BOARD OF DIRECTORS - University College Hospital meeting papers... · 2015-12-04 · Agenda Meeting Title: Board of Directors Date: Wednesday 9th December 2015 Time: 2.00pm Venue:

BOARD OF DIRECTORS

9th DECEMBER 2015

Agenda

Meeting Title: Board of Directors

Date: Wednesday 9th December 2015 Time: 2.00pm

Venue: Education Centre, 1st Floor West Wing, 250 Euston Road

Agenda item Attachment

1. Apologies for Absence and Declarations of Conflict of Interest

2. Minutes of the Meeting held on 11th November

A

3.

Matters Arising Report B

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

5. 5.1.

5.2.

Presentations:

A Patient Story Geoff Bellingan, Medical Director, Surgery & Cancer Board Focus on Safety: Sepsis - UCLH Sepsis Improvement Project Michael Patterson, Consultant in Intensive Care & Emergency Medicine Recent Successes of Antibiotic Patient Group Directions (PGD) for Neutropenic Infections Jonathan Lambert, Consultant Clinical Haematologist

6. Chairman’s Report

C

7. Chief Executive’s Report

D

8. Executive Board Report

E

9. Performance Report

Assessment of Theatre Utilisation

F.1

F.2

10. Quality & Safety Committee Report

G

11. Finance & Contracting Committee Report H

12. Report of the Audit Committee Meeting held on 17th November

I

13. Minutes of the Audit Committee Meeting held on 15th September J

14. Entries in the Seal Register

K

15. Any Other Urgent Business

16. Date of Next Meeting

Wednesday 13th January 2016

17. Dates of Remaining Meetings in 2016 Wednesday 9th March

Wednesday 11th May

Wednesday 13th July

Wednesday 14th September

Wednesday 9th November

A

Agenda Item 2

Minutes of the Meeting held on 11th November 2015

Board of Directors Minutes of the Meeting held on 11th November 2015

Present Richard Murley, Chairman Harry Bush, Vice-Chairman David Lomas, Non-Executive Director Rima Makarem, Non-Executive Director Kieran Murphy, Non-Executive Director Diana Walford, Non-Executive Director Caspar Woolley, Non-Executive Director Geoff Bellingan, Medical Director, Surgery & Cancer Board Jonathan Fielden, Medical Director, Medicine Board Gill Gaskin, Medical Director, Specialist Hospitals Board Neil Griffiths, Deputy Chief Executive Tim Jaggard, Interim Finance Director Robert Naylor, Chief Executive Flo Panel-Coates, Chief Nurse

In attendance Simon Knight, Director of Planning & Performance Ben Morrin, Director of Workforce David Probert, Director of Strategic Development Tonia Ramsden, Director of Corporate Services (Board Secretary) Daniel Farrar, Consultant Anaesthetist (for item 4) Jocelyn Laws, Trust Administrator (Minutes)

Item Matters covered 11/1

Apologies for Absence and Declarations of Interest Apologies were received from Alasdair Breckenridge and Tony Mundy. Declaration of Interest Ben Morrin had advised the Board Secretary that his wife, who was an employee of the Department of Health, had moved to a new post which involved advising on policy relating to NHS trusts’ employment and commissioning. This would be added to the Register of Interests.

11/2 Minutes of the Meeting held on 9th September 2015 The minutes were agreed.

11/p3 Matters Arising Report The report was noted.

11/4 Focus on Safety: Reducing Surgical Harm The Chairman welcomed Dr. Daniel Farrar who presented the background to the initiative to improve compliance with the World Health Organisation Safer Surgery Checklist. The context was the focus on reducing the incidence of never events, the majority of which were related to surgery and interventional procedures. This was an area for improvement identified by the CQC and also nationally by NHS England. The Trust had recorded six never events in 2014 and only one to date in 2015 so there was still room for improvement.

A further issue was to overcome the perception of the checklist as simply a tick-box exercise. The checklist was completed at the end of each surgical procedure but there was a view that this was insufficient. The overall objective was to reduce surgical harm by 50% in UCLH theatres by 2017 and to support a culture of continuous improvement through proactive safety measurement and monitoring. This would be achieved via the use of the Five Steps to Safer Surgery.

Causes of potential never events were numerous and could be related to patient or individual staff member factors, communication or tasks. Daniel Farrar showed a diagram of drivers for improvement which included establishing a good teamwork culture in all operating theatres, reliability of the five steps to safer surgery, implementing strong learning and feedback mechanisms, and education and awareness. These drivers involved setting out expectations for every patient going through theatres, auditing and evaluating the quality of the five steps, using learning from audits, incidents, near misses and complaints and utilising existing and new education methodologies such as e-learning and ‘story telling’ sessions to help prevent recurrence of problems.

Progress to date included the recent launch of a new surgical safety policy, an initial observational audit carried out in May, with a second one currently underway, development of coaching days and training staff to become coaches, and running a number of workshops. Daniel Farrar provided examples of incidents from which staff could learn and which demonstrated that the checklist should not be regarded as a tick box exercise but required all staff to be fully engaged with the processes. However, he emphasised that there was a great deal of good practice in place.

Results from the initial observational audit showed 100% compliance with the completion of checks in the ‘time out’ element of the WHO checklist. However, we needed to ensure that all staff were present and fully engaged for the whole checklist completion and that the surgical pause was carried out.

Next steps included finalising the November audit, the results of which would be reported to the Quality & Safety Committee, feedback on the audit data to theatre teams at audit days and teaching sessions, launch of e-learning and story-telling sessions, and support for teams from the safer surgery coaches from January 2016.

The Chairman asked Daniel Farrar what the CQC were likely to look for during their next visit. Daniel Farrar believed they would want to be assured that we had a clear plan to achieve safer surgery which would entail implementing the five steps and new national standards which had been incorporated into the recent safer

2

surgery policy. Geoff Bellingan thought the CQC would also be interested in our processes for preventing never events. A robust training programme was required and it was essential to protect training days and ensure all relevant staff participated. Gill Gaskin added that developing team working and embedding good habits were also key issues and she felt the CQC would be able to judge whether staff were used to following all elements of the WHO checklist.

Harry Bush was unclear how we could state that time-out checks had been fully completed if not all staff were present at the time. Geoff Bellingan agreed and said this was being addressed through questions in the audits and by investing time in coaching.

The Chairman thanked Daniel Farrar for his presentation.

11/5 Chairman’s Report The Chairman’s report was noted. He highlighted the Professor Aidan Halligan Memorial Lecture that had been held the previous day and said the lecture by Brigadier Kevin Beaton had been an excellent and fitting tribute to Aidan Halligan.

11/6 11/6.1

Chief Executive’s Report CQC Inspection The Trust had been advised that the inspection would take place during week commencing 7th March. Preparations included reviewing the issues raised during the previous visit, learning from reports on recent inspections at other trusts and feedback from a mock inspection undertaken by a team from Newcastle University Hospitals which we would reciprocate.

11/6.2 Financial Performance – Monitor Challenge The report advised that we had been challenged by Monitor to assure them that we would achieve our original budget plan of £20m deficit for 2015/16 and also that we could return to a break-even position on an ongoing basis by the end of the financial year. A recovery plan, due to be submitted by 20th November, was being prepared.

11/6.3 Junior Doctors Potential Industrial Action This issue was noted. Should the strike action go ahead the Trust would put in place contingency plans to ensure patients received the best possible care.

11/6.4 University College Hospital 10 Year Celebration This issue was noted.

11/6.5 Curing Cancer The Board was advised that a documentary entitled Curing Cancer, filmed over 12 months at the UCLH Macmillan Cancer Centre, had won a prestigious award for best science of nature documentary.

3

11/6.6 Senior Staff Changes The report advised that Jonathan Fielden had been appointed as Deputy Medical Director at NHS England, leading on specialist commissioning. The Chief Executive also informed the Board that David Probert had been appointed as Chief Executive at Moorfields. The Board congratulated both on their appointments.

11/7 11/7.1

Executive Board Report uclh future – Information Technology Developments The report advised that the EB had approved two business cases for IT schemes that would improve processes for pathology test requests and streamline the log-on process to various electronic systems to save time and improve efficiency.

11/7.2 ‘A Perfect Week’ – Recalibrating Performance at UCLH The EB had approved a proposal from Jonathan Fielden and Charles House to run an exercise for one week during which time we would focus strongly on all standards and elements that should enable us to maximise patient flow, using a major incident approach. The aim was to increase efficiency to help us face the challenges of increasing attendances to the Emergency Department coupled with the arrival of new haematology patients from the Royal Free London and the need to ringfence orthopaedic beds. During the week a control room would be established, daily review meetings would take place and non-clinical staff would help to facilitate the required processes. The perfect week would commence on 19th November.

11/7.3 CQC Inspection of Mental Health Provision Following the complaint to the CQC as outlined in the patient story presented at the previous meeting, CQC inspectors had visited the Trust in October to look at services for patients with mental health issues and the application of the Mental Health Act.

11/7.4 Amendments to the Scheme of Delegation and Debt Write-off As a result of the CQC inspection referred to above, the EB had considered a proposed additional section to the Scheme of Delegation setting out the staff at each Trust site who had delegated powers under the Mental Health Act. The proposed section was attached to the report and approved by the Board.

A further revision to the Scheme of Delegation, which brought delegated decision-making authority for ICT-related capital schemes in line with those agreed for building schemes, was also attached and approved.

The report advised that the EB had supported a proposal to write off bad debts totalling £2.11m which had accumulated over several years. Details of the type and value of debts were attached to the EB report. In accordance with the Scheme of Delegation the Board was required to approve the write-off of bad debts above £100k; the Board endorsed the EB’s decision.

Rima Makarem confirmed that this issue had been discussed by the Audit Committee and that St. George’s Hospital NHS FT were working with Immigration

4

Service staff on following up debts owed by overseas patients. We could consider doing something similar.

11/7.5 Board Assurance Framework The Quarter 2 Board Assurance Framework had been reviewed by the EB and was attached. Board members noted that the BAF now focused on the Trust’s five strategic objectives. The Chairman felt there should be only one lead director for each principal risk. He also asked about the risks associated with weaknesses in patient tracking and how results of abnormal diagnostic tests were reported back. Gill Gaskin said the patient tracking weaknesses related to follow-up outpatient appointments. As part of the RTT process we had produced a reconciliation report which identified a very small proportion of patients who had not been given appointments. This had now been rectified and there was no evidence that any patient had suffered harm. In the longer term we would be moving to a system of partial booking for patients who did not require follow-up appointment for a considerable time; this would entail entering them on the system and contacting them at a later date to offer specific appointment times.

With regard to diagnostic test results, Geoff Bellingan said we were aiming to implement an IT solution. David Lomas requested assurance that before patients were discharged or transferred to other wards, consultants were advised and the junior doctors had reviewed all test results. Geoff Bellingan said this responsibility was shared with the diagnostic department, for example it was the responsibility of radiologists to highlight abnormalities identified during imaging. The Chairman requested that this issue be referred to the Quality & Safety Committee for further discussion.

11/7.6

Policy Approvals The Board was advised that the EB had approved three new policies, one of which was the Surgical Safety Policy and Procedure referred to earlier in the presentation.

11/7.7 Research Update The update on Biomedical Research Centre and other aspects of research activity at UCLH was noted. Work was ongoing to prepare for the next BRC funding competition round. The Chief Executive drew attention to our good performance in national research league tables relating to recruitment of patients to studies and also the increase in the number of studies on the national portfolio.

11/7.8

Capital and Estates Issues The report was noted. Rima Makarem referred to a newspaper article about trusts being asked to curtail capital expenditure in return for receiving additional revenue. Tim Jaggard said we had not been formally approached but we were having informal discussions with Monitor about the feasibility of slipping some capital expenditure this year. This would require further discussion by the Finance & Contracting Committee.

5

11/7.9 Emergency Preparedness The update on emergency preparedness, resilience and response was noted; it included the latest figures of staff receiving flu vaccinations since the launch of this year’s flu campaign.

11/8

Performance Report Simon Knight presented the key issues. We continued to miss the 99% target for 6 week diagnostic waits although MRI at UCH was now compliant and we were projecting that we would be compliant for endoscopy in December.

With regard to cancer waits, performance against the two week standard for breast symptoms had fallen owing to the unexpected absence of two key team members. Efforts had been made to find locum staff but there were shortages in this staff group. Geoff Bellingan said we had also tried to provide additional capacity elsewhere in the pathway. The position on the 31 day standard and 62 day standard was noted.

The Trust was below the threshold for four hour waiting times in A&E and the Chairman asked Jonathan Fielden to provide an update on the situation. Jonathan Fielden said performance had fallen off partly due to capacity issues but also to high attendances. On the Monday of the previous week we had experienced an unprecedented 484 attendances. While Islington CCG had managed to curb the increase in attendances by their residents, the number of patients from Camden continued to rise. Attendances had also been partly driven by a greater number of overseas visitors than last year during the summer. However, our performance remained above average for London which, as a whole, was facing extreme pressure.

Rima Makarem noted that there was no threshold for sepsis cases and therefore it was not possible to judge whether the number of cases recorded reflected good or poor performance. Simon Knight advised that Sandra Hallett was devising standards against which we would be able to monitor performance.

Harry Bush commented that the average length of stay data on page 6 did not appear to be consistent with the data at specialty level in the quarterly review pages. The Chairman felt that more detailed commentary was required for the next quarterly report.

Action: Director of Planning & Performance

It was noted that surgical specialties had received high volumes of complaints; Geoff Bellingan said that a significant number were related to the transfer of ophthalmology services to the Royal Free, but concerned communication about the move not the quality of the service. We were now working with the Royal Free to improve communication with patients. There was no noticeable theme among other complaints. The Chief Executive said that the overall number of complaints received in September was no more than the average.

With regard to completed appraisals, Ben Morrin advised that current performance was between 70% and 80% and we would be able to assess the quality of appraisals through the staff survey.

6

Kieran Murphy asked whether we were on track to reduce the nursing and midwifery vacancy rate to 7.5% by April if the average time to recruit was 10-12 weeks. Flo Panel-Coates was confident progress would be made, and Ben Morrin said the greatest challenge between February and April was related to recruitment from abroad.

The Chairman referred to the research activity graphs in the quarterly review pack and said that performance did not appear to be very good. Simon Knight advised that more commentary would be given in future reports to provide greater explanation. David Lomas said that in relation to recruitment to bio-resource studies we were not doing as well as other trusts and we needed to recruit patients from other trusts associated with UCL, although patient consent would be required. The process for applying for continued BRC funding would begin in earnest after the Government’s comprehensive spending review and recruitment to clinical studies would be a key measure for success. There would also be a strong focus on other metrics and he felt the Board should consider tracking the same metrics. Simon Knight was requested to discuss this with Nick McNally, Divisional Manager for R & D, and David Lomas to ensure we were measuring the appropriate issues.

Action: Director of Planning & Performance

11/9 Quality & Safety Committee The reports of the September and October meetings were noted. The Committee had reviewed a number of reports including the Duty of Candour compliance report, annual patient safety report and quarterly report from the Adult Safeguarding Committee. They had also received the Learning from Serious Incidents report and an update on the Sign up to Safety Campaign. The Board approved revised Terms of Reference for the Committee which were attached to the September report and noted that they would be reviewed again in the summer to allow David Lomas to make any required changes.

