence information is based only the data from those departments where returns have been received and does not include staff numbers in departments that have

P Larsen

5

Item Matters Covered Action

not provided data. Internal Audit Progress Report and Recommendation Tracker NA reported that 8 final reports had been issued and that the red rating is covered. RM asked on behalf of HB – to what extent is there a review of patient complaints and the patient customer experience. NA responded that external risk assessment looks at learning lessons approach. Feedback from the report “A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture” feeds into this process. Medical Devices NA explained that there had not always been a link working between Medical Physics system for recording equipment and Capital spending. This made it difficult to ensure equipment was not in need of replacement. The action plan was not clear if it had been followed through, there were a number of actions. RM asked why is it rated Amber/Red rather than Red as in sickness reporting. NA responded that the Trust was already resolving the Medical Devices issue whereas there were a number of things that the Trust did not know in relation to sickness reporting. RM observed that it is a culture issue and that there must be a handover process to ensure work is picked up and not dropped. RA responded that there is a good practice of action tracking and reporting, the trust must ensure that the culture is changed to improve this. RM asked if the equipment library deadline of 31st March is achievable. RA responded that the trust is on track to achieve the PID by that date. RA added that the system relies on a manual process and technology is needed help resolve equipment recording issues, we need confidence in the team to ensure working together actually happens to ensure stakeholder engagement. RM asked if this demonstrates that different pockets in the trust are working differently and this is not being picked up. RA responded that there are more stakeholders in the process than previously thought. The PID should demonstrate an improved engagement when it is produced, but this is a difficult balance to achieve. RM asked what are the boundaries and timelines. There is a need to track what equipment the trust has and where it is located.

6

Item Matters Covered Action 6.

RA responded that if the PID recommends an equipment library then it will be put into the procurement process to solve the problem. There is a need to bring together all the strands of the recording systems that do exist. NA commented on the Amber/Red rating for the Fixed Asset Register and that there were no surprises in the audit, it depends on the issues identified previously related to other recording systems and the project to review equipment library options being resolved. Audit reporting and follow up. NA commented on the current layout of the report and recognised that it is not useful and does not add value. RM asked why there were a large number of recommendations with no follow-up. C Makombera responded that there were a large number of low priority recommendations and that a lot of time was spent supporting managers which meant a time lag between the report and a follow-up audit with these managers. Medium and High recommendations are reported in the main report which does go EB. NA added IA will ensure that low priority recommendations are followed up on an annual basis. RM asked if IA review outcomes from recommendations have had a positive outcome. NA responded that this is difficult to do where the recommendation is in relation to, for example, the completion of a document but where it is in relation to an overpayment of salary then that is checked during the follow-up in the next audit. DW asked about GP discharge letters and the problems identified. NA responded that there will be a paper for the next meeting. ACTION: outstanding recommendations to be reported, and paper to be presented to the next meeting setting out the remaining issues in relation to GP referral letters. External Audit Deloitte Quarter 2 report JG reported in their Quarter Two report that they had completed substantially all of their planned procedures for quarter two except for information not available on property valuations and research and development income, although the work performed did not identify any new significant risks and that this work will be completed in quarter 3.The system risk associated with the implementation of the new accounting system will be considered in the new financial year

NA

7

Item Matters Covered Action 7.

following the revised implementation date. JG outlined the issues within the report in relation to the attention the Deloitte will be giving in the coming review. This includes;

• revisiting the accounting system implementation. An additional cost of £15,000 has been identified for this work.

• testing of audit risk, that there are no adjustments and recognise revenue risk

• Joint Venture will be reviewed and continue to monitor. • Consolidation of charities accounts into trust accounts,

conclusion to be set out in a paper. • Reclassification of debtors into NHS and Non-NHS.

RM approved the additional cost of work in relation to reviewing the new accounting system. JG explained that revenue recognition and the lack of signed agreements with Commissioners is causing a cashflow shortage in-year. It was recognised that Specialist Commissioners are now in place and there is a willingness from them to be more assertive and challenge the Trust which needs to be recognised. MF added that it has taken a long time for contracts to be agreed this year as a result of the changes implemented in the NHS at 1st April 2013 which has delayed the subsequent billing. There is also an issue between some commissioners in parts of London to agree contract terms between themselves that is affecting the Trust, although this represents a small element of the overall value of contracts. KM asked why are Deloitte considering the Joint Venture as possibly being on an equity basis. JG responded that there is a choice under IFRS accounting arrangements but the trust policy is to follow the equity route which is suitable treatment as the draft arrangements stand at the moment but this aspect will be kept under review. Risk Management and Assurance Frameworks G: Risk report as at 31st December MF presented the Risk Report as at 31st December, reporting that there are no new Red risks identified this quarter. The CQC visit would cause concern if new risks were identified. The likelihood of a revisit and any further risks is considered to be low. The key highlights review identified capacity constraints and a number of measures were put in place to mitigate risk and has reduced the risk rating from 20 to 16. Performance of 95% has shown an