11/10

Finance & Contracting Committee Harry Bush presented the report. At month 6 the I&E position, prior to donation adjustments and exceptionals, was a deficit of £24.4m which was £13.7m below plan. The latest predicted year end outturn was a £32.5m deficit against the £20m deficit plan, assuming release of £5m Board contingency. This was a £3.3m improvement compared with the Month 5 projection and was due to the conclusion of contract negotiations. Activity was still underperforming against plan and the EB were identifying further measures to enable the Trust to return to a run rate that was consistent with the need to achieve the financial plan. Monitor had also requested a recovery plan aimed at returning to a break-even run rate by the end of 2015/16 that would put us in a position to plan for surpluses on an ongoing basis. This would be extremely challenging as a number of issues, such as the tariff, were outside the Trust’s control. We also needed to focus on cash management and speedier collection of debts.

Harry Bush referred to the contracting update which advised that the Trust had agreed terms of the 2015/16 Camden CCG contract, baseline values for other NE London CCGs and terms and conditions with NHS England for specialist services.

7

The Board confirmed the Quarter 2 Finance Declaration to Monitor as set out in the report.

The Chairman commented that we seemed to have difficulty in accurately forecasting activity and the I&E position. Tim Jaggard agreed there was a need for better processes but he felt there had been some improvement. However, we must begin to consider the challenges for next year and develop the planning process to ensure we linked forecasting to planning, incorporating strategic changes. We must also validate activity projections and make sure we profiled capacity to demand.

11/11 Report of the Audit Committee Meeting held on 15th September Rima Makarem presented the key points. There had been slippage in the work programme of the Internal Auditors and the Committee had requested that they develop a plan for managing the work across the year.

The Committee had received a report from the Local Counter Fraud Specialist. Rima Makarem advised that they would conduct a deep dive into cyber security as the risk could be far-reaching.

The Director of Procurement had presented a report on contract management and recommendations to improve the current approach. The EB would be asked to consider establishing a contract database.

11/12

Minutes of the Audit Committee Meeting held on 21st July The minutes were noted.

11/13 Any Other Business There was none.

11/14 Date of Next Meeting The next meeting would be held on 9th December 2015.

8

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 11th NOVEMBER 2015

Minute no.

Issue Action

11/8 Performance report: Commentary on average length of stay data at specialty level

Explanation of the data will be provided in the next quarterly review slide pack

(Director of Planning & Performance)

11/8 Performance report: R & D metrics - ensure we are measuring appropriate data to align with BRC bid requirements

This will be discussed with Nick McNally, Divisional Manager for R & D, and David Lomas prior to production of next set of quarterly metrics (Director of Planning & Performance)

Items from previous meetings brought forward

Date of Meeting

Minute no.

Issue Outcome

Sept 2015

9/8.2 EB report: Theatre utilisation: Action plan to improve utilisation and throughput; Update on development of metrics and improved reporting for theatre utilisation.

A report on these issues appears on the agenda. Action completed.

Items from previous meetings carried forward to future meetings - None

C

Agenda Item 6

Chairman’s Report

1


CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

9 DECEMBER 2015 1. AIDAN HALLIGAN MEMORIAL LECTURE

I referred to this lecture, which took place on 10 November, in my last report. However, I should record the exceptional talk which was given by Brigadier Kevin Beaton OBE about lessons that the NHS can learn from the army in areas such as leadership and training. One of the interesting statistics was that the army devotes up to £0.5m to training its leaders through courses which on occasions last for weeks. Those present from the NHS left the lecture looking very thoughtful.

2. SLIPPED DISC On 18 November, I recorded a ‘Desert Island Disc’ style interview for UCLH’s Hospital Radio service, ‘Slipped Disc’. This will be broadcast later this month.

3. HEALTH SERVICE JOURNAL AWARDS 2015 Also on 18 November, the Chief Executive and I hosted a table for the prostate cancer team led by Hashim Ahmed who had been nominated for the Acute Trust Innovation Award for their development of the prostate cancer service. I am very pleased to be able to report that the team won the award in the face of fierce competition from a number of other excellent entries. Winning the award is a fitting testament to one of the Trust’s flagship services.

4. WESTMORELAND STREET VISIT On 24 November, the Chief Nurse, Flo Panel-Coates, and I visited UCH at Westmoreland Street. It was very heartening to see the progress that has been made in settling down the service since it moved in back in the summer.

5. TRUST ARCHIVES On 25 November, I spent time in the Trust archives with Penny McMahon, who is being funded by the Middlesex Hospital Endowment Fund to sort and catalogue the archives from the Middlesex Hospital. This is an enormous task but one potentially of great historical interest since the Middlesex Hospital dated back to the mid-18th century.

6. CHRISTMAS OPEN EVENT On 3 December, I attended the annual Christmas Open Event and judged the stands with Neil Griffiths, Deputy Chief Executive. We were very fortunate that Emma Thompson turned on the lights on the Christmas tree and visited some patients on T12 South. As usual the standard of the stands was excellent.

7. PROTON BEAM THERAPY On 9 December, the ground breaking ceremony for the Proton Beam Therapy will take place on the Odeon site. I will be able to report on this at the Board meeting that afternoon.

2

8. ALASDAIR BRECKENRIDGE

This is Alasdair Breckenridge’s last Board Meeting as he is retiring this month. I would like to thank him for his significant contribution to the Hospital. He has brought to us a wonderful mixture of high intelligence, experience and enthusiasm. We wish him all the best in the future.

RICHARD MURLEY CHAIRMAN

D

Agenda Item 7

Chief Executive’s Report

1


CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

9 DECEMBER 2015

PART ONE 1. MONITOR’S Q2 REPORT OF NHS FOUNDATION TRUSTS

I attach as Appendix A, a letter from Monitor which concludes that our Q2 submission has resulted in a financial sustainability risk rating of 2 and a governance rating of ‘under review’. The reduction of our financial risk rating from 3 to 2 has been caused by the changes to Monitor’s risk rating metrics. The letter indicates that a failure to achieve a rating of 3 or above could indicate regulatory action. The Board will be aware that under the new metrics we are unlikely to return to a risk rating of 3 under the prevailing economic situation this financial year. The governance risk rating of ‘under review’ is largely due to our failure to achieve the cancer wait targets. We have engaged with Monitor and local commissioners to address this issue which is referred to elsewhere in the board papers. The letter refers to the FT sector aggregate performance which is available on its website. I have reviewed this document and would like to bring to the Board’s attention some of the key factors. The aggregate analysis indicates that ‘many NHS FTs are under severe pressure. The widespread financial and operational stress within the provider sector was evident’. The FT sectors net deficit at the end of Q2 was £729m, nearly three times more than for the same period last year. There are 151 licensed Foundation Trusts, of which 110 are currently in deficit. As negative as this may appear, the non-Foundation trust sector is in an even worse financial position. The overall provider side deficit at the end of Q2 has been reported as £1.6bn, suggesting that the year-end deficit will be well in excess of £2bn. This issue was of course a key factor in the Chancellor’s statement at the Comprehensive Spending Review (referred to in the next item). The report comments on a number of interesting facts about cost improvement programmes in Foundation Trusts. The average CIP achievement this year is 2.4%, which is broadly the same as for last year. Interestingly, a statement by the new Chief Executive of NHS Improvement (the effective amalgamation of Monitor and the Trust Development Authority) suggests that this is approximately the level which can be achieved for the next financial year. It also indicates the reason why so many trusts are in deficit. It is also interesting to note that approximately 25% of CIPs have been achieved on a non-recurrent basis, a practice which we have discouraged at UCLH. The financial segment analysis indicates that 16 out of the 20 teaching hospital FTs were in deficit and that 6 of these had a red governance risk rating. This is somewhat better than for large and medium acute FTs where 50% are red risk rated. The report refers to particular concerns about emergency care, illustrated by the fact that this was the seventh consecutive quarter that FTs had failed to achieve the 95% A&E target. The average performance of major A&E departments was 92.8% compared to the current position for UCLH of 94.8%.

2

Overall, the Q2 Monitor report reflects the wider concerns about financial and operational performance of the NHS. As previously reported to the Board, both we and other Shelford Group Trusts have consistently warned that these circumstances would prevail and that political solutions are required. In this context I was pleased to see the outcome of the Comprehensive Spending Review and the emphasis on the need for financial investment to support the reforms outlined in the ‘Five Year Forward View’.

2. COMPREHENSIVE SPENDING REVIEW 2016/2020

Directors will be aware of the headlines of the Chancellor’s Comprehensive Spending Review, announced on 25 November. A summary of the key facts as they affect the NHS is attached as Appendix B. The CSR announcement has been broadly welcomed within the NHS, although there have been concerns expressed that the Department of Health’s budget and that of Health Education England will no longer be ‘ring fenced’. This may result in increased contributions to support education and CQC budgets by providers. There were several other announcements affecting health which may have an impact on the Trust. Most notably the £1bn investment in new technology and the £150m to support a new Dementia Research Institute, referred to in the next item.

3. THE DEMENTIA RESEARCH INSTITUTE AND DELIVERING THE 20 YEAR CLINICAL STRATEGY FOR QUEEN SQUARE

The Chancellor’s Comprehensive Spending Review made a £150m commitment to develop the UK’s first Dementia Institute. He confirmed that the Institute would draw together world leading expertise through a national hub with support from the UK’s leading providers of care and research. The process to decide the location of an Institute and its agreed nominal host will be based on an open bidding process likely to be launched in early 2016 and led by the Medical Research Council (MRC). A copy of the Prime Minsters recent press announcement is attached as Appendix C. As Board members will remember a 20 year clinical strategy for Queen Square was presented by Professor John Duncan and endorsed by the Trust Board in 2014. This focused on the development plans for clinical services at Queen Square and the associated requirement for a step change growth in capacity and service redesign. The strategy was divided into three periods of time: short (within 2 years), medium (5-10 years) and long term (10 years+). As a result of endorsement of the strategy in 2014 the Board subsequently approved a £22m investment over two years in clinical infrastructure at Queen Square as well as a number of service developments away from the main clinical hub. A Joint Senior Oversight Group has been working to develop the Strategic Outline Case (SOC) for a major clinical and research facility at Queen Square. The SOC will be reviewed by UCL Council this winter and will focus on the redevelopment of Queen Square House and the adjacent Guilford Street goods yard.

Early estimations suggest the building could cost in the region of £350m and that around 25% of this building could be allocated to UCLH for direct clinical capacity resulting in a 75%/25% split in costs and the use of the overall building. The Oversight Group agreed that as UCL develop their SOC, UCLH will develop a formal response indicating our position to engage more formally in the development of a combined Outline and Full Business Case. This work is currently underway. It is likely that should UCLH

3

not wish to be considered partners in this development, UCL would reduce the current planned footprint of development and therefore the overall cost of build. An early assessment has suggested that the allocated clinical space would facilitate the required clinical capacity to help deliver the longer term 20 year clinical vision for Queen Square, incorporating an increase of beds, critical care and operating theatres. It has been suggested by the Oversight Group that with the exception of UCLH borrowing, and direct UCL funding, all philanthropic and government funding for the development will be equally allocated on a 75%/25% basis. This would likely result in the direct UCLH requirement for new capital funding of around £50m. It has been made clear to all parties that any capital requirement from UCLH does not currently form part of the Trusts capital plan. Modelling is now underway to understand how through increased clinical activity UCLH could support the business case. The UCLH response to the UCL SOC will be ready for consideration by the Board of Directors by March 2016.

4. SPECIALIST TARRIF – CHANGES TO THE NATIONAL TARRIF OBJECTION MECHANISM

The Board will be aware of the long standing dispute about the National Tariff and the under- funding of specialist services in particular. I attach as Appendix D a copy of a letter from the Shelford Group to the Secretary of State which sets out our continuing concerns about this position. The Board will also be aware of proposed changes to the Tariff Objection Mechanism which were debated recently by the Delegated Legislation Committee of the House of Commons. Following that debate, the Committee supported the Government’s changes by 9 votes to 6. Following that the issue was debated in the House of Lords with amendments proposed by Lord Hunt of Kings Heath who said that the changes ‘are fundamentally unfair, and do not achieve their policy objectives……and are in direct contradiction to the assurances given by Lord Howe on 6 March 2012’. Following a detailed discussion in the House of Lords, Lord Hunt withdrew his amendment and the motion was agreed. I will be happy to provide full transcripts of these discussions on request. During the Lords discussion it was noted that former Health Minister, Lord Warner, announced that he will shortly be chairing a commission to consider the future approach to commissioning of specialist services which will report next April. The Shelford Group will of course approach Lord Warner to express its concerns.

5. THE PERFECT WEEK

Emergency access Performance Our Emergency access performance remains challenged, despite considerable focus and efforts to improve. This should however be seen in the round of London performance where we remain at or, just, above average performance, on published data (Appendix E). The reasons for our current performance challenges have been shared last month but in short: Attendances After a lull over the early part of the year to last year’s levels we are again much higher than last year. This increase is mostly from local Camden GP practice areas. We have not seen a similar rise from Islington who have been more proactive in dealing with wider GP access to date. Work is in progress with both Camden and Islington to enable better GP access and safe redirection of patients

4

Emergency Department Processes We have been challenged to protect our Urgent Treatment Centre due to Emergency Department (ED) capacity constraints and still have variation in application of the internal professional standards for use of Clinical Decision Unit, Rapid Assessment and Treatment and Escalation. The ED transformation and “productive” work streams focus on regaining previous consistent performance in these areas. “Exit Block” In July we closed beds to enable works for increasing side rooms for Royal Free Haematology. Re-opening these beds took longer than intended due to staffing challenges and thus our Bed Occupancy increased >85% and in Medicine has been sustained >90%. This has impeded flow of patients to the ward, as well as “blocked” space within the Emergency Department to allow assessment of other cases, particularly those needing major cubicles. At a ward level we still struggle to get adequate number of patients ready to go first thing in the morning and particularly before lunch. Thus there is a mis-match between the requirement for beds (electives predominately morning, emergencies later in the day) and admissions. With the change in staff, particularly junior staff in August (Foundation year and Core Medical/Surgical Trainee) and October (Speciality registrar) we have found an increased need to realign working practices to how we run at UCLH. There is a focus to try and reduce this risk in February (next FY/CMT change-over). Escalation and speciality review We continue to have very variable practice in escalation of problems within and outside the ED. We have reviewed and are re-emphasising the need for appropriate escalation. We remain challenged to escalate capacity beyond what is already open within the tower at short notice. Escalation to specialities, when raised by the department, is taken up by the relevant Divisional Clinical Director and where required Medical Director. Sadly this currently requires re-education every change of junior staff. Delayed transfers of Care and repatriations We have had very good support from our Camden social care colleagues keeping our delays in this area to low numbers (around 20 patients). However we traditionally see an increase in this area over winter. We had some issues with Islington over the summer when they changed their practice, but escalation and senior review has improved this position. UCH Tower Capacity We remain challenged for UCH tower capacity and are running at >85% occupancy, >90% occupancy for medical beds. We have put in place mitigations for this with increased use of CDU and Ambulatory Emergency Care, Flexible use of paediatric beds with 18-20yr old appropriate patients, pushing increases in the use of UCLH@home. We will be transferring Jubilee ward across to Central North West London (allowing us to repatriate our nursing staff) and are pushing to ensure that we maintain access to more than the currently offered 10 beds. Our current predictions show that we will be very tight in February and thus further mitigations are required. This is additional to the impact of UCLH future on reductions in length of stay. Emergency Department capacity With the continued pressure from attendances exacerbated by sub-optimum flow through the organisation we required more space to see and effectively treat and care for patients within or close to department. Through close working with our clinical research facility colleagues we have negotiated the ability to “flex” into the Clinical Research Facility (CRF) space in the evenings (2200-0600). We have also agreed that we will be able to move fully into the CRF space in February. To enable this we are looking at providing alternative accommodation for the CRF whilst works on 170 Tottenham Court Road are completed.

5

Trajectory for improvement We submitted a trajectory for improvement to the November Board meeting and are slightly behind this trajectory but aim with the above actions to achieve improvements enabling us to achieve Quarter 4 and annual performance. However Quarter 3 will be very challenging. Perfect Week The concept of the perfect week came from our Divisional Clinical Director colleagues to achieve 3 outcomes

1. Prepare for the arrival of Royal Free Clinical Haematology 2. Ring fence beds for Elective Orthopaedics 3. Re-calibrate flow through UCLH for urgent and elective care patients and thus improve

care, experience and performance

Over 4 weeks of planning we took best practice from several other trusts and had our proposals reviewed by the originator of the process Dr Peter Gordon. The process uses a “command and control” centre /major incident approach with Ward liaison Officers across UCH tower to help achieve the above objectives. We are currently collating the data; our ability to get real-time data electronically is limited, but our headline findings are: Objectives:

1. We continued to cope with between 7 and 14 haematology patients outside their core bed base and did not transgress into space being made available for the transfer. Patients from Royal Free are now transferring down as (re-) planned for 4th December (delayed due to junior doctors’ dispute).

2. We managed, for the first time, to ring fence 2 of the “ideal” 4 bays for elective orthopaedics during the week. We have now ring-fenced 4 bays which will allow us to meet best practice and safety requirements for elective orthopaedic patients.

3. Whilst we remain challenged on our urgent (and elective) patient flow, each day saw improvement on many of our metrics. We also identified some hard data on areas for further improvement. ED performance improved across most of the week and was better each day compared to the poor performance the previous day.

Other outcomes: “We really felt to be one organisation” was one of several very positive comments at the “hot debrief” After Action Review held on 25th November and led by Dr Yogi Amin. We had 83 volunteer Ward Liaison Officers across the UCH tower, many non-clinical, including executive colleagues giving up their time to ensure rapid escalation of issues to aid ward work and patient flow. The Perfect Week Bronze team resolved the vast majority of these and those not were resolved by silver or gold. We also had excellent rapid support from our IFM colleagues and Camden Social Care. Key learning already shared was the significant number of patients (10-20%). not progressing through their care on a given day. Perfect week interventions improved this other than on Sunday. Common use of the patient status at a glance board and more rapid escalation have been highlighted as learning points. We have also now calculated and shared the number of patients wards require to have ready to go each morning and before lunch. Whilst one to two patients seems a small number (10 for AMU) this is still a challenge to achieve for many. But wards are now more aware of the requirement.

6

It is clear that not all wards get early senior review in a timely fashion. The perfect week allowed this escalation, but there was a common collaboration between ward and medical staff to not expect this, particularly at weekends. This has been shared across the organisation, but more needs to be done to achieve this critically important way of working. Other metrics showing some improvement: Ward discharges by 1200 (12-21%) TTOs day before discharge (17-21%), ward occupancy (92-89%, lowest point 86%) ICU waits for discharge >6hrs, ICU discharges >2000 eliminated, during the week, our early indications are that none of our “balancing measures worsened. We will complete analysis of the data and more formally communicate key learning across the organisation in the coming weeks. We would like to thank the efforts of all staff across the organisation in all areas clinical and non-clinical and our colleagues in IFM and externally for their support and joint focus on patient care during the week.

6. JUNIOR DOCTORS INDUSTRIAL ACTION

Following conciliatory talks between the BMA, NHS Employers and the Department of Health, industrial action by junior doctors in England, which was due to begin at 8 a.m. on 1 December was suspended on 30 November. The Government has also agreed not to proceed with the introduction of a new contract and national negotiation shall continue through the next month. Though staff across the Trust worked to put contingency plans in place we needed to cancel 66 non-urgent elective patients and over 320 outpatient appointments. A significant majority of those have been rescheduled for early this month.

7. SENIOR APPOINTMENTS

Following discussions between the Chairman, Jonathan Fielden and I, we have agreed to invite Dr Charles House to become Interim Medical Director for the Medicine Clinical Board until such time as a decision about a substantive appointment can be made. Jonathan Fielden’s position as the Board’s nominee on the Pathology Joint Venture (HSL) will expire when he leaves the Trust next March. Following discussions with Jonathan, I should like to recommend to the Board that Dr Vanya Gant be nominated to join Mike Foster as one of our two nominees to the HSL Board.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

1 December 2015

Sir Robert Naylor Chief Executive University College London Hospitals NHS Foundation Trust 2nd Floor Central 250 Euston Road London NW1 2PQ

Dear Sir Robert

Q2 2015/16 monitoring of NHS foundation trusts

Our analysis of your Q2 submissions is now complete. Based on this work, the trust’s current ratings are:

Financial sustainability risk rating: 2

Governance rating: Under review

These ratings will be published on Monitor’s website later in December.

The trust has been allocated a financial sustainability risk rating of 2 and has failed to meet

multiple cancer targets including the cancer 62 day wait for first treatment target which has

triggered consideration for further regulatory action. The trust was placed under review in

Q1 due to the trust achieving a capital service capacity rating of 1.

Monitor uses the measures of financial robustness and efficiency underlying the financial

sustainability risk rating as indicators to assess the level of financial risk. A failure by a

foundation trust to achieve a financial sustainability risk rating of 3 or above could indicate

that the trust is providing health care services in breach of its licence. Accordingly, in such

circumstances, Monitor could consider whether to take any regulatory action under the

Health and Social Care Act 2012, taking into account, as appropriate, its published

guidance on the licence and enforcement action including its Enforcement Guidance1 and

the Risk Assessment Framework2.

Monitor uses the cancer wait targets (amongst others) as indicators to assess the quality of

governance at foundation trusts, in accordance with its licence. In this instance we will not

take further regulatory action in respect of cancer performance, but will engage with you as

part of our Tripartite approach to address your performance issues.

1 www.monitor-nhsft.gov.uk/node/2622

2 www.monitor.gov.uk/raf

Wellington House 133-155 Waterloo Road London SE1 8UG

T: 020 3747 0000 E: [email protected] W: www.gov.uk/ monitor

Chief Executive's Report Appendix A

http://www.monitor-nhsft.gov.uk/node/2622

http://www.monitor.gov.uk/raf

Monitor will continue to review the trust’s financial position and progress against its

recovery plan through recently established monthly financial review meetings. Therefore,

the trust’s governance rating will remain ‘Under Review’ for this quarter.

A report on the FT sector aggregate performance from Q2 2015/16 is now available on our website1 which I hope you will find of interest. We have also issued a press release2 setting out a summary of the key findings across the FT sector from the Q2 monitoring cycle. If you have any queries relating to the above, please contact me by telephone on 02037470619 or by email ([email protected]). Yours sincerely

Victoria Jeffries Senior Regional Manager cc: Mr Richard Murley, Chairman,

Mr Tim Jaggard, Interim Finance Director

1 https://www.gov.uk/government/publications/nhs-providers-quarterly-performance-report-quarter-2-201516

2 https://www.gov.uk/government/news/challenging-environment-for-nhs-providers

https://www.gov.uk/government/publications/nhs-providers-quarterly-performance-report-quarter-2-201516

https://www.gov.uk/government/news/challenging-environment-for-nhs-providers

Chief Executive's Report Appendix B

https://www.gov.uk/government/topical-events/autumn-statement-and-spending-review-2015

o

o

o

↑

↑

↑

↑

↑

↑

↑

↑

↑

↑

↑

↑

•

•

•

•

•

•

•

•

•

o o o o

o

o o

o

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/479566/Further_devolution_manchester_nov_2015.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/479566/Further_devolution_manchester_nov_2015.pdf

Chief Executive’s Report Appendix C

Press release

PM announces funding for UK’s first Dementia Research Institute

The UK’s first Dementia Research Institute will receive up to £150 million to drive forward research and innovation in fighting dementia.

•UK’s first Dementia Research Institute set to receive up to £150 million to launch step change in research and development

•institute to draw together world-leading dementia expertise to accelerate the pace of research, develop new diagnostic tests and tackle the progression of the disease

•latest step in long-term strategy to combat dementia – which already includes over £300 million committed for UK research and a separate global fund to drive international innovation

The UK’s first Dementia Research Institute is set to receive up to £150 million to deliver a step change in research and development to tackle the disease.

Led by the Medical Research Council, the institute will bring together world-leading experts, universities and organisations to drive forward research and innovation in fighting dementia – a disease that affects an estimated 850,000 in Britain, a figure that’s expected to double in the next 20 years.

The institute will have a central UK hub, with links to universities across the country and will build on the centres of excellence in dementia already operating across the UK. The Medical Research Council will open a competitive process in the new year asking universities to come forward to host the institute itself and will lead the search for a director to head it.

The commitment to form a UK-based institute, was announced by the Prime Minister in his Challenge on Dementia 2020 in February – a long-term strategy focused on boosting research, improving care and further raising public awareness about the disease.

This follows a commitment from G8 health ministers to aim to identify a cure or a disease modifying therapy for dementia by 2025, with the first ever $100 million global Dementia Discovery Fund unveiled by Health Secretary Jeremy Hunt in March this year.

Once established, the institute will draw together world-leading researchers, charities and universities to take forward 3 key strands of work:

•accelerate the pace of discovery research in order to boost drug development

•attract new partnerships with the biopharmaceutical sector to develop new treatments and ways of diagnosing dementia

•develop and promote strategies for interventions that prevent the development or progression of dementia

Prime Minister David Cameron said:

“For far too long this terrible condition has been ignored, down-played or mistaken as a part of the ageing process. When the truth is – dementia is one of the greatest enemies of humanity.

“I have been clear that I want Britain to lead the way in tackling this disease. And we have already taken great strides – since 2010 investment in research has doubled, hundreds of thousands of NHS and care staff have had specialist training and more than 1 million dementia friends have taken part in awareness sessions across the country.

“This institute is another great step – and will allow us to draw together cutting-edge research tools and expertise to defeat this disease once and for all.”

Dementia is widely regarded as representing one of the toughest medical and economic challenges of our society. Beyond the work already underway in the UK, the government has also been working with other countries to tackle this global health challenge.

Chief Executive's Report Appendix D

Chief Executive’s Report Appendix E

0

20

40

60

80

100

120

140

19/1

0/20

15

26/1

0/20

15

02/1

1/20

15

09/1

1/20

15

16/1

1/20

15

23/1

1/20

15

ED Delays Specialty Beds Other Clinical Exception Diagnostics Transfer

153132 133

176

213

173

3954

67

94 91

67

13 12 16 17 23 145 7 10 1 7 50

50

100

150

200

250

19/10/2015 26/10/2015 02/11/2015 09/11/2015 16/11/2015 23/11/2015

Admitted Discharged Referred Transferred to other provider Left Department Other Died

Perfect Week

Perfect Week

Early Perfect Week metrics

% of patient on the ward with ”red days” – ie days when senior (nurse) feels progress not being made

Some staff balancing measure: quality huddles, breaks and planned staffing

ED performance, Pre, during and Post Perfect Week

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Thursday Friday Saturday Sunday Monday Tuesday Wedneday

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

planned versus actual nursestaffing

Quality huddle held

Staff breaks

70

75

80

85

90

95

Thursday Friday Saturday Sunday Monday Tuesday Wednesday

Pre

Perfect week

Post

E

Agenda Item 8

Executive Board Report


Executive Board Report to the Board of Directors, December 2015

1. Winter Tower Bed Capacity The EB received a report which presented the latest outputs from modelling the predicted bed requirements in the UCH Tower for the remaining months of 2015/16. This work identified potential significant capacity pressures in quarter 4 and the paper

set out a number of mitigating actions to address these pressures. Agreed actions include:-

• Continuing efforts to reduce lengths of stay;

• A targeted approach to increasing the use of UCLH@home within those specialties with agreed pathways;

• Pursuing agreement from Camden CCG to ensure that 10 beds on Jubilee Ward (now managed by Central & North West London NHS FT) are ring-fenced for use by UCLH, and negotiating with Camden on the provision of an additional 7 step-down beds to fully replace the capacity at St. Pancras that was previously available;

• Expediting the move of the Clinical Research Facility to provide an additional 19 bed spaces for the Clinical Decision Unit or ambulatory care. This in turn will enable us to move ambulatory care away from the Acute Medical Unit, thereby providing two additional side rooms in the AMU.

In addition, the EB agreed that further options for mitigation should be explored, including the possible provision of a Surgical Assessment Unit in the Tower to deliver ambulatory care for emergency surgical patients, but space for such a facility would need to be identified. Despite these measures, we are still predicting a shortfall of four beds in December and in February, with no surplus capacity in January. Board members will recognise that this presents a risk to achievement of the A&E four hour wait target and a potential requirement to cancel elective work in these months. 2. Transforming End of Life Care The EB received a report from the End of Life Care (EoLC) Board from which it was

noted that approximately 400 staff working in Elderly Care, Oncology, the Hyper-Acute Stroke Unit (HASU), AMU and ward T8 have been trained in five ‘enablers’ of EoLC. Confidence in discussing the wishes and preferences with, and recognising the needs of, patients who are dying has risen considerably in these areas. 750 staff have been trained in the use of ‘Excellent Care in the Last Days of Life’ since September, and two local trusts have now adopted our documentation.

Two new courses for more intense training have been developed – ‘Difficult

Conversations’ for junior nursing staff and ‘Talking DNA CPR’ for senior medical and nursing staffing.

Elderly Care has achieved a sustained cultural change, with length of stay falling from

an average of 17.4 days to 15 days and a reduction in the 30 day readmission rate from 45% to 7%.

2

Since June of this year, 28 surveys completed by bereaved relatives have been

returned. 96% of respondents reported that their loved one was treated with dignity and respect in the last days of life, and 93% rated the care received as good or excellent.

The report also advised that since the withdrawal of PERRT nurse support, there has been some slippage in the correct completion of DNA CPR forms. The EoLC team is working closely to achieve a reversal of this trend, and a solution is being developed with the support of the Quality directorate.

3. Jimmy Savile Inquiry – Disclosure and Barring Service Rechecks

Board members will recall that the report into lessons learned from the NHS investigations into matters relating to Jimmy Savile was published in February. An action plan to respond to the recommendations that arose from the inquiry was shared with the Board in June. The action plan summarised the measures there were already in place designed to prevent harm to our patients, staff and visitors and indicated where additional steps were required to ensure we were compliant with all the recommendations.