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Item Matters Covered Action

improvement, this will remain a high risk until the ED scheme is completed in 2016. Capacity risk has seen good progress in bed provision, the effect is seen in emergency care pathway. Pathology remains a risk although this risk should improve when the JV is signed. The timescale has been affected by a VAT issue that is in the process of being resolved. RM asked if this was likely to be resolved in the current financial year. MF responded that this is unlikely although there is no definitive answer to timescale at the moment. Majax has experienced two incidents that have highlighted that the staff contact system in the case of an emergency is not as robust as it should be. The manual controls have been enhanced until an automated staff contact system is in place that confirms whether contact has been successful. A&E 4 hour waits has not featured previously as a risk in its own right, CQC report highlighted reputational risk and changes have been made which should demonstrate core improvements. H: Assurance Framework as at 31st December MF explained that the reports are drawn from Lead Directors objectives, the focus is on a method for testing using a 10% random sample, and where one or more of the components of the objectives have worsened and there are 7 amber/red ‘Gaps in Control’. This work has not been finalised at this stage but it is planned to complete prior to Board papers being issued. There are 7 amber/red gaps in control, 4 objectives rated as red by directors in terms of delivery (with 3 at amber/red). All other gaps in control, assurance gaps in action plan progress have been self-rated by directors as amber/green or green. Regarding amber/red ‘Gaps in control’ there are 6 largely related to delays in completing actions which were planned to be implemented to ensure additional controls. Regarding ‘delivery of objective plan progress’ the four red ratings relate to delivery challenges reported by directors. Waits for Planned Care is where UCLH is Provider of choice but is red rated for planned waits from risk of capacity. It is planned to report this in more detail at the next meeting ACTION: update on Waits for Planned Care from Assurance report at the next meeting. It was noted that the checklist does not capture problems in the Cancer Centre and changing the patient experience and does not work as a lessons learnt.

MF

9

Item Matters Covered Action 8.

ACTION: RM to meet with D Probert to clarify the missing issues Financial and Accounting Issues Annual Report and Quality Accounts Timetable. The timetable was noted.

9. Any items requested for Cross-Committee referral. Healthcare Acquired Infection report was discussed at the January QSC meeting.

10. Audit Committee work programme

No comments.

11. Any Other Business

No other business.

12. Date and time of next meeting.

Tuesday 25th March 2014 at 9.00am in the Trustees Boardroom, 5th Floor East Papers deadline: Monday 17th March 5pm

Note: Part of Section 4 has been redacted owing to commercial sensitivity issues.

10

L

Agenda Item 14

Minutes of the Audit Committee Meeting held on 25th March

1

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Tuesday, 25thMarch 2014

Present: Audit Committee Members RimaMakarem Non-Executive Director and Chair (RM) Diana Walford Non-Executive Director (DW) Kieran Murphy Non-Executive Director (KM) Harry Bush Non-Executive Director (HB) Non-Members Richard Alexander Finance Director (RA) Tonia Ramsden Director of Corporate Services (TR) Tim Jaggard Deputy Director of Finance (TJ) Nick Atkinson Baker Tilly (NA) Clive Makombera Baker Tilly (CM) Mike Peasley Interim Chief Accountant (MP) Julian Hunt Deloitte (JH for item 6) Heather Bygrave Deloitte (HBgve) Mark Trevallion Baker Tilly (MT) Hannah Wenlock Baker Tilly (HW) Adam Cook Head of Facilities Management and Commercial Services (AC for item

3) Peter Wilson Consultant, Clinical Microbiology & Virology (PW for item 3) Rachel Maybank Associate Director of communications (RMbk for item 8) Item Matters Covered Action 1. Apologies for Absence There were no apologies 2. Minutes of the Meeting held on 28thJanuary2014

The minutes were agreed.

3. Matters Arising

Matters Arising item 200 Project Evaluation RM updated the Committee with the outcome of a discussion with David Probert regarding the ability to support projects in the Trust. This item to be included on the AC agenda for September meeting. ACTION: Projectsupportand evaluation to be included on September AC agenda.

David Probert

2

Item Matters Covered Action

Matters Arising item 211 GP referral letters NA confirmed that a number of recommendations had been signed off and that Internal audit will request the evidence to support this. ACTION: Internal Audit to request evidence supporting recommendations sign-off. Water Quality. AC confirmed that a report was being drafted to be presented to the Estates Steering Committee and EB regarding the risks arising from any issues with water quality. The report will include action taken at the Cancer Centre to replace taps and changes to cleaning and gardening arrangements to minimize risk. Arrangements are under way to decant services from the Rosenheim Building in preparation for its closure. DW asked that the report also be presented to Q&SC. Ci Finance System update RA outlined changes to the Governance arrangements and the project team structure, confirming that the Project Governance Board also includes a representative from the supplier organisation. RM asked what alternative arrangements were in place and did this include roll-back to the old system. RA responded that the backup arrangements included a paper based ordering system to deal with urgent orders, key users had been identified and a dedicated helpdesk was being provided. The Trust has, in recent years, reported the month 1 financial position which may not be possible in the event of a roll-back. KM asked what confidence did the Trust have in the supplier NEP. RA responded that NEP accept the complexity of the Trust and the data transfer requirements outlined in the specification. NEP bring a strong discipline to the financial process in an NHS Trust. Cii SFI’s & SOD’s TJ outlined the proposed changes to the Scheme of Delegation to reflect recent EB endorsed changes to the capital approval process, together with minor amendments to the quotation and tender waiver arrangements. The Trust also acknowledges that there needs to be a fundamental rewrite of the SFI’s and SoD’s to align with the devolved clinical board and management structure.

NA

3

Item Matters Covered Action 4. 5.

HB asked how the proposed changes deal with issues that are regarded as novel or contentious. TJ responded that there needs to be flexibility in the process of authorisation and agreed that additional wording will be added to cover approval for items that would be regarded as novel or contentious. DW asked if there was sufficient resource within the Trust to carry out the review of the SFI’s and SoD’s without requiring external support. TJ responded that the Trust will review what support is available from both external and internal sources. RM asked for an analysis of what external consultancy advice costs the Trust and which companies provide that service, in order to demonstrate whether there is any bias in company selection, to be presented to the September AC. ACTION: report on cost of external consultancy advice for the September AC, together with an update on high cost interims. Risk Management and Assurance Frameworks Q&SC DW reported that the results from the audit of healthcare infections was available. TR confirmed that a response will be provided. ACTION: response from audit of healthcare infections Internal Audit Di Internal Audit Annual Plan NA outlined the Annual Plan for 2014/15 and confirmed that the plan is based on reviewing and evaluating the risk management, control and governance arrangements in place and how these arrangements help the Trust achieve its objectives. HB asked if the Trust monitored the long term benefits of QEP changes and savings previously identified. NA responded that financial savings have a recurrent effect that will be monitored through the budgeting process. Quality changes are more difficult to assess. NA confirmed that the number of days and fees are reduced compared to 2013/14 which saw the implementation of the Audit

TJ

TR

4

Item Matters Covered Action

Universe which in itself caused an increase in fees and days. RM asked how the audit days are distributed through the year to evidence where the audit work is planned to ensure minimising back loading of audit days towards the end of the financial year. NA responded that an analysis would be provided. ACTION: Analysis of distribution of audit days to be provided. HB asked how gaps in the control process are followed up in relation to the sickness absence audit follow-up work. NA responded that this will be picked up but the effect of the implementation of the rostering system will be taken into account. KM asked how does the Trust compare with other NHS organisations in terms of audit days. NA responded that UCLH compares with other large Trusts. The Internal Audit Plan 2014/15 was approved. Dii Internal Audit Progress report NA presented the audit progress report and highlighted one red rated report on Private Patients and Overseas Visitors, issued since the last AC meeting which may require reference in the Head of Internal Audit Opinion.NA presented the Private and Overseas Patient report, from item Div on the Agenda, rated as red, RA presented the management response from item Dv. RM asked why only 6 of the 16 Private and Overseas Patient recommendations were being addressed. RA responded that he had been asked by EB to respond to the report and had selected the 6 main areas for the focusof attention. The remaining areas will be reviewed following the outcome of the 6 main concerns HB asked about the effectiveness of divisional business plans and the delivery of those plans in relation to the Internal Audit Progress report. NA responded that this is incorporated in the next review. DW asked if budget setting is effective. RA responded that traditionally the Trust underplanned for income but the extra emphasis placed on contract activity meant that this year the income plans were