The Board was subsequently advised that all actions had been completed with the

exception of one, related to a recommendation concerning disclosure and barring service (DBS) checks for all eligible staff every three years. We have robust processes in place for all new staff to ensure they are DBS cleared if required, but we do not currently recheck staff once they have started at UCLH. This is not a legal requirement and given the significant resource implications involved in a re-checking programme of this scale the EB agreed to reconsider the issue at a later date.

A further report from Workforce was recently considered which set out options for DBS

rechecking. Following discussion the EB agreed that existing staff working in high risk areas who have contact with vulnerable patients, and who have not undergone a DBS check within the last three years, should be prioritised for rechecks. Areas defined as high risk include paediatrics, women’s health, critical care, emergency department, medical specialties, stroke and rehabilitation. We believe this approach is one that will be adopted by the majority of London teaching trusts.

The next step will be to agree a policy going forward in terms of frequency of rechecks

and identifying how the associated costs can be met. We will be liaising with neighbouring trusts to determine a consistent approach.

4. National Digital Maturity Programme The EB receives monthly updates from its sub-committee - the Digital Services Delivery Board (previously the ICT Strategy Board). The recent report advised that the DSDB had received a presentation on the National Digital Maturity Programme which is being co-ordinated by the National Information Board. The role of the NIB is to put data and technology to work safely for patients, service users and the professionals who serve them, and to develop the strategic priorities for data and technology. It brings together organisations from the NHS, public health, clinical science, social care and local government.

3

The aims of the NIB are:

• That all patient and care records must be digital, real time and inter-operable by 2020 and should be paper-free at the point of care; • Clinicians in primary, urgent and emergency care must be operating without paper records by 2018; • To raise the profile of informatics at Board level and increase clinical leadership; • New incentives to become fully digitally linked to commissioning of services, inspection and accreditation. A Digital Maturity Index will track increases in the effective use of IT, digital services and data.

UCLH participated in a recent pilot exercise with NHS England to test the new Digital Maturity Assessment process. The results of the Digital Maturity Assessment will be published and incorporated into assessments by the Care Quality Commission and NHS Improvement programme. The Digital Maturity Assessments will also be linked to future potential funding opportunities which may be generated as a result of the Comprehensive Spending Review. 5. Observerships The EB considered a recommendation to apply charges for all observerships issued at

UCLH. An observership is issued to an individual who attends and observes within the workplace and who is supervised at all times. Observers do not contribute directly to the provision of clinical services. We currently issue around 800 observerships each year and could potentially generate a substantial income if we were to apply charges. Other London teaching trusts charge between £50 and £300 per observership.

The EB agreed that UCLH should commence charging for observerships from the

beginning of the 2016/17 financial year. Prior to that, we will consult with partner organisations within UCLPartners to develop a policy.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

F1

Agenda Item 9

Performance Report

Report to Board of Directors

Current issues Action Month first raised

A&E (Page 7) We were below the threshold for A&E patients being seen within four hours. This is the third time we have breached this threshold since February. The emergency division have a recovery plan in place to support the improvement of performance against the access target.

August 2015

Diagnostic waits

(Page 7)

The Trust missed the target for diagnostic waits within six weeks in October. Performance is improving month on month since January but we are still below the threshold. Diagnostic performance dipped in October due to ECHO breaching (after three months of being compliant) This was due to reduced capacity while setting up an SLA with Barts. They will be compliant by December. Endoscopy and Queen Square MRI continue to be non-compliant. Endoscopy are projecting compliance by December whilst Queen Square are developing a clearance plan.

December 2014

Cancer waits

(Page 8)

We are now compliant with the 31 day subsequent surgical standard, this reflects the improved access to robotic surgery in urology. We are still not achieving the 31 day first standard, this is due to ongoing breaches in the urology HIFU and cryotherapy services.

Breast symptomatic and breast two week wait performance is very challenged due to two two team members being on unexpected extended leave. This takes out almost half of our core capacity for two week appointments. We are putting on additional internal capacity where we can and also exploring outsourcing options. GPs have been notified about the extended waits.

July 2013

eVTE Risk Assessments completed (Page 10)

We were narrowly worse than the 95% standard of patients being assessed for VTE in October. This was due to specialist hospitals and medicine board not achieving target. Junior doctors will be reminded about the importance of doing assessments, and leads have communicated to the respective clinicians the need for their teams to complete eVTEs.

September 2014

Falls with harm (Page 11)

There were 28 ‘low harm’ falls reported in October, with no fractures/moderate or severe harm incidents reported in that month.

January 2015

Complaint responses (Page 13)

We were worse than threshold for complaints response times in October, but there was a 9% improvement from September. There were 86 complaints for the month which is significantly more than in any of the previous six months.

February 2015

Friends & Family Test (IP survey) (Page 13)

The friends and family IP survey score remains above the threshold at 96.4% for October compared to 96% in September. The inpatient response rate continues to steadily increase from 24% in September to 27.5% in October. The target response rate is set at 40%.

October 2015

October 2015

Month 7 - October

Board of Directors Performance Report

Month 7 - October

1. Executive summaries

2. Finance 3. Delivery of QEP

4. Access

5. Patient Safety and Quality metrics

6. Workforce

7. Externally Reported Frameworks

8. Research and Development

9. Appendix A: Quarterly review of top 10 objectives72.60%

Page Con

Board of Directors Performance ReportContents

Month 7 - October

Board of Directors Performance Report

Data quality score:

√√ high data quality

√ sufficient data quality

x not sufficient data quality

Tru

st

actu

al

Tru

st

thre

shold

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Tru

st

actu

al

Tru

st

thre

shold

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

% Elective variance -10.0% 0% 9.1% -6.7% -13.9% -6.9% 21.6% -5.6% -9.2% Number of MRSA Bacteraemias 0 0 0 0 0 2 0 2 0

% Daycase variance -5.1% 0% -9.4% -2.4% -8.0% -0.6% -5.6% -1.1% 1.4%

Number of clostridium difficile

cases reported (excluding

successful appeals) 43 15 18 10

% Non-elective variance -15.5% 0% 6.1% -1.8% -29.1% -13.9% 4.1% -3.8% -25.0% % Hand Hygiene Compliance94.9% 95.0% 92.2% 97.0% 94.7% 95.1% 92.1% 96.5% 95.0%

Outpatient Variance -3.1% 0% -7.8% -2.1% -2.2% 1.1% -4.2% 1.8% 2.4%Number of MSSA Bacteraemias

(Trust Attributable) 4 2 1 3 0 19 3 5 11

Discharge rate from outpatient

attendance (for target clinics)21.6% 25% 26.5% 11.9% 26.1% 19.8% 23.2% 8.4% 25.8%

Tower elective theatre utilisation 72.9% 85% 31.5% 73.1% 74.5% 73.9% 20.8% 74.2% 74.1%All Pressure Ulcers Acquired at

UCLH 9 4 3 4 2 43 13 18 12

Queen Square theatre utilisation 77.6% 85% 77.6% 70.0% 70.0% Inpatient falls with serious harm0 0 0 0 0 1 1 0 0

Percentage of Completed eVTE

Risk Assessments 94.6% 95.0% 93.6% 95.7% 93.4% 95.4% 95.9% 96.2% 94.2%

% incomplete pathways < 18 weeks 94.1% 92.0% 96.0% 93.2% 94.2% 94.3% 96.6% 92.8% 94.5%Complaints responded to within

target time 68.2% 85.0% 100.0% 71.4% 55.9% 74.8% 92.9% 72.1% 67.5%

A&E attendances within 4 hours 90.9% 95.0% 90.87% 95.5% 95.5%Friends & Family Test (IP survey)

New 96.4% 96.0% 96.9% 97.2% 95.7% 96.9% 97.6% 97.1% 96.4%

% Diagnostic waiting list within 6

weeks95.4% 99.0% 81.0% 97.8% 93.1% 96.1% 88.5% 96.7% 94.8%

Average time to recruit (request

pack - start date)14.2 14.6 13.9 14.6 14.6

Cancer 62 Day GP referral to

treatment 68.8% 85.0% 100.0% 56.9% 41.7% 78.0% 95.3% 72.1% 86.7%

% Statutory and mandatory training

compliance82.0% 90.0% 82.8% 83.9% 81.7%

Cancer 62 day referral from

screening to treatment90.0% 90.0% 75.0% 100.0% 76.7% 70.0% 81.4%

Appraisal Tier 4 - The remaining

workforce85.0% 90% 86.0% 81.0% 87.0%

Cancer 31 Day Subsequent

Surgery Treatment96.1% 94.0% 100.0% 92.9% 100.0% 88.9% 100.0% 79.3% 100.0% Vacancy Rate (Trust rate)

8.6% N/A 8.6% 8.0% 11.5%

Cancer 31 Day Subsequent

Chemotherapy Treatment100.0% 98.0% 100.0% 100.0% 99.5% 99.3% 99.8%

Cancer 31 Day Subsequent:

Radiotherapy94.6% 94.0% 100.0% 91.4% 100.0% 97.2% 100.0% 96.2% 98.8%

Tru

st

YT

D

Cancer 31 Day Subsequent: Other 52.8% 98.0% 58.3% 100.0% 59.5% 46.5% 100.0%HEADLINE FINANCIAL

PERFORMANCE (Overall Rating) 2

Cancer 31 days from diagnosis to

first treatment89.4% 96.0% 100.0% 86.7% 100.0% 89.5% 98.1% 85.6% 97.9%

1. Operational Performance (Debt

Service Cover) 1

Cancer GP referral to appointment 82.8% 93.0% 93.1% 90.5% 56.8% 90.2% 90.4% 91.3% 87.3%2. Cash and Balance Sheet

Performance (Liquidity) 4

Cancer 14 day wait from referral

(symptomatic breast)25.0% 93.0% 25.0% 81.8% 81.8%

Income and expenditure plan and

CIP delivery

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

All Service = Trust Total

1.2 Executive summary: board performance

This month Year to date

Activity

Page 4

Finance

Page 2

Workforce

Pages 14 - 16

Quality and

safety

Pages 11 - 13

This month Year to date

Month 7 - October

Efficiency

and

productivity

Page 7

Cancer

Page 9

Infection

Page 10

18 weeks and

other access

indicators

Page 8

Page 2

2. Financial Performance2.1 Financial Performance Summary

Month 7 - October

Page 3

2. Financial Performance2.2 Service lines summary

Month 7 - October

Page 4

Month 7 - October

2. Financial Performance2.3 Clinical income summary

Page 5

Month 7 - October

3. Delivery of CIP3.1 CIP update

3. Delivery of CIP3.2 Efficiency and productivity

Tru

st th

resh

old

Tru

st a

ctu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Tower elective theatre utilisation 85% 73.4% 73.1% 74.5%

Queen Square theatre utilisation 85% 77.6% 77.6%

Discharge rate from outpatient

attendance (for target clinics)25% 21.6% 26.5% 11.9% 26.1%

DNA rate 8% 11.1% 13.5% 10.5% 10.8%

Average length of stay for key

specialties- elective admissions3.3 3.9 6.1 4.5 3.5

Average length of stay for key

specialties- Non elective admissions5.1 4.0 3.5 7.1 3.5

Page 6

This month

Month 7 - October

Theatre Utilisation - Tower theatre utilisation increased by 0.8% in the month to 73.4%. There is a detailed review of theatre utilisation underway which will report to the December Trust Board. This analyses the reasons for poor utilisation and presentes a change to the wya the metric is calculated. LOS – CHKS, our benchmarking supplier, have developed an expected LOS metric which takes account of the HRG and patient condition. In order to take account of case mix changes, we are monitoring improvement against expected LOS each month. This means that the target changes each month according to case mix, and we expect a % improvement in relation to the expected LOS. In this way we can monitor real LOS improvements rather than just case mix changes. The expected LOS has some exclusions, including day case, maternity, transfers and cancelled operations. Therefore we have applied the same exclusions to the actual LOS presented here.

60%

65%

70%

75%

80%

85%

Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

Percentage trust theatre utilisation - All Services

Tower elective theatre utilisation - total elective time utilised Queen Square theatre utilisation

4. Access4.1 Access Targets - Referral to treatment

Tru

st

thre

shold

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

% incomplete pathways < 18 weeks 92% 94.1% 96.0% 93.2% 94.2%

Patients waiting > 52 weeks 0 0 0 0 0

Patients waiting 40-52 weeks 33 9 6 18

Measure of Tip-in rate/numbers

% data quality issues on waiting list 5% 9.1% 12.7% 11.3% 7.7%

% cases not validated > 14 weeks tbc 34.9% 52.6% 33.1% 33.0%

% Diagnostic waiting list > 6 weeks 99% 95.4% 81.0% 97.8% 93.1%

% Last Minute Cancellations to Elective

Surgery0.6% 0.3% 0.0% 0.6% 0.0%

% Cancelled Operations Readmitted

Within 28 Days95.0% 100.0% 100.0% 100.0%

A&E attendances within 4 hours 95% 90.9% 90.9%

Page 7

This month

Month 7 - October

86%

88%

90%

92%

94%

96%

98%

100%


A&E attendances within 4 hours

A&E attendances within 4 hours Target

The RTT targets in October changed so that trusts are now only monitored against the incomplete standard. As a trust we were compliant with this. Diagnostic performance dipped in October due to a number of long waits for ECHO tests (after 3 months of being compliant). This was due to reduced capacity while setting up an SLA with Barts. They will be compliant by December. Endoscopy and Queen Square MRI continue to be non-compliant. Endoscopy are projecting compliance by December whilst Queen Square are developing a clearance plan. We were below the threshold for A&E patients being seen with 4 hours. This is the third consecutive month of breaching the standard. The emergency division have a recovery plan in place to support the improvement of performance against the access target. Key actions currently being progressed are embedding the new escalation policy, recruiting to the vacant middle grade doctor and nursing posts, and introducing non-clinical floor co-ordinator posts to improve patient flow. The clinical research facility has been identified as the best location for a surge area and plans are being finalised around staffing and IT. The performance is reviewed daily and the emergency services division is monitoring the impact of these improvement actions. The 'Perfect Week' initiative will also help understand obstacles to patient flow and will provide additional escalation support across the tower over 7 days.

70%

75%

80%

85%

90%

95%

100%


Referral to treatment % incomplete pathways under 18 weeks

% incomplete pathways < 18 weeks

Target

Available for November

Thre

shold

Tru

st actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Exclu

din

g

bre

aches n

ot in

our

contr

ol

Two week wait from referral to date first seen93% 82.8% 93.1% 90.5% 56.8% 89.5%

Two week wait from referral to date first seen: breast symptoms 93% 25.0% 25.0% 29.0%

31-day wait from diagnosis to first treatment 96% 89.4% 100.0% 86.7% 100.0% 95.7%

31-day wait for second or subsequent treatment: surgery94% 96.1% 100.0% 92.9% 100.0% 100.0%

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

31-day wait for second or subsequent treatment: Radiotherapy94% 94.6% 100.0% 91.4% 100.0% 94.6%

31-day wait for second or subsequent treatment: other98% 52.8% 58.3% 100.0% 100.0%

62-day wait for first treatment from urgent GP referral to treatment85% 68.8% 100.0% 56.9% 41.7% 82.1%

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


Page 8

Month 7 - October

This month

4. Access4.2 Access Targets – Cancer

Breast symptomatic and breast two week wait performance is very challenged due to two two team members being on unexpected extended leave. This takes out almost half of our core capacity for two week appointments. We are putting on additional internal capactiy where we can and also exploring outsourcing options. GPs have been notified about the extended waits. Other than in breast, most two week wait breaches are due to patient choice. Specialties have developed plans to increase two week wait capacity in order to offer more choice to patients and therefore reduce breaches due to patient choice. We are now compliant with the 31 day subsequent surgical standard, this reflects the improved access to robotic surgery in urology. We are still not achieving the 31 day first standard, this is due to ongoing breaches in the urology HIFU and cryotherapy services. We were also below the 62 day standard, with 22.5 breaches. Of these, seven were and six were gynaecology. Validation is still underway so the internal performance may improve but that this stage 13 of the breaches were caused by factors outside of the trust’s direct control, primarily late referrals.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15 Aug-15

Sep-15

Oct-15

Cancer 62 day referral targets

Target (GP referral to treatment)

Cancer 62 day referral from screening to treatment

Target (screening to treatment)

65%

70%

75%

80%

85%

90%

95%

100%

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15 Aug-15

Sep-15

Oct-15

Cancer 2 week referral targets

Cancer GP referral to appointment

Cancer 14 day wait from referral (symptomatic breast)

Target

5. Quality5.1 Infection

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

Number of MRSA Bacteraemias 3 2 0 2 0

Number of clostridium difficile cases

reported (excluding successful

appeals)

57 43 15 18 10


due to lapses in care15


under review28


successfully appealed16

Number of MSSA Bacteraemias 16 19 3 5 11

% Hand Hygiene Compliance (this

month)95.0% 94.9% 92.2% 97.0% 94.7%


Page 9

YEAR TO DATE

Month 7 - October

We have reported 59 cases of C diff as at the end of October. 16 of these cases have been successfully appealed as not being lapses in care. 15 cases of C diff have been found to be a lapse in care by the Trust. 28 cases are still under review. Therefore, our worst case position currently is 43 cases against the October year to date threshold of 57. There are 19 cases of MSSA year to date against a threshold of 15 cases. There was one case for October in the GI division who are awaiting the root cause analysis from the infection control team; however it is likely to be an infection from a biliary drain. There was one case this month for surgical specialties. This has been reviewed internally and by commissioners with no lapses identified. Hand Hygiene compliance was marginally below threshold. The medicine board have raised some data issues which are being investigated and compliance issues are being challenged real-time.

0

1

2

3

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

MRSA bacteraemia / infections - All Services

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

0

20

40

60

80

100

120


Clostridium difficile infections post 48 hrs - All Services

CDiff Actuals Monthly excl. successful appeals CDiff Threshold Monthly

CDiff Actuals YTD excl. successful appeals CDiff Threshold YTD

Tru

st

thre

shold

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

% Harm free care (National Safety

Thermometer)95.0% 96.5% 90.8% 100.0% 98.0%

% Harm free care (Hospital acquired

only)95.0% 97.9% 94.8% 100.0% 98.6%

Patients with preventable dose

omissions10.0% 8.7% 5.5% 12.5% 9.5%

% eVTE Risk Assessments completed 95.0% 94.6% 93.6% 95.7% 93.4%

The trust threshold is an aggregate of individual clinical board thresholds

Page 10

5. Quality5.2 Safety

This month

Month 7 - October

We were better than the threshold of 95% for the National Safety Thermometer harm free care indicator. However the medicine board are not achieving compliance within emergency services and medical specialties. The low performance is reflective of a number of prior to admission emergency department patients that acquire issues in the community which must be reported against UCLH. We were narrowly worse than the 95% standard of patients being assessed for VTE in October. This was due to specialist hospitals and medicine board not achieving target. Queen Square were below threshold. Junior doctors will be reminded about the importance of doing assessments, and leads have communicated to the respective clinicians the need for their teams to complete eVTEs. Paediatrics have requested that the cohorting criteria is updated to include patients who are day cases on T11E and day cases on T12S.

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%


Patients with preventable dose omissions- All Services

Preventable dose omissions Target

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%


VTE risk assessment - All Services

Percentage of Completed eVTE Risk Assessments Target

5. Quality5.3 Safety

Tru

st

thre

shold

Tru

st

actu

al

Medic

ine

Surg

ery

&

Cancer

Specia

list

Hospitals

Inpatient falls with serious harm 0 0 0 0 0

Inpatient falls with harm 20 28 3 6 18

% of Serious Incidents (SI) reports

submitted within the designated

timescale (60 working days)

94.0% 100.0% 100.0% 100.0%

All Pressure Ulcers Acquired 4 9 3 4 2

Number of Grade three Pressure

Ulcers Acquired1 1 1 0 0

Number of Grade four Pressure Ulcers

Acquired0 0 0 0 0


Page 11

This month

Month 7 - October

Two inpatient falls with harm were under UCLH@Home and therefore has not been allocated to a board but has

been accounted for in the overall Trust figure

0

1

2

3

4

5

6

0

20

40

60

80

100

120

140

160


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

Inpatient falls with harm Patient falls Falls per 1000 beddays

There were 28 ‘low harm’ falls reported in October, with no fractures/moderate or severe harm incidents reported. The results from the 2015 Royal College of Physicians Inpatient Falls audit are due to be presented at QSC in November. This audit highlighted a range of good practice, and areas which we need to focus on, for example pharmacy reviews, postural blood pressure measurement and call bell response. These actions are being led by the Falls Darzi nurse the MDT falls team, monitored through the Harm Free Care Committee. There is an increase in overall hospital acquired pressure ulcers (HAPU) numbers this month, with ninr pressure ulcers reported across five clinical areas (eight grade two and one grade three HAPU) The grade three was reported in the infection division. This case related to a patient who was approaching end of life. The tissue viability nurses assessed the damage as attributable to acute skin failure. There were however gaps in the SSKIN bundle documentation and improvements required in the patients repositioning schedule. The learning points from this incident have been actioned by the infection team and the themes will form part of a wider communication of trust-wide themes related to HAPU (and falls) in November and December. The number of complex patients ‘admitted with’ grade two, three and four pressure ulcers remains high, running at between one - three per day. The majority of these pressure ulcers improve throughout the patients admission, however this remains an area of risk.. The largest UCLH-wide audit of pressure ulcer care in four years was completed this month (with our partners Medstrom). The initial feedback and learning will be presented at Harm Free Care Committee in November, and Trust-wide thereafter.

0

2

4

6

8

10

12

14


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

Grade 4 Grade 3 Grade 2

5. Quality5.4 Outcomes

Tru

st

thre

sh

old

Tru

st

actu

al

Me

dic

ine

Su

rge

ry &

Ca

nce

r

Sp

ecia

list

Ho

sp

ita

ls

Emergency readmissions within 30

days (with PbR exclusions)3.1% 3.0% 6.6% 3.0% 1.2%

A&E to admission conversion rate 20.0% 10.0% 10.0%

Cases of harm in theatres 10 6 4

Sepsis cases 49 21 23 5

% Complete Vital Signs collected 96.0% 97.1% 100.0% 94.7% 97.2%

% deteriorating patients escalated

according to protocol90.0% 97.4% 100.0% 98.1% 96.7%

Local SHMI (1 yr rolling data) 0.56 0.51 0.73 0.48


Page 12

This month

Month 7 - October

We were compliant for the emergency readmissions within 30 days target. However Medicine were worse than threshold at 6.6% for September, which is an improvement from 9% in August. We were compliant in achieving the threshold for vital signs observations in October. Surgery and cancer board were marginally worse than threshold. This was driven by low submission numbers from T9 South; the ward sister and matron are investigating.

75%

80%

85%

90%

95%

100%


% Complete Vital Signs collected - All Services

Percentage of Complete Vital Signs New Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15

Emergency readmissions within 30 days (with PbR exclusions)

Emergency readmissions within 30 days (with PbR exclusions)

5. Quality5.5 Patient Experience

Tru

st

thre

sh

old

Tru

st

actu

al

Med

icin

e

Su

rgery

&

Ca

nce

r

Sp

ecia

list

Ho

sp

itals

Complaints responded to within target time 85.0% 68.2% 100.0% 71.4% 55.9%

Friends & Family Test (IP survey) 96% 96.4% 96.9% 97.2% 95.7%

Friends & Family Test (AE survey ) 95% 94.5% 94.5%

Friends & Family Test (OP survey) 91.5% 90.5% 95.0% 92.1%

Friends & Family Test (Transport) 95.5%

% of hospital appointments postponed by

hospital5.4% 7.7% 7.2% 3.9%

Page 13

This month

Month 7 - October

We were worse than threshold for complaints response times in October, but there was a 9% improvement from September. There were 86 complaints for the month which is significantly more than in any of the previous six months. Surgical specialties have seen a significant improvement in October (60%) from September (22.8%). Complaints are being reviewed and prioritised weekly by the senior management team to address the backlog. Queen Square has identified a manager to track and coordinate complaints. Clinical leads are responsible for responding to complaints and sharing what is learned with colleagues. They are working with senior management to address a backlog which has built up. Many of the backlog complaints are complex, and part of the responsibility of the manager responsible will be to ensure extended timelines for these complaints are negotiated with complainants and recorded on our systemts. EDH had two cancellations that were not responded to within the target time. One patient refused to be contacted and the other was satisfied with the telephone response but the written response was delayed. The friends and family IP survey score remains above the threshold at 96.4% for October compared to 96% in September. The inpatient response rate continues to steadily increase from 24% in September to 27.5% in October. The target response rate is set at 40%, there is work to be done with day case areas in order to achieve this target. The friends and family A&E survey score is just worse than threshold at 94.5% (dropping from 95.1% in September). The response rate has dropped to 17.5% in October (from 27.3% in September) worse than the 20% target and the lowest response rate this year. A&E had their busiest month in October which contributed to the lower response rate as well as a regular challenge of encouraging clinical staff in prioritising feedback.

0

10

20

30

40

50

60

70

80

90

100

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Patient experience - Complaints received

Number of Patient Complaints Complaints responded to within target time Target

0%

20%

40%

60%

80%

100%


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

Friends & Family Test (IP survey) New FFT AE score

6. Workforce 6.1 Performance indicators

Page 14

Month 7 - October

6. Workforce 6.2 Performance indicators

Page 15

Month 7 - October

6. Workforce 6.3 Nursing and Midwifery Detailed Workforce Dashboard

Page 16

Month 7 - October

Estimated riskThresholds Weighting Oct 15 Q1 Q2 Comments

57 1.0 43 29 37

25 cases still

under review,

12 lapses in

care

92% 1.0 94.1% 94.3% 93.8%See page 8 for

detail.

85% 68.8% 70.1% 67.9% See page 15 for

detail.

90% 90.0% 76.7% 100.0%See page 9 for

detail

94% 96.1% 88.9% 91.1%See page 9 for

detail

98% 100.0% 99.5% 99.7%See page 9 for

detail

94% 94.6% 97.2% 97.4%See page 9 for

detail

96% 0.5 89.4% 89.5% 88.8%See page 9 for

detail

93% 82.8% 90.2% 90.6%See page 9 for

detail

93% 25.0% 81.8% 86.1%See page 9 for

detail

95% 1.0 90.9% 95.5% 95.0% See page 8 for

detail

Green Green Green

Page 17

Month 7 - October

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

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 - incomplete pathways

Page 18

7. Externally Reported Frameworks 7.2 CQUIN and financial penalty summary

Month 7 - October

Financial Penalties

Financial Plan

assumptions

MRSA £ -

C. Difficile £ -

RTT penalties £ -

RTT 52+ penalties £ -

Cancer waits £ -

A&E £ -

Diagnostic waits £ -

LAS 30 & 60 Minute handover £ -

VTE risk assessments £ - Mixed sex accommodation

breach £ -

Total penaties £1,000,000 £0 £0 £0 £0 £0

Non-reimbursed activity -

Contract metrics

Financial Plan

assumptionsQ1 Q2 Q3 Q4

Emergency readmissions TBC

Emergency readmissions First / follow up ratios (full year

projection)TBC

Total non-reimbursed

penalties£0 £0 £0.00 £0 £0 £ -

Overall penalty / risk /

non-reimbursement£0 £0 £0 £0 £0

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

Will be finalised once contracts are signed off

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

Will be finalised once contracts are signed off

F2

Agenda Item 9

Assessment of Theatre Utilisation

Report to Board of Directors, December 2015

Next steps to improving Trust Theatre Utilisation

This report follows the paper that was submitted to the Board in September and presents progress against the objectives set out in that paper. The overall objective is to identify some clear steps for improving the use of our theatres.

This report describes the next steps undertaken to improve and more comprehensively measure the use of our theatres. The purpose of this paper is to:

1. Provide further detail on the main factors leading to our failure to make full use of theatre sessions.

2. Provide further detail on the main factors driving low utilisation on used lists (through late starts, gaps and early finishes).

3. Describe the revised set of metrics that will enable us to measure comprehensively the use of our theatre resources including theatre productivity

1. Closed and unused sessions Reducing the number of un-used and closed theatre sessions provides an opportunity to increase productive use of our theatre resources. As a development since the last report to the Board, we now have a uniform mechanism for tracking closed and un-used sessions across all our theatres to allow improved analysis and improvement across the trust. Based on the records that we have from UCH main theatres and the Macmillan Cancer Centre for April to October 2015 the main reasons for closed and unused sessions were as follows:

Reasons

No. Closed (>6 weeks’

notice)

No. Unused

(<6 weeks’ notice) Total

Staff Unavailable > Unplanned (eg Sickness) 2 7 9 Staff Unavailable > Planned (eg Annual/Study Leave) 126 52 178 Maintenance > Unplanned 2 2 4 Equipment Issue > Failure 0 0 0 Equipment Issue > Unavailable 0 1 1 List Not Filled > Admin Error 0 0 0 List Not Filled > Other 33 18 51 List Not Filled > Patient Cancellation at Late Notice 0 4 4 Clinically Appropriate 0 2 2 Timetable Changes 73 0 73 Not Known 1 0 1 Grand Total 237 86 323

The total number of available sessions in the period was 2813

1

Timetable Changes / Planned Maintenance – In addition to the numbers in the table above, 116 sessions were closed due to rescheduling and upgrade work in theatres. All of these occurrences were from June to September 2015 and were the result of theatres using the planned strategic service moves to undertake important upgrade works. Normally planned maintenance has minimal impact on scheduled sessions as this work is done at weekends or on audit days.

The main drivers for closed and unused sessions were as follows:

• Theatre Lists Not Filled – Theatre lists went unfilled for a variety of reasons but the most common reasons were of a lack of suitably worked-up patients for specialist lists, outpatient clinics not operating to create decisions to admit or errors in the booking process.

• Staff Unavailability – Sessions not being used as a result of planned leave is

the single biggest issue contributing to both closed and unused sessions. The table identifies both closed sessions (where six weeks’ notice has been given but the list has not been taken up another specialty) and unused sessions (where the required notice was not given).

Ensuring that planned leave does not lead to un-used sessions needs to be a major aim to improving use of our theatres. There is a fundamental issue that consultants are job-planned to work 42 weeks of the year, whilst we expect theatres to run for 50 weeks of the year. We have operational protocols in place to enable reallocation of lists between teams, but job plans are generally fixed and other specialties may not readily have surgeons available to cover lists at these points during the week.