NA

5

Item Matters Covered Action

more realistic. RM asked for clarification of the management response to business planning recommendation being “a virtual document”. CM responded that this meant the recording of the planning process was through emails. DW asked how the Quality Accounts – Data Quality audit calculated the % achieved for the vital signs data when there were a number of wards that did not return any data. NA responded that the calculation was based on the wards that did respond and could give a misleading interpretation of the actual % being achieved. RM asked that this report be referred to Q&SC. ACTION: Quality Accounts – Data Quality audit report be referred to Q&SC. DW asked if Consultants performing private work were asked to confirm that they had indemnity insurance. RM also asked if the Trust confirmed that private work was being performed outside of trust contract time. TR responded that this will be covered by the Consultants Job Plan ACTION: confirmation that indemnity insurance and time spent on private work is covered in the Job Plan. Dii&Diii Recommendations Summary and Tracker. NA presented the recommendations summary and recommendations tracker reports. Dvii Head of Internal Audit Opinion NA presented the Head of Internal Audit Opinion, the draft report giving significant assurance that there is a generally sound system of internal control. There were two red reports issued during the year which could impact on the Trust achievement of its objectives and four reports where some assurance could be provided. KM noted that the Private and Overseas Patients reference does not include the scale of the problem and there is no reference to timescale for resolution. NA agreed. ACTION: Opinion to include scale of the problem and timescale for

NA/TR

TR

6

Item Matters Covered Action 6.

resolution. Dviii Counter Fraud 2014/15 workplan MT presented the 2014/15 workplan. RM asked why cyber fraud was not in the workplan NA responded that this is regularly reviewed in the Quarterly Counter Fraud meetings. KM asked how many staff in the Trust contact counter fraud. HW responded that there is a noticeable increase in website visits after fraud alertness messages are issued. NA added that Counter Fraud recognised where material fraud risks are and direct resources on those areas. RA added that the management arrangements within Baker Tilly in relation to counter fraud had been improved in the last three months. Dix Counter Fraud Progress Report MT presented the Progress report. RM asked when the workplan will deliver by and progress be reported, in relation to the loaning of stock, and can an update be provided in April. MT responded that it was important to ensure that controls are in place in order for compliance to be checked. ACTION: update Counter Fraud progress at September meeting in relation to the loaning of stock. HB asked if there was an issue of internet misuse. NA responded that this was discussed at the last QCFM and would be picked up in a performance review. External Audit HBgve presented the report and highlighted the Executive summary points: update on Significant Risks, Quality report, update on other areas, benchmarking and the draft letter of representation. Julian Hunt was introduced to present the PAS/EPR system briefing included in the Update on Other Areas of the report relating to risks and challenges facing the Trust. JH outlined the seven key risks in relation to the selection of an Electronic Patient Record system. There is a need to ensure clarity of the IM&T strategy and its alignment to the business strategy. An OBC and FBC must be linked to the long term financial model and ensure successful engagement with key stakeholders. The procurement

NA

MT

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Item Matters Covered Action

exercise uses a Competitive Dialogue process which is complex and time consuming whilst ensure good governance in all aspects of the programme. This process will be challenging whilst it is critical to ensure clinical involvement and confidence throughout the programme. Delivering all of the benefits expected will happen through changing working practices and ensuring clinical staff utilisation of new technology. KM asked who has JH worked with and what benefits have been realised. JH responded that Addenbrookes spent one year on the specification and that a hospital in the USA had quantified clinical benefits, adding that the decision needs to address whether to utilise a single or multiple platform solution. HB asked what benefits the Trust would get without a system. JH responded that the Trust needs to consider modifying off-the-shelf systems at a small level. It will be changes to processes enforced by a system that are key. There is no technology which does everything, he believed that design responsibility should be led at CEO level to ensure clinicians are on board with the project. JH suggested that his counterpart in the USA would be a useful contact in informing the Board in the process. JH was thanked for his report and left the meeting. HBgve confirmed the Deloitte response to the Trust proposal not consolidate the Charitable Accounts into the Trust Accounts for this financial year on the basis that the Trust does not have sufficient influence over decision making or financial governance of any of the charities. HBgve outlined the draft Letter of Representation which forms part of the annual report process. KM asked where the Letter of Representation is dealt with in the Trust. TR responded that it goes to EB prior to coming to AC. HBgve presented the Benchmarking review from the Q3 return. RM asked about the level of debtor days in the benchmarking review. RA responded that the level of overperformance is high which was linked to the late signing of contracts in December. Traditionally large value settlements are made in March and April. KM asked if the high debtor days is a short or long term issue. NA responded that it is too early to say yet. HB added that this is the first year of CCG’s and that the debtor issue reflected the split of