There are numerous mechanisms within specialties to enable cross cover of sessions including use of registrars to undertake less complex lists, organising surgeons into teams that cross cover leave, or employment of locum surgeons with flexible job plans that can cover sessions. GI and anaesthetics are using electronic rotas to manage team time-tables, plan leave and manage cross cover of clinical commitments.

However, even with these mechanisms we are not providing full cross cover within teams.

We will be investigating and implementing the following actions to tackle this issue:

• Review of medical leave policy to ensure there is adequate notice for leave and sufficient cover mandated across teams (already underway by Director of Workforce)

• Agree common approach to job planning for academics • Implementation of electronic records for leave planning in all surgical teams

2

• Increased flexibility in the consultant job plan in order to prioritise cross cover of lists (as opposed to administrative PAs (Programmed Activities) or clinics for example).

• Consider use of flexible session payments as this may be cheapest way to cover the gap. This would need to be closely managed and has not been used for this reason yet.

• Incentivise cross cover within teams through full visibility of numbers of sessions released by each specialty team or division. Those with significant release rates will have their overall allocation reduced (see section 3 of this paper).

• Each theatre department to ensure that there is a structure for reviewing forthcoming lists which includes escalation to the Divisional Manager (DM) or Divisional Clinical Director (DCD) where lists do not get booked.

• Establish a Trust-wide, standardised methodology for scheduling theatre lists.

2. Understanding and tackling late starts, early finishes and gaps Within operational sessions time can be lost to late starts, early finishes and gaps between patients. The break down on time lost to each of these reasons in April to October 2015 was as follows:

Site Number of

Sessions % Unused Sessions

% of Total Session

Time Lost to Late Starts

% of Total Session

Time Lost to Early

Finishes

% of Total Session Lost

to Gaps Between Patients

% of Total Session

Time Used for Clinical Treatment

UCH Main Theatres 2175 1.8% 5.0% 10.6% 9.2% 74.0% MCC 344 2.4% 7.3% 18.1% 16.1% 58.0% NHNN 827 4.9% 8.2% 11.8% 6.3% 70.9% RNTNEH 901 2.0% 10.6% 10.8% 9.7% 67.6% Grand Total 4247 2.6% 6.7% 11.4% 9.0% 71.3%

Appendix A provides the results of an audit undertaken in August and September of this year in UCH theatres to understand the reasons for late starts.

The following table summarises the main drivers for late starts, early finishes and gaps alongside actions to address these. Lost utilisation

Reason Action to address

Late starts

Surgeon or anaesthetist delayed

Each surgical team to understand if reason for delay is within control of clinician, if clinician is expected to undertake other clinical duties that delays them then this must be addressed across the team. Each theatre department to ensure clarity about expected start

3

Lost utilisation

Reason Action to address

times in theatre. Empower theatre scrub team to escalate delays in clinicians arriving to the surgical management team.

Late starts

List order changed

The list order needs to be locked down the day before. This should be followed and theatre teams should not agree to veer from the agreed list order without sign off by the DCD or DM.

Late starts and gaps

Patient not ready on the ward

Reducing the number of list order changes will also reduce the number of delays. Surgical teams to Understand if this is due to patients being reviewed by the surgical team on the ward before going to theatre. If so then the consent and pre-theatre process must be reviewed across the team. Clear expectations on theatre start times should be reiterated to all surgical wards. Shift hand-overs should work around theatre start times.

Early finishes

List not fully booked

Ensure each theatre department has a weekly review of booked theatre lists and the division is notified where lists are under-booked. Implement weekly divisional review of all theatre lists to ensure they are fully booked. This has effectively driven up utilisation at RNTNEH and is in place in surgical specialties, GI and QS.

Early finishes

Patient on list cancelled

Patients can be cancelled due to bed capacity – this issue is being address via the co-ordination Centre work-stream within UCH Future. Patients can also be cancelled due to poor pre-assessment or planning. This is being addressed via the Elective work-stream within UCH Future.

Each theatre department and surgical division will now undertake those actions that are not currently in place in the department. UCH Future, as part of the theatre utilisation work, will take forward the actions to address late starts, early finishes and gaps.

3. How we will now measure use of our theatres

In the previous paper we described inconsistencies in how theatre utilisation was measured between the different sites. Since September reporting we have standardised reporting across all sites (the previous methodology made Queen Square utilisation look worse than it actually was).

4

Following on from the detailed review of our utilisation metric against the Civil Eyes metric undertaken as part of the last paper, we have agreed a revised methodology for measuring utilisation. Key elements from this are as follows:

• Exclude unused sessions from the utilisation metric because the drivers of unused sessions are very different from that of operational utilisation.

• Standard theatre benchmarking already excludes emergency lists from utilisation metrics because the work is by its nature unplanned and so trusts cannot control how well filled the lists are. We will also exclude certain other lists that are filled at short notice for urgent (although not emergency) cases.

• Because our proposed internal metric would be different from that of standard NHS benchmarking for theatre utilisation, Civil Eyes we will also report the Civil Eyes benchmark metric to ensure that we do not take false confidence from our internal measure

• We would report alongside the utilisation indicator a series of other metrics which give us a much fuller account of our use of theatre resources:

► Numbers of sessions not used, broken down by notice given and reason, allowing an assessment of reasonableness of non-use

► Numbers of sessions released by specialties and numbers of ad hoc sessions taken up by specialties, giving an indication of whether planned allocations are appropriate

• The performance team will also develop a metric for measuring theatre productivity. This will be done in conjunction with surgical divisions. We need to be very careful that such a metric does not incentivise faster operating at the expense of quality.

4. Next Steps

The Trust Board are asked to note the following actions:

• Implementation of actions recommended to reduce unused and closed sessions and improve theatre utilisation with oversight by UCH Future.

• Improved tracking of full range of measures to track use of our theatre resources

Nina Griffith, Gareth Adams, Simon Knight Planning and Performance 30 November 2015

5

Appendix A

Results of audit of late starts in UCH Theatres in August and September 2015

There were a total of 381 late starts in UCH Main Theatres in this period with 68% of all elective sessions beginning after the scheduled start time. Of the 381 late starts in UCH theatres 126 had reasons recorded that could be used as part of this analysis.

The chart below shows the number of minutes lost as a result of late starts and the number of late starts by reason.

At the Macmillan Cancer Centre (MCC) there were 209 late starts across the two month period, 75% of total sessions. Of the 209 late starts 64 had useable reasons recorded.

6

G

Agenda Item 10

Quality and Safety Committee Report

November Quality and Safety Committee summary report to the Board of Directors December 2015

1. Clinical Effectiveness

Introduction of New Interventional procedures

The steering group (CESG) reported that in quarter two, five new interventional procedures were approved, two are in progress and three have been incorporated into usual practice, with a further three remaining under review due to low numbers.

National Confidential Enquiries

MBRRACE-UK report: Saving Lives, Improving Mothers’ Care - CESG reported that a clear action plan is in place to address the remaining unmet recommendation for direct consultant to consultant referral for suspected surgical cases.

NCEPOD study of care of patients undergoing lower limb amputation - QSC were informed that although the recommendations have been listed as part/not-met by physiotherapy and dietetics it should be noted that not all recommendations are applicable to UCLH as the vast majority of patients are cared for at the Royal Free Hospital.

High Level Reports Royal College of Emergency Medicine report on Acute and emergency care, July 2014- QSC was informed that the Medical Director for the Medicine Board has agreed to take this forward as part of the 7 day working project.

RCP acute care toolkit 12 for acute kidney injury and intravenous fluid therapy- QSC was informed that the Trust is part of the UCLP AKI collaborative and a local acute kidney injury group has been set up, led by Dr Gaston which will report to QSC.

2. NICE monitoring

The Trust proposes to change the current approach of corporate monitoring of non-mandatory NICE guidance implementation. Divisions would no longer be asked by the Quality and Safety department to complete initial and follow-up compliance assessment questionnaires and action plans for non-mandatory NICE guidance. The Q&S department would continue to provide implementation and monitoring recommendations to the divisions for non-mandatory guidance

Adopting the changes proposed in this report could enable resources and time to be focused on mandatory aspects of NICE guidance and incorporate and cover the breadth of other guidance such as Quality Standards e.g. ensuring divisional oversight of all guidance including Quality Standards as referred in the CQC inspection frameworks.

The Trust is legally obliged to fund medicines and treatments recommended by NICE’s technology appraisals within three months of its date of publication. However, QSC recommended that the Executive Board approve a proposal not to monitor all non-mandatory NICE guidance as the commissioners have not laid financial expectation on the Trust to do this.

3. NHS Litigation Authority (NHSLA)

The NHSLA have launched a national initiative to publish a Claims Scorecard for all NHS services to assist in examining claims and costs. It was acknowledged that there are some limitations to the data but it is felt that it may strengthen existing approaches to claims review at divisional level.

http://www.rcem.ac.uk/Shop-Floor/Policy/Acute%20and%20emergency%20care%20-%20prescribing%20the%20remedy

QSC will request review and assurances relating to claims which fall into the red and amber categories. There were three high value/ high value claims related to spinal neurosurgery therefore, although the spinal pathway was reviewed both internally and externally last year the associate divisional Clinical Director for Queen Square is to review the neurosurgery claims and report back to QSC.

4. Clinical Audit and Quality improvement

The Clinical Audit and Quality Improvement committee (CAQIC) reported on the; Annual audit of audits: compliance with the UCLH clinical audit policy Despite a number of changes discussed between the medical directors and the CAQIC chair improvement is slow. The CAQIC chair will meet with the Director of Education to review this report and Clinical Audit at UCLH. Record Keeping Re-Audit Results broadly static, improvement still required regarding identification of who wrote the entry and recording the time of the entry. The Audit leads are to carry out a snapshot audit to identify non-compliant staff and generate improvement. Community Acquired Pneumonia This audit compares the Trust’s scores with national compliance rates against international standards including antibiotic prescribing. A mortality prediction score, CURB65, should be calculated for each patient to establish severity and inform the treatment plan. This was completed for 62% of patients lower than the national average of 82%. A project has been set up to establish an urgent pathway for patients with community acquired pneumonia.

UCLH Emergency Department GP Discharge Summary Audit

This multi-centre audit was completed, in collaboration with five Central London CCG GP surgeries, to ascertain compliance with mutually agreed standards of emergency department (ED) discharge summaries and establish if there is variation between GP and ED expectation. As a result of this audit the ED produced a standard operating procedure (SOP) setting out minimum requirements.

4. National Audits 4.1 Falls Audit report (Falls and Fragility Fracture Audit Programme- RCP) 4.1.1 UCLH reports approximately 100 falls reported a month, with around a quarter of these incidents reporting some harm (predominately low harm). Overall, the incidence of ‘all falls reported’ has increased over the past two years at UCLH; this is in part due to the inclusion of new categories of falls (2014), as well as a heightened awareness of reporting secondary to a falls reduction campaign in 2015. Importantly, the number of moderate or severe harms related to falls has significantly reduced in Q1 & Q2 this year in comparison to the same period last year. In September 2015 the Trust appointed its first Falls Darzi Nurse, who is tasked with leading the quality improvement programme to reduce harm from falls in the coming year 4.1.2 The Royal College of Physicians National Audit of Inpatient falls was carried out over two days in the summer of 2015. Summary of Results:

• The national mean for “falls reported per 1,000 occupied bed days” was 5.6 for acute hospitals. UCLH was lower at 3.95.

• The national mean for “falls with moderate, severe harm or death per 1000 occupied bed days” was 0.19. UCLH was lower at 0.16.

• Across London, UCLH ranks in the top-four Trusts for (the lowest) numbers of ‘falls reported’ and the bottom four for (highest) numbers of ‘moderate or severe harm’ following a fall

Areas of good practice and areas for improvement have been identified and an action plan is underway. 4.2 Dementia Carers Audit report 4.2.1 The 2014/15 CQUIN articulates that: ‘The Provider must demonstrate that they have undertaken a monthly audit of carers of people with dementia to test whether they feel supported and reported the results to the Board.’ Following considerable difficulties in securing engagement with the audit it was agreed to fund a carers liaison post to provide dedicated expert time and focus to carers. Unfortunately this post holder then left the Trust. As part of their work the nurse specialists for Older People are providing support to carers including facilitating communication between ward teams and the community. Strong links have now been established with third sector organisations that are providing the expertise in terms of financial support, housing and ongoing assistance following discharge. 4.2.2 In addition, the nurse specialists have been working with the Patient Experience Team to find additional ways in which carers can be supported at UCLH. As a consequence of this, the Trust has signed up to ‘John’s Campaign’ ,a national movement, calling for the families and carers of people with dementia to have the same rights as the parents of sick children. Leading on from this a Carers Card has been piloted - which enables carers to visit patients outside of usual visiting time and at night. The service provided to support carers for people living with dementia admitted to UCLH on the non-elective pathway is comparable with other peer London Trusts. It is anticipated that the Dementia CQUIN for 2015-16 will focus once again on the provision of support for carers; this will give the Trust an opportunity to enhance our service further. 5. Claims & Inquests The increase in the number of clinical claims received continues and there continues to be high numbers of claims reported to the NHSLA. The closure of four high value claims resulted in significant increase in damages for this six months. There have been no new Prevention of Future Death rulings. Recent case law in Consent Cases following Montgomery found that a trust breached its duty of care as that the patient had been deprived of their choice of surgeon. The operation was not successful, and the claimant alleged she would not have had the procedure had she known earlier that her chosen surgeon was not available. It was not sufficient for the Trust to have a standard term in the consent form advising the patient there is no guarantee on a specific surgeon performing the procedure. The Judge found that the claimant had been deprived of their choice of surgeon and followed the Montgomery v Lanarkshire decision by highlighting the importance of patient autonomy. Lessons to be learned from Claims and Inquests have been shared with staff.

6. Complaints

The annual Complaints report, providing the analysis of formal complaints for 2014-15, is enclosed for Board members only. Following the meeting it will be uploaded to the UCLH Website. 7. Controlled Drugs (CD) The Trust continues to demonstrate a high level of compliance with the Ward Pharmacist/Sister monthly CD audits. A total of 83 Controlled Drug incidents were reported during the quarter which is broadly in line with the number of incidents reported over the last 2 years. There were no serious

incidents involving CD in the quarter. The template of the report has been reviewed and will include more in depth information about incidents. Two Occurrence Reports have been submitted to the London Local Intelligence Network (LIN) in the last quarter.

8. Annual Patient Reported Outcome Measures (PROMS) The headline participation rate for 2014-15 for return of pre-operative questionnaires was 84.7% (76.2% in England) and a response rate of 71.5% (73.6% in England) for post-operative questionnaires returned. The Trust’s case-mix adjusted average health gain as compared to the national average is summarised as follows: Groin hernia repair (EQ-5D) is below the national average. The EQ-5D Index for Hip Replacements is just below the national average, and the Oxford Hip Score is just above the national average. Hip revision data is not available. The EQ-5D Index for Knee Replacements and the Oxford Knee Score are below the national average. Both scores fall outside of the 99.8% control limit making the Trust an outlier. Knee revision data is not available. The EQ-5D Index for Varicose Veins is in line with the national average and the Trust’s Aberdeen Varicose Vein Score is above the national average and just blow the upper 99.8% control limit. The health gain for condition specific measures reported by patients for primary hip replacement was 21.7 (21.4 in England), for primary knee replacements was 13.3 (16.3 in England), The gain on the Aberdeen Varicose Vein Questionnaire for varicose vein respondents following their operation was -4.1 (-8.7 in England). Recent developments relating to non-mandatory PROMs were reported. An electronic PROM was introduced to the outpatients department of the RLHIM as of October 2014. Unfortunately patient participation has been disappointing. Steps have been taken to improve patient participation. The project will re-launch on 18th November.

9. Quality & Safety Committee effectiveness

QSC discussed how we can be assured that what is addressed at QSC reaches all staff. Several methods of dissemination are in place including the CEO’s Team Brief, Safety Huddles, Message of the Week, the monthly Quality and Safety bulletin, walk rounds etc. The main area of concern is reaching the medical staff who have no common forum. QSC is to give some consideration to audit and the Director of Education is to add learning from serious incidents to competency assessments.

10. Duty Of Candour Compliance with duty of candour shows overall compliance has improved since April from 26% to 58% for phase 1 (completed within 10 working days). Phase 2 compliance, however, has fallen from 27% to 25% between August and November. There is a large variation between those divisions which are doing well and those divisions who still have low compliance. There is a significant backlog that is not being addressed, despite recent communications and support with serious incidents (which are duty of candour applicable). The drop in incidents considered moderate harm was also noted. A case notes audit has commenced.

11. Risk Coordination Board (RCB) A review and refresh of Trust wide risks by the Medical Directors and Chief Nurse and other executive directors is planned in December. This will include a review of clinical risks and in particular trust wide clinical risks. This will form the basis for consideration of regular review of

clinical risks and subsequent monitoring by the RCB and reporting to the Quality and Safety Committee. It is planned that QSC will report to the RCB on risks for integration with the risk register and identify significant risks arising from SUI's, complaints, claims, national alerts and patient safety priorities starting in quarter 3.The Audit Committee will be supplementing the Risk report.

12. Trust Quality & Safety performance Book

QSC received the Performance Book for September 2015. QSC will ensure that messages about hand washing and ‘being seen to wash your hands’ are shared widely for leadership and role modelling.

It was noted that there has been no ‘strain drift’ this year with the ‘flu vaccine and this message is also being shared widely.

H

Agenda Item 11

Finance and 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 Wednesday 2nd December 2015, relating to the financial performance and contracting position of the Trust as at 31st October 2015.

1.2 The Board of Directors is asked to: • Note the financial performance for the first seven months of the 2015/16

financial year, and associated financial issues, • Note the 2016/17 financial planning update presented to the Committee

focusing on the level of cost improvement plan (CIP) savings that the Trust should target next year, and

• Note the contracting update.

2. Financial Performance 2.1 The Interim Finance Director informed the Committee that the Trust’s income and

expenditure variance to plan, when reported prior to donation-related adjustments and exceptional items, worsened by £1.4m in the month of October (around £0.5m worse than forecast), resulting in a year-to-date shortfall against plan of £15.1m. This position included the year-to-date release of £3.6m from the Trust’s Board contingency. Table 1, below, shows year-to-date and in-month financial performance for the Trust’s clinical boards and corporate budgets.

Table 1 – 2015/16 month 7 financial position

2.2 The Committee reviewed a latest bottom-up forecast generated from clinical boards and corporate areas. Although there was a slight deterioration in the underlying position compared to the previous month’s set of projections, as the forecast continued to assume only £5m of the Board contingency was released from the Trust’s £10m Board contingency, the Committee agreed that the Trust’s year-end forecast (when reported prior to donation-related adjustments and exceptional items) should remain unchanged at a £32.5m deficit.

2.3 The Committee also received an update on the fortnightly financial performance review meetings, which were reviewing progress from clinical boards and corporate directorates in their plans to return to planned run-rate and delivering the Trust’s originally planned deficit (before donation adjustments) of £20m. The Committee noted that the most

Page 1 of 4

recent financial performance review meetings had included presentations of recovery plans from the three divisions in “special measures” (Queen Square, GI Services and Medical Specialties).

2.4 The Committee noted that the most significant area of concern was Queen Square division, which was reporting a £8.4m year-to-date adverse variance against plan at month 7, which included a £5.4m shortfall on clinical income from patient activity.

The Interim Finance Director informed the Committee that the Trust’s Recovery PMO was regularly meeting Queen Square to provide appropriate challenge and support to further develop robust recovery plans. The agreed key initial actions were:

• Given absences within Queen Square’s general management, informatics, human resources and finance teams, combined with recruitment difficulty, it had been agreed to provide the division with interim support recognising that this was a short-term solution. The Interim Finance Director also mentioned that the Director of Organisational Development had agreed to lead a review of the organisational structure at Queen Square to ensure it was appropriate for managing the on-going challenges.

• A continued focus on maximising capacity utilisation in Queen Square, particularly as income underperformance remained the main driver of the year-to-date shortfall against plan. The Committee noted that the intention was for all clinical teams in Queen Square to deliver a 10% increase in the volume of patients treated and Specialist Hospitals Board were developing plans with clinical leads and managers to deliver this.

The Interim Finance Director advised the Committee that whilst he was still cautious as to the delivery of Queen Square’s year-end forecast, there were potentially a number of opportunities as well as risks in the forecast, which represented a more balanced perspective than in previous months.

2.5 The Committee also noted that the UCLH recovery plan, as previously discussed by the Executive Board, FCC and the Trust Board during November, had been formally submitted to Monitor on by Friday 20th November. The Committee noted that this plan included a range of further recovery initiatives that should improve the Trust’s run-rate, going into the new financial year, by around £5m (on an annual basis).

2.6 The Committee also discussed progress being made to deliver workforce-related financial recovery actions in 2015/16, particularly savings from the additional headcount reductions and the impact of bank/agency controls. The Interim Finance Director also pointed out that further work was being undertaken by workforce and finance teams to ensure a clear and consistent approach to reporting bank & agency expenditure in order to address current reporting issues.

The Committee asked if an update on progress on these issues as well as workforce savings that were planned to be delivered as part of the further set of recovery actions to improve the Trust’s run-rate could be provided to the next FCC meeting.

3. Other Financial Issues 3.1 The month 7 position on performance against cost improvement (CIP) schemes showed

that the Trust had delivered year-to-date savings of £21.6m, a shortfall of £1.1m against the planned target of £22.7m. The full-year forecast showed that schemes totalling £43.1m had now been identified (i.e. 100% of the full-year target of £43.0m) with full year equivalent savings of £47.9m.

3.2 The Trust’s cash balance at 30th November 2015 (month 8) was £62m, which was £23m behind plan, although this represented a £3m improvement in variance to plan from the

Page 2 of 4

previous month. The Interim Finance Director informed the Committee that the shortfall on cash continued to relate to outstanding debt with commissioner debt.

The Committee was presented with a more detailed analysis of the cash position, including key variances and forecast, which showed that the Trust was forecasting a return to its planned year-end cash position by 31st March 2016, with any further potential upsides to this depending on the prompt collection of cash in relation to the new agreed contact values for 2015/16.

3.3 The Committee reviewed a pack of productivity analysis provided to the Trust as part of the programme of work led by Lord Carter to review hospital productivity and develop a suitable metric that could be applied across all Trusts allowing for relative complexity. The Committee noted that whilst there were concerns with the accuracy of the underpinning data & key assumptions, the Trust would continue to support the development of the ‘model hospital’.

The Interim Finance Director also informed the Committee that he would lead on generating a proposal for taking forward the whole productivity agenda, including the work of Lord Carter, in a more coordinated way.

3.4 The Committee also briefly reviewed an update on financial performance for the UCH Education Centre and Staff College leadership development programme, analysed by internal and external activity.

The Chief Executive informed the Committee that the Executive Board would be undertaking a review of pricing arrangements for the Education Centre and associated training programmes.

4. 2016/17 Financial Planning Update

4.1 The Interim Finance Director presented the Committee with a paper setting out the level of savings that were considered to be deliverable by the Trust in 2016/17, prior to having full certainty of the underlying tariff and wider income and expenditure position.

4.2 The Interim Finance Director informed the Committee that this approach differed from previous years where the CIP target had been generated as the balancing item in order to achieve a planned I&E position after understanding the bottom-up planning modelling from clinical boards and corporate directorates. The Interim Finance Director pointed out that this would allow earlier CIP target setting for clinical boards and corporate directorates and ensure an appropriate level of efficiency was in place, which was not only sufficiently challenging to make inroads into the recurrent deficit, but also remained deliverable. The planned deficit would then become known when there was more certainty in relation to the 2016/17 position.

4.3 The Committee reviewed a 2016/17 CIP range from £35m to £55m, which included an indicative breakdown showing the potential savings as a result of Board approved actions and transformation schemes, with a residual requirement to be identified through other schemes.

4.4 The Committee recommended that the Trust should work towards a target of £45m to move the Trust closer to a break-even position, and to test through the planning process the quality impact assessment of delivering such a significant efficiency saving before making a final recommendation to the Board as to the planned 2016/17 income and expenditure position.

5. Contracting Update 5.1 The Director of Planning and Performance provided the Committee with an update on

the current contracting position for 2015/16; mentioning that the Trust had signed the contract documentation with NHS England, and that progress was continuing to be

Page 3 of 4

made towards contract signature with Camden CCG and the other North and East London CCGs.

5.2 The Director of Planning and Performance was also pleased to inform the Committee that the Trust had now agreed baseline values with 80 of the other 81 associates to the Camden CCG contract.

5.3 The Committee also noted the good progress that had been made on resolving outstanding 2014/15 commissioner billing challenges, and the clearance of debt that had resulted.

Dr Harry Bush Tim Jaggard Chair of FCC Interim Finance Director 3rd December 2015

Page 4 of 4

I

Agenda Item 12

Report of the Audit Committee Meeting 17th November 2015

with - 1 –


Report to Board of Directors – 9 December 2015

MAIN POINTS FROM THE AUDIT COMMITTEE

The Audit Committee (AC) met on 17 November to consider the following important matters. 1. Internal Audit (IA)

1.1. Assurance reports

AC reviewed a progress report which included the findings from two outstanding Baker Tilly reports and two final TIAA reports. Management had accepted the recommendations and had plans in place to deliver the actions. AC noted there was no high priority or urgent actions. The reports and ratings were:

2014/15 Learning Lessons Amber / Green

2014/15 Clinical Division Service Review Amber / Green

2015/16 Central Alerts System (CAS) Review Yellow

2015/16 Estates Maintenance Green

From 2015/16 the classification of the overall assurance of IA reports would be as follows:

Green Substantial Assurance

Yellow Reasonable Assurance

Amber Limited Assurance

Red No Assurance

Discussion focused on two reports, learning lessons and the CAS review. 1.2. Learning Lessons

The aim of the audit was to test how well the Trust learns from its incidents and prevents future risks. AC noted that as issues and incidents arose they were dealt with and that the QSC monitored recommendations and action plans. However, although lessons from adverse events were published in a quarterly quality and safety bulletin it was not easy to measure the extent to which improvements were made to practice. AC referred the report to the QSC for discussion. 1.3. CAS Review

The CAS is a Department of Health managed web based system for issuing safety alerts and other important information to the NHS. IA reviewed the process for handling alerts and identified some areas for improvement including a revision of the CAS response form to include a record of action taken after the alert that could then be followed up by the relevant trust committee. AC noted that IA would audit the CAS annually. 1.4. Workplans

AC noted that the 2015/16 workplan was behind schedule. IA aimed to present 15 reports at the next meeting. IA also presented an early draft of the 2016/17 audit timetable with a plan for each quarter of the year. AC also noted that the number outstanding unimplemented recommendations from the past audits had reduced from 39 to 13 and that the Finance Director was actively involved in reducing these further.

- 2 –

2. External Q2 report and sector development update

External Audit (EA) provided an oral report on Q2 which is on track with the plan. EA advised that a discussion should be held at the next meeting on the going concern statement (a statement according to the concept of a going concern in the public sector). AC supported this proposal; the discussion would take into account cash forecast and tariff demands. EA also updated on sector developments highlighting the new guidance on agency controls, an NHSLA consultation on the culture of candour and new secondary legislation regarding false or misleading information; details have been forwarded to the lead directors.

3. Follow Up Reports

3.1. Working Whilst Sick

In July 2014 proactive counter fraud work highlighted working whilst sick as a potential issue for organisations. Liz O’Hara, Head of Workforce updated on mechanisms in place to safeguard against this issue and the action taken where this is a concern. AC noted that the recently reviewed anti-fraud and bribery policy would include specific examples of fraud in an appendix including where an individual had been dismissed for working whilst sick. The code of conduct would also be reinforced to remind staff they need to get approval to work elsewhere if UCLH is the primary employer. 3.2. Job Planning and Appraisal

Jennie Friswell, Head of Medical Workforce presented an update on job planning and appraisal rates both of which support the delivery of a safe and efficient clinical service. Since the last IA report further improvements in completion had been made with 91% of appraisals completed and 74% of job plans received. Westmoreland Street had been an area of particular concern; AC was advised that the move had caused some disruption but an action plan was now in place to complete the work. AC was also pleased to note that a link had been established between job planning, the completion of mandatory training and the clinical excellence award process. AC had previously been told that work was being undertaken to develop an electronic system with the aim to improve compliance, this was now being progressed. 3.3. Standing Financial Instructions (SFIs)

AC had approved revisions to the SFIs and the Scheme of Delegation (SoD) which aimed to improve usability in December 2014. Dominic Firth, Interim Deputy Director of Finance presented a report on the use of SFIs following rollout of the new version. AC noted that the SFIs had been well received and in particular that changes to the procurement rules had brought improved internal control and greater rigour to non-pay purchasing. Some further improvements were noted and these would be actioned at the next review; these were not material.

4. Board Assurance Framework (BAF) and Risk Report

AC reviewed a risk and assurance report for quarter 2 noting that both had been discussed by the Risk Co-ordination Board (RCB) and Executive Board. On the BAF, AC was pleased with the revised template which had been used for two quarters. AC made a number of suggestions which could improve the process. These included showing the risk appetite and the date the risk was first classified. AC also provided a view on how controls could be strengthened by recording any external assurance that had been completed e.g. IA reports. AC also raised a number of specific questions for the Executive Leads; these would be considered as part of the Q3 review.

with - 3 –

On risk management, AC noted that that all red and high level amber risks on Datix were being reviewed and validated by the Divisions and Corporate functions to ensure they were up-to-date and comply with Trust policy. The aim was to clearly identify any Trustwide risks. RCB had begun the process and had not identified any areas of concern. AC noted the work and it was agreed that the high level amber risks would be presented to the Board with the next risk report. AC had previously been advised that the Trust was introducing a four colour risk matrix, the report advised that the risk policy now reflected this and would shortly be rolled out across the Trust.