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Item Matters Covered Action 7. 8. 9.

specialties from fewer PCT’s to many CCG’s. RA added that for the future the level of overperformance should be less because contracts reflect better performance and consequently a reduced level of cash at risk. Report to the Governing Body TR presented the paper outlining the proposal to present the Annual Report to both the Board of Directors and the Governing Body that has been agreed by the Lead Governor, thus avoiding two separate reports as presented in previous years. The proposed change of presentation was accepted. Draft Annual Report RMbk presented the draft Annual Report which does not include additional requirements from new guidance from Monitor received on the 17th March. Those authors affected by the new guidance have been requested to update and amend their sections. The draft annual report does not include significant information as data is not available until the end of the financial year and cross referencing of page numbers can not be implemented until the designed version is complete. There will be a sub edit to ensure consistency, inclusion of any comments from AC and an Executive read-through prior to formal adoption at a special Board meeting on 23rd May. HB commented that there are references to patients throughout the document but should these be brought together in one part of the report and that whilst the CQC is mentioned the recommendations are not presented. RMbk responded that the report would be modified to cover this. DW asked what the issues the Trust wants to express to the public and where do they appear in the report. RMbk responded that was difficult to do since it is not a marketing but a governance document. ACTION:detailed comments to RMbk by 4th April. HBgve left the meeting at this point. Audit Committee work programme. The Audit Committee work programme was accepted with no additional comments.

RMbk

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Item Matters Covered Action 10. 11.

Annual Governance Statement The draft annual governance statement process was outlined to the meeting which asses the functioning of the system of internal control and a review the effectiveness of that system. A self-assessment review of compliance with the Trust’s new Provider Licence introduced by Monitor in April 2013 is undertaken. TJ presented a summary of evidence the Trust provides. This is to demonstrate how the Board reviews the evidence to comply with two specific elements of the Licence (the quarterly governance and finance risk ratings). The report was noted with no further comments. Finance and Accounting Issues Ji Update on fixed Asset disaggregation TJ outlined the update on fixed asset disaggregation and the proposal to charge to expenditure an adjustment to depreciation of £3.1m representing the cumulative change to calculated depreciation arising from a correction to the category of assets originally applied in error. The review also identified that assets also had incorrect asset lives associated with them resulting in a combination of lengthening and shortening asset lives that resulted in the change to the depreciation charge this financial year. The additional depreciation charge did not warrant a prior year adjustment since it was below the materiality level. An impairment charge of £1.7m identified where enabling works should have been charged to buildings, and furniture and fittings revaluation to zero, which will be corrected in this financial year. The disaggregation process also identified £70k of charge to capital that should have originally been a charge to revenue that was being written off in this financial year. The report was accepted. Jii Draft Accounting Policies TJ presented the draft accounting policies report for 2013/14 that included the Consolidation of Charities Accounts into the Trust Accounts and a modified absorption accounting requirement for items transferred to Trust from the changes to the NHS introduced on the 1st April 2013. The Trust proposed that the Consolidation of Charity Accounts did not apply because the Trust does not directly influence operations of the

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Item Matters Covered Action 12. 13. 14. 15.

charities associated with the Trust. This proposal was supported by Deloitte and included in the report presented earlier. The Trust is not affected by the modified absorption accounting arrangements because there were no assets transferred to the Trust from other NHS organisations on the 1st April 2013. The report was accepted. Review of Financial Reports K Losses and Special Payments Report The Losses and Special Payments report was accepted. Cross Committee referral No items for cross committee referral. Any Other Business No further business. Date and Time of the Next Meeting Tuesday 22nd April 2014 at 9:00. Venue: Chairman/CEO meeting room, 2nd Floor, 250 Euston Rd. Papers deadline: Monday 14th April 5pm