Rima Makarem Audit Committee Chair

J

Agenda Item 13

Audit Commitee Minutes

1

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Tuesday 15th September 2015

Present: Audit Committee Members Rima Makarem Non-Executive Director and Chair (RM) Diana Walford Non-Executive Director (DW) Harry Bush Non-Executive Director (HB) Non-Members Tonia Ramsden Director of Corporate Services (TR) Tim Jaggard Director of Finance (Interim) (TJ) Dominic Firth Deputy Director of Finance (Interim) (DF) Nick Atkinson Counter Fraud, Baker Tilly (NA) Hannah Wenlock Counter Fraud, Baker Tilly (HW) Paul Grady Internal Audit, TIAA (PG) Philip Lazenby Internal Audit, TIAA (PL) Craig Wisdom Deloitte (CW), External Audit Anthony Hargreaves Deloitte (AH), External Audit Pia Larsen Director of Procurement (PLar), For Item 4a Nick McNally Divisional Manager, R&D (NM), For Item 4b Mairi Bell Chief Accountant; Minutes

Matters Covered

1. Apologies for Absence

Apologies received from Kieran Murphy. 2. Minutes of the Meeting held on 21st July 2015

The minutes were agreed subject to a correction from DW. 3. Matters Arising AC agreed to close the following MA items as completed: MA 266, MA 274, MA 275, MA 277, MA 278, MA 279, MA 280 MA 285 – Confirmation was received that all write-off items related to emergency admissions. MA 292 - PG advised that a meeting was scheduled to agree the approach to this.

2

Matters Covered

MA 291 – PL confirmed that an October start date had been agreed in discussions with PLar. MA 290 – PG advised this was still outstanding, and following further liaison with HR, an update would be provided to November AC. RM updated that Cyber Security had been proposed as a Deep-Dive session. 4. Other Reports 4a Procurement Report PLar attended to update AC on Procurement. PLar reminded AC of the brief to report on Contract Management, setting out a good process and identifying areas for improvement. PLar highlighted large contract within IT, and noted significant liaison with David Hill. PLar advised that there were inconsistent approaches to contract management across UCLH, with many large service contracts managed within Boards, such as IT or Patient Transport. PLar also noted the Pathology contract, with a contract manager recently appointed to Medicine Board, and noted that procurement had been able to contribute to this process. PLar noted that it was difficult to find a good example of a procurement model within the NHS. PLar noted that the Procurement team had expanded their span of input over the past twelve months to get more involved, giving some examples of where procurement had contributed, also further noting that often services came to procurement after the event. RM asked if procurement were troubleshooting or doing a systematic review. PLar responded that the revised thresholds in the SFIs had flushed out more items and given procurement visibility sooner, allowing them to provide more support. PLar was not able to confirm a % of contracts reviewed by procurement, but confirmed that the direction of travel was towards comprehensive review. RM asked about the governance arrangements, noting this was unclear, with some done centrally and some done in services. PLar replied that there were no procurement people within the services, noting that although some very good attempts had been seen, the key skill set of e.g. contract negotiation, was not always present. RM commented that Finance and HR had professional people working directly for Boards. HB added that the devolved authority should mean devolved responsibility for taking decisions, not doing the job with unskilled resources, and that Boards should have advice from the centre. TJ noted that there was a difficulty in ongoing management of contracts in ensuring that accountability was clear. HB asked if anyone had dotted line responsibility to procurement. PLar replied that no-one did, and that contract management within services tended to focus on service aspects and good service management, noting that robust discussions on IT contracts

3

Matters Covered

only took place after Procurement got involved. DF asked if there would be a weakening of the service side with enhanced focus on the contract. PLar replied that a good contract manager would draw together finance and service aspects. PLar then updated AC on feedback from a private sector organisation with a well-regarded procurement function. PLar particularly emphasised that relationships with supplier were carried out at the appropriate level, with top tier suppliers having direct relationships with the most senior managers. PLar explained this was important in order to hold suppliers to account. PLar noted that in the private sector model, responsibility was clearly defined, while contract management remained part of the procurement function. RM commented that a lot of good ideas had been heard and asked what the next steps were. PLar replied that this would be to have a contract management tool in place, fully populated with trust-wide data. PLar also added that the responsibility for contract management needed to be determined. RM asked about procurement savings in the transformation work programme. NG replied that procurement savings were at the heart of financial transformation, with a 5 year model indicating an estimated £20-£25m could be saved. NG added that control and standardisation were key aspects of achieving this, noting too much variation in current processes. RM suggested that the contract database would help to identify how much of a problem there was, and asked about the timeframe for implementation. PLar responded that there was currently a focus on CIP, and someone needed to be identified to lead this work, if it was agreed to be a priority. TJ highlighted the conflict between the need to do such tasks and the focus on reducing corporate posts. DW asked if the loss to the organisation from current poor performance could be estimated. PLar replied that a resource to do this work would be expected to pay for itself. RM recommended this be highlighted to EB as a priority. NA suggested starting with a few key contracts, and HB noted that even a 5% saving would be a continuing reduction of several £m. ACTION - Highlight to EB that procurement review work should be undertaken as a priority 4b Waivers Report PLar presented an update report on procurement waivers, noting an upward trend following the reduction in procurement threshold in the revised SFIs. PLar added this was a positive movement, with procurement having significantly increased visibility. PLar highlighted some large waivers, e.g. soft FM services at Queen Square. PLar advised that some level of waivers would always be required, particularly where

4

Matters Covered

one supplier was able to do the work. PLar noted that procuring services for the Westmorland site had been a challenge. RM asked if bad practice was now being seen for the first time. PLar replied that it was, and noted that refreshed communications on the SFIs were reminding people who could enter commercial arrangements with suppliers, with most queries now coming through procurement. 4c Response to R&D Audit NM attended to provide a response to the Internal Audit on R&D. RM introduced the discussion, advising NM that AC wanted more detail about the Internal Audit report on R&D. NM advised AC that the concerns raised had been taken very seriously, with the paper setting out responses. NM advised that the audit process in the Joint Research Office had been reviewed, and expressed regret to AC that the impression had been given that the audit process was not a priority. NM further explained that the paper included some evidence of the controls in place, the regular processes to be followed when making awards and communications to NIHR on spend and research. NM noted that NIHR were evolving their systems and improving the controls in place. NM acknowledged that senior R&D managers were unsighted on this audit, and only became aware when issues were raised. NM noted that internal systems should have picked this up. TJ noted there were issues on both sides, with sign-off of the APM at the start of the audit the key point to get appropriate senior engagement. TJ noted common theme on escalation in regard to internal audit and similar processes. RM asked if R&D was on the plan. PG confirmed that it was for later in the year, and that discussions had recently taken place with NM. RM said that it was important for all involved to know up front, and for sponsor and lead to be clear. RM also noted that most things would be held electronically and shouldn’t be too difficult to handover. NM confirmed that it should be, and noted that the system could have been better explained to a junior auditor at the outset. PG added that an early conversation often gets 90% of what’s required. DW asked about research papers to the Board. TJ replied that his was embedded in the financial reporting, with FCC getting a more granular update. RM suggested the Board could see items by exception. TJ advised that the next bid for BRC Funding would be taking place, suggesting the Board could review in more detail, with the best way through FCC. ACTION – Next bid for BRC to be reviewed in more detail

5

Matters Covered

4d Policy Review (Expenses) TJ presented the new draft of the Expenses policy, noting the main changes were to responsibilities laid out in Section 3, making the claimant’s manager responsible for approving the claim, rather than the payroll department. RM asked if the receipts proposal was tight enough, and DW asked about travel payment with contactless cards. DW suggested including contactless payment specifically. HB asked about section 12.1. TJ replied that this was to advise staff the Trust had no liabilities ion putting through expenses. NA added that individuals were responsible for their own tax. HB suggested a clearer wording was needed for this statement. RM asked about the communication of the policy. TJ replied that this would be via the Intranet, to be found by a policy search when required. TR suggested circulating to Divisional managers on cascade. ACTION – update expenses policy to include mention of contactless payment ACTION – clarify wording on section 12.1of expenses policy 4e Policy Review (Anti-Fraud & Bribery) TJ presented the new Anti-Fraud & Bribery policy, a combination of the previous Counter Fraud policy, and Anti-Bribery section previously contained within the Code of Conduct. AC suggested a number of minor revisions to the draft policy, which were agreed. ACTION – update policy in line with AC discussion 4d Policy Review (Disposal of Capital Assets) TJ presented a new policy on disposal of capital assets, noting that this fulfilled a requirement of the SFIs for this policy to be in place. RM asked about assets below £5,000. TJ replied that the records would not always be as good for assets below the capitalisation threshold. RM asked about iPads and laptops. TJ repled that this linked back to tracking personal assets, which would be done via ESR, although a small control weakness in identifying these before employees left. TJ also noted that the IT team made sure iPads/laptops were returned in cases where replacements were issued. AH noted a link to information governance in the case of IT equipment.

6

Matters Covered

5 Internal Audit 5a Internal Audit Progress Report PG presented the Internal Audit Progress Report, noting moderate progress with a couple of draft reports and commented that traction was starting to be felt. PG also added that follow up was being done, with a reduction in outstanding recommendations, which had peaked at 155 and was now down to 39, excluding new TIAA reports. RM noted that previously IA had reported it difficult to get engagement. PL replied that good movement had been seen in the previous couple of weeks, as summer holidays had ended and a significant push had come from EB. PL noted that monthly fraud meetings had also been helpful. TJ commented that there wasn’t much detail on WIP, where work was ongoing but recommendations couldn’t yet be closed, such as P2P. PG replied that the focus so far had been on closed/open, but detail on WIP could be included in future reporting. HB commented on the timetable, noting the delayed start and the back-ended workload from the prior year. PL suggested it would be helpful to submit the audit plan early for next year to avoid similar delay, proposing to bring an early draft to November AC. RM and HB agreed this would be a good idea. PG noted the CQC mock inspection, and confirmed IA would be able to assist if this was required by CQC leads. RM noted that the end of Q2 was approaching and asked if catch up to the plan was possible. PG agreed it would be challenging, but thought it was feasible. PL suggested emailing RM with regular monthly progress. ACTION – bring draft of 16/17 Audit Plan to November AC 5b Internal Audit Charter PG presented the Internal Audit Charter. RM asked about the comment on APMs being issued to AC. PL replied that this section should be deleted as not applicable to UCLH, with APMs agreed by Executive leads. PL suggested advising AC directly for specific audits. TJ asked about the KPIs and what the obligations of the Trust were. PL noted that this was monitored, but most Trusts didn’t want this information. TJ suggested strengthening the section on escalation and PG agreed to do this. PG also suggested pulling out a one page briefing on the roles of IA and managers. TR suggested attaching this to the IA report to EB, and RM added that audit leads for new reports should also be given this. RM confirmed that the Charter was approved subject to agreed minor revisions. ACTION – update Internal Audit Charter with agreed changes

7

Matters Covered

6 Counter Fraud 6a Counter Fraud Progress Report NA presented the Counter Fraud Progress Report. NA highlighted a review of the Heat Map, with an increased risk for illegal working and procurement / conflicts of interest. RM asked how new risks would be looked at, as the LPEs were not linked to the two increased risks. NA replied that the procurement side may be picked up in an LPE, and that new risks would also be discussed in quarterly fraud meetings. NA highlighted some specific actions in reactive investigations, noting that some information had been received from a secondary employer for case 530/4 after a long delay and that a new case involving abuse of position, 111/5 had been started. DW asked about certificate sponsorship compliance on page 167, asking how seriously this would have been taken in HR. NA replied that Ben Morrin was very aware of this, with Counter Fraud engagement through Liz O’Hara. RM noted an immigration review at St George’s and agreed to pass information to Counter Fraud. HW noted that there was now agreement in place for Counter Fraud review of policies. NA added this process was now much improved. RM asked about pg 189, stating that UCLH had not submitted creditor matches. HW confirmed this had been done now. RM noted outstanding recommendations from a 2013 LPE, adding that AC needed to see these as per the IA recommendation tracker. HW noted that these recommendations were currently reported to EB and TJ added that these were discussed at the quarterly fraud meeting. HB asked about how gifts and hospitality were registered. TR replied that forms were completed and sent in. HB asked if this was happening in practice. TR confirmed that forms were regularly received, and that reminders were issued quarterly, which always generated additional returns. DW asked if staff on honorary contracts were included. TR confirmed they were, but specific targeting was required. ACTION – RM to update CF on immigration review ACTION – Outstanding CF recommendations to be included in the report 6b Fraud Risk Assessment NA highlighted the Fraud Risk Assessment, noting that 95% of responses to recommendations in the Fraud Risk Assessment had been received, including all those relating to Finance.

8

Matters Covered

7 External Audit CW introduced the External Audit plan for 2015-16 and Q1Progress Report, and advised AC that he was taking over from Heather Bygrave. CW led a page turn review of the report, highlighting key points including a continued focus on quarterly review, changes to the regulatory cycle with a bigger role for the NAO, a new code replacing the Monitor code, significant changes expected to VfM auditing. HB asked about the VfM changes. CW replied that where current reporting was by exception, more rigorous testing and risk assessing approach was expected to be required. CW suggested that a workshop covering the changes would be beneficial. PG asked if there would be more flexibility to rely on IA work in respect of VfM. CW replied that the standard was specific on disallowing reliance, however there would be a focus on leveraging IA work where possible to inform a risk based approach, although independent substantive testing would have to be done by external audit. RM asked when the new guidance would be available. CW replied that there was a draft out, with comments to be made during September. CW noted a final version was expected before the end of the calendar year. RM asked about selection of indicators, and whether the governors would be guided. CW responded that this would not be for auditors to do, but management may advise on options. TJ added that this dialogue was an important part of the selection. AH noted that the indicator selected in the previous year had proven difficult to audit, with the audit trail hard to understand. CW noted that the significant risk areas from the previous year were still the same, but that there would be quarterly review of potential new risk areas. CW also noted a similar materiality threshold applied to the previous year. TJ highlighted a correction on EHRS, noting that an outlined business case had already been to Board, but that there would be delays around timing until a Chief Executive was in post. CW noted a reduction in fees, but advised that fees for quality and VfM review were indicative pending final guidance being released. CW noted that the impact on fees of guidance changes had been raised with the NAO. 8 Risk Update on risk by Committees dealing with risk FCC No update was provided

9

Matters Covered

QSC No update was provided 9. Audit Committee Work Programme TR advised AC that an updated work programme was now available. 10. Any Other Business None. Date of Next Meeting 9am, Tuesday 17th November 2015, Chairman/CEO Meeting Room , 2nd floor central

K

Agenda Item 14

Entries in the Seal Register

Seal Report – September 2015

BOARD OF DIRECTORS MEETING – 9th December 2015

Entries in the Seal Register since the last Report to the Board

Number Date of Entry

Entry Details Supporting Information

764 and 765

23 September 2015

Agreement between University College London Hospitals NHS Foundation Trust and The Mayor and Burgesses of The London Borough of Camden; and The Mayor and Burgesses of The London Borough of Islington

This is a lease for part of a Wing of 250 Euston Road for the joint social work departments supporting the NHS

766 and 767

17 November 2015

Agreement University College London Hospitals NHS Foundation Trust and the The Trustees of UCLH Charity

This document grants a licence to carry out work to 4th floor and basement of 140 Tottenham Court Road to relocate the Clinical Research Facility from the UCH EGA Wing

Documents

BOARD OF DIRECTORS - University College Hospital meeting papers... · 2015-12-04 · Agenda Meeting Title: Board of Directors Date: Wednesday 9th December 2015 Time: 2.00pm Venue: