Board paper March 2013 - Agenda Board... · NBT’s progression to Foundation status and development of the associated quality assurance frameworks would provide the assurance that

North Bristol NHS Trust Board Meeting

Thursday 28 March 2013 11.30am, Board Room, Trust Headquarters, Frenchay Hospital

AGENDA FOR PUBLIC SESSION

1. APOLOGIES: Mike Coupe 2. TO RECEIVE QUESTIONS FROM MEMBERS OF THE PUBLIC 3. TO RECEIVE QUESTIONS FROM LINKS REPRESENTATIVES 4. MINUTES Minutes of the Trust Board meeting held on 28 February 2013 Enc 5. ACTION LOG Enc 6. GOVERNANCE, QUALITY AND SAFETY

6.1 Quality Report & Patient Story (verbal) SJ/Enc 6.2 Monthly Summary of Serious Incidents/Serious Case Reviews SJ/Enc 6.3 Safeguarding Adults SJ/Enc 6.4 Staff Attitude Survey HH/Enc 6.5 Monitor’s Regulatory Framework BB/Enc

7. STRATEGY 7.1 Redevelopment Board Highlight Report TD/Enc 7.2 Move Project Update TD/Pres’n 7.3 Foundation Trust/Acute Services Review (Clinical Summit

Feedback) HH/Enc

8. SERVICE DELIVERY AND PERFORMANCE 8.1 Annual Budget 2013/14 BB/Enc 8.2 Management Information Reports 8.2.1 Activity and Performance SK/Enc 8.2.2 Infection Control Report CB/Enc 8.2.3 Finance Report BB/Enc 8.2.4 Road to 2014 – Programme Management Office (PMO) Implementation report HH/Enc 8.2.5 Single Operating Model M-NO/Enc 9. COMMUNICATIONS 9.1 Chairman’s Report PR/Verbal 9.2 Chief Executive’s Report M-NO/Verbal

10. INFORMATION

10.1 Declarations of Interest 2012-13 M-NO/Enc 11. ANY OTHER BUSINESS 12. NEXT MEETING Thursday 25th April 2013

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North Bristol NHS Trust Minutes of the North Bristol NHS Trust meeting held on 28 February 2013

Present: Mr P Rilett (Chairman) Mrs S Jones Mr B Boa Mr S Karakusevic Dr C Burton Mr M Lawton Mr M Coupe Mr R Mould Mr K Guy Ms M-N Orzel Mr H Hayer Mr N Patel Mr S Hughes Professor A Waterman-Pearson In Attendance: Mr T Bartlett Mr C Puckett Mr P Cresswell Mr N Stibbs Observers: Mr J Britton Ms K Tomlinson Ms G Johnston Apologies: Mr S Wood

ACTION 24/13 QUESTIONS FROM THE PUBLIC Mr Puckett noted from the minutes of the January meeting that the

statement regarding the NHS Constitution within the Single Operating Model had changed and had allowed the Trust to alter its answer. The Unions felt that the original wording of the statement should be reinstated, particularly in the light of the findings of the Francis Enquiry. The Chairman agreed to feed this view back to the Strategic Health Authority and reaffirmed that the Trust was fully committed to trying to achieve all the rights and pledges held in the Constitution.

PC

25/13 QUESTIONS FROM LINKS There were no LINKs representatives present and following recent

correspondence with the LINks lead it was hoped that one could be present for the March meeting.

26/13 MINUTES The minutes of the meeting of 29 November 2012 were agreed as

an accurate record, subject to the substitution of the word ‘Authority’ for ‘SHA’ in Minute 11/13.

NS

27/13 MATTERS ARISING/ACTION LOG

i) Closed Actions The Board reviewed the Action Log and agreed that three actions from September and October and Actions 8 and 12 from January had been completed and would, therefore, be closed.

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The following items were discussed in more detail:

(ii) Redevelopment and BoF Governance (Minute 145 refers) Agreed to be discussed in March. (iii) Community Patient Story (Minute 192/12 refers) Agreed to be discussed in March. (iv) Action 2 (Minute 6/13 refers) Chris Burton reported that the apparently high number of

caesarean section procedures undertaken in the Trust had been raised with the Women’s and Children’s Directorate at an Executive Review meeting and an explanation and any necessary actions would be reported though the Quality Committee in March (v) Action 3 (Minute 6/13 refers) The Board noted that the final inspection report from the CQC visit to Southmead the previous month had yet to be received. (vi) Action 9 (Minute 12/13 refers) Sasha Karakusevic reported that the new activity and performance reports would be ready for the new financial year. (vii) Action 6 (Minute 9/13 refers) The Board agreed that the word ‘Some’ be removed from the action.

NS

28/13 QUALITY REPORT

Chris Burton presented the national Quality Outcomes Framework which benchmarked a series of quality data against any hospital in England. Online access was currently restricted to nursing and medical directors and he showed about a dozen sets of statistics. They all showed that North Bristol was functioning at a reasonably good quality level in comparison to other Foundation and NHS Trusts although the aspiration was to continually improve beyond current levels. Comments on the indicators were invited and the board agreed that numbers of complaints would be a useful addition. In future, Chris Burton said he would report monthly on any data that showed NBT as an outlier and give a quarterly report on the most important indicators. Sue Jones presented the Quality Dashboard and highlighted:

the lower number of reported grade 2 ulcers,

CB CB

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29/13

the screening of 55% of patients for malnutrition the praise from the CQC regarding nutrition and food

standards 28% of colorectal patients reporting an infection within 30

days of a procedure which the Control of Infection Committee was investigating.

The Board noted that the report quoted percentage figures sometimes when actual numbers were very low, which was of limited meaning. It was agreed that the actual numbers be used in such cases. The Board resolved to note the reports PATIENT STORY Sue Jones verbally provided a patient story concerning an active middle aged lady with a skull based tumour. She had received the news of her situation very badly but had been encouraged pre-operatively to set herself goals post operatively and, in her own words, she had set them ambitiously. Looking back she had also felt very lucky to have had a GP with an interest in neurology, to have lived within 50 miles of one of the best neurosurgical facilities in the world and to have met both the dedicated staff and to have been able to listen to the experience of a previous patient. A month on from the operation she had ticked off every goal so far. Her experience was a reminder of the importance to a patient of the individuals in a team and of effective team working. The Board resolved to note the report.

SJ

30/13 MID STAFFORDSHIRE PUBLIC INQUIRY REPORT Sue Jones introduced a report on the recently published inquiry

findings regarding events at the Mid Staffordshire Foundation Trust. The recommendations focussed on:

Openness, honesty, transparency and candour Strengthening nursing Strengthening leadership making more usable, comparable

information available There were implications for the speed of progression of NHS Trusts to FT status with greater emphasis on outcomes and experience and Monitor was introducing a new risk assessment framework with additional measures to enable better judgement on governance. For North Bristol the next steps were:

to produce a specific work plan for nursing adopt iCARE as a vehicle to implement the Trust’s values to continue the quality strategy and ensure outcomes and

patient experience equalled the Trust’s safety culture

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implement the Friends and Family Test conclude the recovery plan for the complaints process

NBT’s progression to Foundation status and development of the associated quality assurance frameworks would provide the assurance that developments in governance structures were effective. Harry Hayer reported that the Prime minister was due to respond to Parliament regarding the Inquiry on 26th March and was likely to set some priorities for health service organisations. At that week’s staff side meeting it had been agreed that time should be set aside at the next Partnership Forum for discussion about the issue and the board agreed that a workshop session be utilised to debate the implications. A proper review could be undertaken in April with a report to the Board in May. The Board considered that there was a risk that an ‘industry’ could be set up around the Francis Inquiry but it did give the opportunity to challenge and change culture. Boards would have to focus on patient experience measures and ensure that all staff were engaged on the necessary changes. The Board was also aware that much work had already been done by the Patient Experience Group. It was also noted that many incidents were reported through the electronic system but those who did so needed to know that their concerns had been recorded and some action taken. The Chairman pointed out that it was going to be difficult to know if and when the organisation had moved to being ‘open and transparent’ but some of the language used around patient experience was negative and the Trust could learn from Carillion’s ‘Don’t walk by’ campaign and could, for example, consider changing the name of the Complaints Team to something more positive sounding. The Board noted the report.

M-NO SJ

31/13

SAFE STAFFING Sue Jones presented a report giving assurance to the Board on nurse staffing within NBTs adult inpatient areas. She also reported that in the ten months to the end of January 2013 the number of reports of unsafe staffing had reduced to 785 compared to 934 in the same period in the previous year. She said that the NHS Institute’s Safer Nursing Care Tool which measured acuity and dependency was being piloted in the Trust and planning towards the new hospital was being undertaken by the Non Medical Clinical Workforce stream. The Board noted the report but considered that future reports needed to be benchmarked and compared with other data to

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32/13 33/13

provide real assurance and/or the basis for discussion. RISK MANAGEMENT STRATEGY AND POLICY Marie-Noelle Orzel presented a significantly changed Risk Management Strategy and Policy for approval. A map of the Trust’s risk management structure would be brought forward via the Governance and Risk Management Committee. In answer to Nick Patel it was noted that innovation risks would be reported through the system as a project risk. The Board approved the Risk Management Strategy and Policy. STANDING FINANCIAL INSTRUCTIONS AND DETAILED SCHEME OF DELEGATION

SJ

Following a review Bill Boa presented revised Standing Financial

Instructions and a Detailed Scheme of Delegation which had been approved by the Audit Committee. The one significant change had been to include a section outlining the circumstances when it might be appropriate to suspend some tendering rules. Items of over £1million were generally part of framework contracts and orders for such items or services, therefore, were not included in the ordering system and Bill Boa agreed to double check that these were covered. Subject to the addition of the Chairman of the Board’s approval for any temporary suspension of normal controls regarding tendering the Board approved the revised SFIs and Scheme of Delegation.

BB

34/13

REDEVELOPMENT PROJECT

Mike Coupe presented the highlight report from the Southmead

Hospital redevelopment Project and highlighted: construction work was on programme the Building Research peer review of the fire strategy

continued and would report in March revised proposals from Carillion for the Emergency

Department corridor were awaited 230 Move leads had been appointed and he would give

more information about the Move project at the next meeting The Board noted that 3,100 responses to the hospital naming competition had been received so far with no clear favourite. The Board would be asked in April to make a decision. The Board noted the report.

35/13 ACTIVITY AND PERFORMANCE REPORT Sasha Karakusevic presented a brief report on the Trust’s patient

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36/13

activity and advised that the backlog of patients waiting over 18 weeks could not be completed by the end of the financial year but would be achieved by the end of June. Orthopaedics and neurosurgery had the largest backlogs. Since September the validation of incomplete pathways had reduced steadily and directorates had weekly targets to achieve a given number of records to check. All cancer targets in January had been met but a short term MRI breakdown had meant that the six week diagnostic target had not been achieved. It was resolved to note the Activity and Performance report. INFECTION CONTROL REPORT Chris Burton introduced this report and noted that there had been two cases of MRSA bacteraemia in January, one in ITU at Southmead and one in the Surgical directorate. It was the first MRSA bacteraemia in Southmead ITU for nearly 90 weeks. The numbers of C Diff incidences continued to give concern and the year-end target had been breached in January. There had been evidence in one case of cross-infection with learning from it of the need to isolate symptomatic patients quickly. The infection prevention control team was reviewing antibiotic prescribing and, with commissioning colleagues, the prescribing of proton pump inhibitors. Recent evidence had also emerged that the use of probiotics, which had been tried previously to a limited extent by the Trust, may be worth revisiting. NICU was about to transfer back to its original location following the pseudomonas outbreak and national experts had commended the Trust for its work in minimising the future risk.

37/13

The Board noted the report. FINANCE REPORT Bill Boa advised that the overall financial position to the end of January was broadly breakeven with another month of contingencies and reserves used. Income from PCTs had reduced and much of this was to do with the reduced capacity of NICU during its temporary transfer. Funding had been reserved at the beginning of the year but the planned behaviour to reduce directorate expenditure had not materialised which had forced the release of the reserves to support the Trust. In answer to a question raised at the last meeting he confirmed that debtors had increased as a result of two issues. The slow allocation of cash to debts because of the implementation of an upgrade to the Oracle system and debates in the new organisational system between Care Commissioning Groups and specialist commissioners as to who should be paying bills.

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38/13

Nick Patel questioned why there had been recent Press comment about the Trust’s plans to reduce spending by £92 million. Bill Boa reminded the Board that this was the plan for the next three years and that the comments had arisen from a briefing given by the Unions. The Board noted that nurse specialling had caused a significant increase in nursing and midwifery variance from budget in January and the larger variance in the health care assistants budget had arisen because this was the area most affected by the CRES plans which had not been achieved. The Board noted the report. PROGRAMME MANAGEMENT OFFICE REPORT Harry Hayer presented a report on the progress in implementing the PMO and assurance on the Road to 2014 programme. Each member of the scrutiny team could now work on any of their colleagues’ areas and the timelines for every individual programme were now being aligned into a critical path for a single plan. The Board noted the report.

39/13 SINGLE OPERATING MODEL Marie-Noelle Orzel reported that the Governance Risk Rating had

improved in January largely due to the achievement of cancer targets. Complaints, however, had nearly doubled from the December total and the Board asked that such rises be accompanied by explanations in reports. The Board agreed to maintain the same statements as in January subject to correction on errors on the SHMI and HSMR data. The Board approved the report subject to the agreed changes.

SJ PC

40/13 41/13

CHAIRMAN’S REPORT Peter Rilett reported that he had attended the last meeting of the chairmen and chief executives in the SHA where Sir Ian Carruthers had praised the performance of the South West over the last 18 months and Trusts were left with the view that quality, performance and money were the primary focus for the future. CHIEF EXECUTIVE’S REPORT Marie-Noelle reported on the following:

There had been no consultant appointments in January Some of the Board had met with local authority and provider

colleagues and shown the new hospital

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42/13 43/13

The Soil Association had awarded the Trust its Silver Award, the only NHS organisation to have such an accolade. The Board agreed the catering staff be congratulated.

GOVERNANCE AND RISK MANAGEMENT COMMITTEE The Board received the summary report from the meeting of the Governance and Risk Management Committee held on 7th February. The Board noted the Committee had:

approved terms of reference for two sub-committees endorsed arrangements for governance of the Core Clinical

Services Directorate approved a summary of changes to the Trust’s registration

of locations with the CQC been given assurance regarding the Trust’s position with the

CQC Quality risk Profile been given assurance about the Trust’s maternity services

against the CQC’s market report, by the Local Supervising Authority and a follow-up report on the Cervical Screening Service

been given assurance about the compliance of the Riverside Unit with CQC outcomes

The Board noted the report. AUDIT COMMITTEE

The Board received the report from the meeting of the Audit

Committee held on 30th January which included revised terms of reference of the committee.

44/13

The Board noted the report and approved the terms of reference. ANY OTHER BUSINESS

There was no other business. 45/13 NEXT MEETING The next meeting will be held on Thursday 28 March 2013 in the

Board Room, Trust Headquarters, Frenchay Hospital, commencing at 11.30am.

North Bristol NHS Trust Trust Board (Public Session) Action Log 2013

Meeting Date

Minute Ref

Action No.

Action Owner Review Date (s)

Status Info.

26/7/12 145/12 Proposals to be made on the governance of the Redevelopment Project and relationship with Building Our Future Programme

HH/MC 28/02/13 & 28/3/13

A Under discussion but not yet in position to finalise. Will go to March Board meeting private session .

25/10/12 192/12 Patient Experience Dashboard – to provide a patient experience in a community based setting.

SJ 28/02/13 & 28/3/13

A Agreed at Feb meeting to report to March meeting. Item 6.1

31/1/13 6/13 3 Final CQC report on January visit to Southmead to be put on to Trust website and e-mailed to all Board members when received

SJ 28/2/13 & 28/3/13

O

31/1/13 9/13 6 Professional Standards Authority standards for Board members to be used in 360 degree assessment of executives along with a refreshed skills audit. Will form part of the Board development programme.

HH 28/3/13 AA Private session

28/2/13 24/13 13 SHA to be asked to reconsider the wording of Statement 6 in the SOM

M-NO 28/3/13 O

28/2/13 27/13 (iv)

15 Board to consider reasons for caesarean section increase through Quality Report

SJ 28/3/13 O

28/2/13 28/13 16 Monthly Quality Report to include any outlying performance data shown by national quality dashboard and a quarterly report to be made to Board on the most important indicators

CB 28/3/13 A Item 6.1

28/2/13 28/13 17 Actual numbers (of patients/episodes etc) to be used instead of percentages in Quality Report where numbers are low

CB/SJ 28/3/13 A Item 6.1

28/2/13 30/13 20 Execs to require responses to be made to incident forms

M-NO 28/3/13 O

28/2/13 33/13 24 Bill Boa to check process for orders over £1m that are not undertaken through Purchasing Consortium

BB 28/3/13 O

27/10/12 182/12 Review of Governance and Risk Management Committee

M-NO 25/4/13 O Future item

31/1/13 8/13 5 In future the BR&AR Tracker section should include some narrative against the red rated risks.

PC 25/4/13 O Will be included for next BR&AR update in April 13.

ACTION LOG StatusA Agenda - this meeting

O Open

C Closed


Meeting Date

Minute Ref

Action No.


Status Info.


O Open

C Closed

31/1/13 10/13 7 Redevelopment Project to report to Board on key performance indicators and overview of 'Move' project in future

MC 28/2/13 & 25/4/13

O Executive Team want to delay implementation and tie in with broader review of standard reports to NBT Board. Agreed at Feb Board

31/1/13 12/13 9 Board to have written activity and performance reports that have trend information similar to Patient Experience Dashboard

SK 28/2/13 & 25/4/13

O Whole report being reviewed for 2013/4 meetings

28/2/13 30/13 19 Execs to consider changes to title of AC Team and Carillion's 'Don't walk by' campaign.

M-NO 25/4/13 O Future item

28/2/13 31/13 21 Safe Staffing reports in future to include benchmarking and triangulation with other data where possible

SJ 25/4/13 O Future item

28/2/13 30/13 18 Execs to discuss Francis Enquiry recommendations following PM's response at the Partnership Forum with the unions and Board to discuss at a workshop session

HH/M-NO

30/5/13 O Future item

29/11/12 212/12 Amend Terms of Reference of Executive Team to include a responsibility for the formulation of strategy

PC 28/02/13 & 27/6/13

O Overtaken by events following discussion at Away day and broader governance review now required.

31/1/13 Jun-13 1 Quality Report to include high level assessment against the new Trust Development Authority national quality dashboard

CB 28/2/13 C TDA dashboard demonstrated at meeting

31/1/13 Jun-13 2 High level of caesarean section procedures to be highlighted to Quality Committee and directorate requested to investigate

CB 28/2/13 C Raised at Exec Review meeting and will be reported through Clin. Risk Committee. See Action 15

31/1/13 Jul-13 4 Francis Enquiry Report and its implications for NBT to be reviewed at next Trust board meeting

SJ 28/2/13 C Discussed at meeting

31/1/13 15/13 10 Investigate reasons for high level of debtors BB 28/2/13 C Reported to February Board


Meeting Date

Minute Ref

Action No.


Status Info.


O Open

C Closed

31/1/13 16/13 11 Building our Future performance report to come to public session in future and include forward looking issues as well as reviewing past performance.

HH 28/2/13 C First report to public board in Feb

28/2/13 26/13 14 Minute 11/13 to be changed NS 28/3/13 C Recorded in minutes

North Bristol NHS Trust - Quality Indicators Appendix 1

NOTE: Subsequent validation by clinical teams can alter scores retrospectively. Charts were correct at time report was produced

There were 205 cases with EWS scored correctly in February = 87%.There were 11 confirmed calls in February. The rolling mean is 1.01 comparedto national average of 2.5.

In February 183 out of 236 were correctly completed according to the oxygen prescribing policy. This is 78% being recorded correctly.

Of the 236 sets of notes reviewed in February, 16 were high EWS scoring. Of these 16 sets were scored correctly -100%. All patients who had signs of deterioration had care escalated for medical review.

There were 158 falls in February 2013. Compared to the same month last year - there were 212 falls in February 2012

There were no falls resulting in serious injury during February.

Preventing Deterioration - Confirmed Cardiac Arrest calls - Rate per 1000 discharges

0

0.5

1

1.5

2

2.5

3

01/1

2/20

11

01/0

1/20

12

01/0

2/20

12

01/0

3/20

12

01/0

4/20

12

01/0

5/20

12

01/0

6/20

12

01/0

7/20

12

01/0

8/20

12

01/0

9/20

12

01/1

0/20

12

01/1

1/20

12

01/1

2/20

12

01/0

1/20

13

01/0

2/20

13

Confirmed arrests National Ave

Preventing Deterioration Oxygen Correctly prescribed(source Clinical Audit)

0%

20%

40%

60%

80%

100%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Audit score Target

Total Falls - All severity levels (Target 10% reduction on11/12)

0

50

100

150

200

250

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Actual TargetSource - safeguard

Preventing Deterioration EWS correctly recorded(source Clinical Audit)

0%

20%

40%

60%

80%

100%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Audit score Target

Preventing Deterioration High EWS - agreed escalationfollowed (source Clinical Audit)

Target Audit score

Severe Falls (Level 4 +)

0

1

2

3

4

5

6

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Nu

mb

er o

f 4+

fal

ls

Source - safeguard

North Bristol NHS Trust - Quality Indicators


The falls rate for February 2013 is 4.6. with the rolling mean at 5.0. The falls rate for the same period in January 2012 was 6.8

Chart uses Cerner rather than note sampling as the source. In February 52% of patients were recorded on Cerner as screened for malnutrition. Excludes patient admissions with Length of Stay of less than 24 hours.

No change to chart as published quarterly - relative risk for Quarter 1 12/13 = 93.34

Rolling year cumulative relative risk = 87.6The rate per 10,000 bed days was 13.3 in February, with 38 patients with grade 2+ PU's. There was 1 patients with 1 grade 3 PU , with 0 patients with a grade 4 PU.

At February end - wards achieving silver or gold on nutrition was at 70%, 29 out of 41 wards audited over the year. However documentation standards have been raised in NQAT audits to improve quality of documentation, particularly at the bedside..

Cquin - Tissue Viability - Patients with grade 2 +Ulcer /10,000 beddays

02468

101214161820

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

ActualSource AIMS

Cquin - Nutrition % of wards where Current Survey at Silver/Gold (source NQAT Survey)

0%

20%

40%

60%

80%

100%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

12

Feb

-12

Actual Target

Cquin - Nutrition Screen for Malnutrition within 24 Hrs of Admission

(source Cerner risk assessment)

0%

20%

40%

60%

80%

100%Ja

n-12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Actual TargetFalls - Rate per 1000 Bed days

0

2

4

6

8

10

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Rat

e o

f F

alls

per

100

0 b

day

s

Source - safeguard

North Bristol NHS Trust - Quality Indicators


Compliance with the catheter care bundle was at 78% in February.In February 7 of 30 patients asked said they were told their discharge date = 23%. However this was a small sample size

Catheter insertion for the catheter care bundle achieved 95% compliance in February

Shows total number of patients with an infection compared to total number of operations. In December 7% of patients reported a surgical site infection, 30 days after surgery. (1 patient of 14)

2012/13 CQUIN full implementation by end of year achieved. NBT harm rate at 91.5%. National improvement target still to be defined. National rate12/13 = 91.8%.

Patient informed of discharge date (source NQAT)

0%

20%

40%

60%

80%

100%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Audit score Target

CAUTI - Insertion compliance (source - clinical Audit)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Audit score Target

CAUTI - Ongoing care compliance(source - clinical Audit)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Audit score Target

Surgical Site Infections - Post op 30 days SSI rates (source - Colerectal Surgery Audit)

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Safety Thermometer - Harm free care rate

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%Ju

n-12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Report to Trust Board – 28th March 2013 Agenda Item 6.1

Report Title Quality Report to Board

For Information Discussion Assurance Approval Status

Prepared by Lesley Le-Pine – Head of Clinical Governance

Board Sponsor Sue Jones – Director of Nursing

Appendices Appendix 1 - Quality dashboard

For Information

Executive Summary:

NBT mortality rate is lower than the national average

HSMR – rate remains below the national expected mortality rate of 100 the rolling mean is 87.6 using the Dr Fosters age adjusted casemix. SHMI – Quarter 1 to April – June 2012 is 93.3 which is stable and as expected

The rolling mean rate of cardiac arrest calls is now 1.0 per 1000 discharges.

Preventing Deterioration – Cardiac arrest rates remain well below the national average of 2.5 per 1000 discharges. There was a decrease in confirmed arrest calls in February - 11 compared to 20 calls in January.

Overall - falls continue to reduce compared to the same period last year.

Falls – There were no serious falls in February. There were 158 falls in February this year compared to 212 falls in the same month last year.

Pressure ulcer incidence is 13.3 patients per 10,000 bed days.

Pressure Ulcers: 38 patients were reported with grade 2 pressure ulcers in February compared to 52 in January. There was 1 patient with a grade 3 ulcer, with 0 patients with grade 4 pressure ulcers in January.

Rate of screening within 24hrs of admission has remained similar to last month.

Nutrition - Number of wards rated silver or gold via NQAT for nutrition was 70%. In February 52% patients were screened for malnutrition. Measure uses entries reported on Cerner rather than an audit of patient notes as the source.

Less patients audited knew their discharge date.

NQAT audit – 23% of patients knew their discharge date in February compared to 58% in January however this was a small sample and not a reliable indicator.

In December 7% of colorectal patients reported an SSI at 30 days.

Surgical site infections (SSI) – 1 out of 14 of colorectal patients reported an infection 30 days post procedure – 7% compared to 28% in November.

Catheter insertion compliance has increased to 92.3%.

CAUTI – Catheter insertion was 95% compliance in February compared to 87% in January. Compliance with ongoing care achieved 78.3% in February compared to 74% in January.

The CQUIN for the Safety Thermometer for ‘harm free’ care has been achieved.

Safety Thermometer - Compliance with CQUIN target of 75% completion by Quarter 3 has been achieved and 100% expected for Quarter 4. ‘Harm rate’ is currently at 91.5% compared to the national rate of 91.8%.

Action Required

The Trust Board is asked to note the contents of this report

Key Risks: Quality Strategy objectives may not be achieved this will impact on CQUINs agreed with commissioners.

Impact on Patients: All measures relate to the delivery of patient care, achievement of gateways/CQUIN targets helps to build confidence in Trust service provision and assure the public/other key stakeholders that the organisation is meeting quality and safety standards

Trust Objectives Services exemplary of quality & safety, No waits no delays

CQC Outcomes O16 – assessing & monitoring quality of services

NHS Constitution Considered as applicable Equality Issues: Considered throughout

Financial Issues: As indicated in regard to incentive payments/ penalties.

Other Legal/ regulatory Issues

Considered throughout.

Report to Trust Board – 28 March 2013 Agenda Item 6.2

Report Title Summary of Serious Incidents (SIs) reported in February 2013


Prepared by Olga Van Rijswijck – Clinical Risk Manager Lesley Le-Pine – Head of Clinical Governance


For Information Executive Summary:

2 new Serious Incidents reported.

1x delay accessing ICU bed, 1x breach of policy.

0 Never Events There were no never events reported during February.

0 incidents breached the 2 day reporting deadline

All incidents in February were reported to commissioners within 48 hours of notification.

0 incidents breached 45/60 completion deadline in Feb

0 incident had a sign off date within February 2013 that breached

(1 incident from January remains open breaching deadline)

0 Safeguarding Incident No safeguarding incidents reported as an SI.

0 Whistleblowing Incidents No whistleblowing incidents were reported.

No specific themes were identified this month

Incidents reported from different wards/areas with no common causal factors identified.

Action Required

The Trust Board is asked to note the contents of this report.

Key Risks: Reporting incidents and completion of root cause analysis (RCA) investigations for serious incident within timescales is set in the contract with Commissioners and can result in financial penalties for the Trust if timescales are breached.

Impact on Patients: Actions implemented following RCA investigations and sharing of lessons learned should reduce occurrence of similar incidents, thus improving patient safety, patient confidence and helping to maintain the positive reputation of the Trust.


CQC Outcomes O21: Incidents


Financial Issues: As indicated in regard to incentive payments/ penalties.

Other Legal/ regulatory Issues


SERIOUS INCIDENT TRACKING

Open - not subject to PCT timescales STEIS No Incident

Date 2 day deadline

Directorate Ward Description 45/60 day RCA deadline met

Additional info

2012/8707 04/04/12 YES Medicine D Ward Adult Safeguarding N/A 2012/8710 04/04/12 YES Medicine D Ward Adult Safeguarding N/A

Not subject to usual timescales. Both relate to same incident - as two patients involved,.

2011/16609 31/08/11 YES WCH BRCU Safeguarding/Child protection N/A Not subject to usual timescales 2012/30925 06/12/12 YES WCH Neuro Safeguarding/Child protection N/A Not subject to usual timescales Open - BREACHES STEIS No Incident

Date 2 day deadline


Additional info

2012/29215 16/11/12 YES Surgery Ward 205 Patient fall – fractured hip 24/01/13 CLOSED 06/03/2013 2013/2164 21/01/13 YES Medicine FRH 206 Deteriorating patient 22/03/2013 Recalled to April CRC - Will breach RCA - Closures February 2013 STEIS No Incident

Date 2 day deadline


Additional info

2012/19826 13/08/12 YES Medicine Elgar 4 Patient fall - Subdural 15/10/12 CLOSED 2012/28222 26/10/12 YES Medicine Malvern Patient fall - fracture 14/01/13 CLOSED 2012/32106 17/12/12 YES Operations ED 9 x 12 hour trolley breach 21/02/13 CLOSED 2012/32102 29/10/12 YES Operations ED 1 x 12 hour trolley breach 21/02/13 Submitted for closure 19/02/2013 – pending 2012/32711 19/12/12 YES MSK FRH 202 Patient fall - Subdural 27/02/13 CLOSED 2013/864 04/01/13 YES Operations ED 1 x 12 Hour Trolley Breach 11/03/2013 CLOSED Open Serious Incidents - CURRENT WITHIN TIMESCALE STEIS No Incident

Date 2 day deadline


Additional info

2012/32758 22/12/12 YES Medicine ED Drug error - renal failure Ext 07/03/13 CLOSED 2013/578 07/01/13 YES Core Clinical FRH ITU N Displaced Tracheostomy 08/03/2013 Submitted for closure 08/03/2013 - pending 2013/2167 17/01/13 YES Surgery SMH DCU Unexpected outcome - discharged day case patient 25/03/2013 Post March CRC - amended report awaited 2013/2705 20/01/13 YES MSK SMH Severn Patient fall - fracture 29/03/2013 March Falls group 2013/2758 22/01/13 YES Core Clinical Radiology Burn from MRI 02/04/2013 Post March CRC – amended report awaited 2013/3525 30/01/13 YES Medicine FRH ward 30 Patient fall - fracture 09/04/2013 2013/3525 2013/3613 23/01/13 YES Neuro Burden Patient fall, subdural 09/04/2013 2013/3613 NEW - Serious Incidents reported February 2013 STEIS No Incident

Date 2 day deadline


Additional info

2013/6246 27/02/13 YES CCS Theatres Unauthorised x-ray. Breach of policy. 03/05/2013 2013/6248 27/02/13 YES Ops/CCS/

Medicine ED Delay in accessing ICU bed. 03/05/2013

ROOT CAUSES AND LESSONS LEARNT FROM INCIDENTS CLOSED IN NOVEMBER & DECEMBER 2012

Incident Type

Directorate Root Causes Actions taken / Learning Implemented

2012/19826 Medicine Patient required assistance ward staff not able to assist her in time to prevent the fall.

Importance of regular assessment, especially if patients condition is fluctuating Frequent moves of already confused patients can be a contributing issue. Staff reminded to escalate call for additional staffing earlier. Improved communication between physio & nursing staff required.

2012/28222 Medicine Un-witnessed fall: Specialling nurse (1:1) should have been with the patient - fall was not communicated to the night staff

Appropriate actions commenced once clinical teams were aware of fall. Staff reminded of key information to handover between shifts – such as any falls

2012/32711 MSK Patient confusion exacerbated by fatigue (secondary to dialysis) contributed to fall: Treatment focused on medical needs rather than assessing for unseen trauma associated with fall.

Specific teaching using case studies now included at doctors induction training.

2013/912 Operations Trust Black Escalation Increase in patient admission requirements with no patient movement throughout the trust. 2012/32102 2012/32106 2013/864 2013/2978

Operations Operations Operations Operations

12 hour trolley breach 30/10/2012 9 x 12 hour trolley breach 16/12/2012 12 hour trolley breach 04/01/2013 12 hour trolley breach 29/01/2013 (Lack of capacity meant patients had to remain within the ED department outside the 4 hour target and increasingly some outside the 12 hour target)

Root causes: Busy emergency take (high number of GP and 999 requirements for transfer to hospitals). Lack of capacity (gender specific). Reduced discharges, increased outliers, patients with a LOS >14 days and delayed discharges due to social services. Lack of escalation to executive on call. Lack of adherence to/ understanding of escalation policy. Lessons learnt: Reinforced importance of early escalation, escalation roles and responsibilities. Review of escalation triggers and policy – in progress. Training for site managers and on call managers – dates set for March and April Working with partners has been consolidated and improved – Policy in place for reporting breaches 7 day working has been highlighted as key. Progress has been made with senior manager & nursing support at weekends and out of hours Robust and clear process needs to be established to halt elective lists in a critical incident or black escalation to preserve capacity Further review of template for bed meetings was undertaken and has commenced - elective lists are reviewed at bed meeting 14.30 daily Arrangements for managing repatriations reviewed in all specialities to ensure timely repatriation A full capacity policy for ED has been developed. Implementation of log for on call manager & the site manager (better documentation of situation & action, to facilitate debrief and ensure accountability).

Comment [SJ(oN1]: Was it a factor in this case?

Comment [SJ(oN2]: Was there any action for the specialing nurse? May not need to be added, but useful for me to know if asked

Serious Incidents Dashboard – February 2013

Serious Incidents Rate per 1000 Bed Days Mar 2012 - Feb 2013

0

0.050.1

0.15

0.2

0.250.3

0.35

0.4

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Per

100

0 B

ed D

ays

Rate per 1000 bed days Median

*SI Count and *SI Rate by Directorate per 1000 Bed Days Mar 2012 to Feb 2013

0

10

20

30

40

Cor

eC

linic

al

Med

icin

e

Mus

culo

Neu

ro

Ren

al

Sur

gery

W &

C

SI

Co

un

t

00.20.40.60.811.21.41.61.8

SI

Rat

e p

er 1

000

Bed

Day

s

SI Count SI Rate

The number of SI’s reported in February has shown a decrease in numbers this is within normal variation. The median has been consistent over the past year.

Bars show actual count of SIs, but take no account of activity level, hence medicine appears high. Green diamond shows SI rate per 1000 bed days. CCS appears as an outlier, due to low number of bed days.

*Types of SI reported Mar 2012 to Feb 2013 N = 76

0 5 10 15 20 25 30 35

Patient FallDelayed Treatment

Breach Of PolicyDeteriorating PatientAdult Safeguarding

MedicationWrong Site Surgery

Staff IncidentPatient Suicide

Infection ControlUnexpected Admission To Nicu

Suspension Of MaternityMaternity- Cord Prolapse

Maternity - Delay In DeliveryMaternal Death

Fall > DeathDocumentation

Number of Serious Incidents Closed and Open Breaching deadlines

Mar 2012 - Feb 2013

27

3 4 45

13

112

54

12

3 4 53

34

11

1

0%

20%

40%

60%

80%

100%

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb

-13

Closed Open Breaching Deadlines

Despite being the most commonly reported type of SI, patient fall SIs are showing a reduction in overall numbers. *Please note this excludes Pressure Ulcer and Infection Control data;

In February - 4 Serious Incidents were closed and none remained open breaching deadline. The number of incidents breaching closure deadline has fallen.

a low number of bed days in CCS, therefore rate is high.

Appendix 1

Safeguarding Adults - Annual Report 2012/13

Introduction This paper outlines the work undertaken by North Bristol NHS Trust (NBT) in relation to the Safeguarding Adult Agenda for 2012/13. It identifies a work plan for moving safeguarding work forward into 2013 to further disseminate and strengthen NBTs duty of care to safeguard those adults who are unable to protect themselves from harm or exploitation. Background All public sector organisations are required to provide systems and processes to identify and support patients who may be vulnerable or at risk of abuse and harm. The NHS along with social services and the police are given key responsibilities for safeguarding vulnerable adults. The CQC state that ‘the term safeguarding, whether it is used in relation to health or social care, refers to an organisation’s responsibility to protect people whose circumstances make them particularly vulnerable to abuse, neglect and/or harm.’ Definition of a vulnerable adult is: - “a person over 18 years old who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of themselves or unable to protect him or herself against significant harm”

Law Commission (1998) Operational Management The NBT adult safeguarding team is made up of the following roles: –

Key personnel Staff member (WTE) Executive Lead Sue Jones - Director of Nursing Non-Executive Lead Nick Patel Strategic Lead Gareth Howells - Deputy Director of Nursing Operational Lead Linda Davies (1.0wte) - Adult Safeguarding Lead Administrative Lead Sean Collins (0.5wte) - Safeguarding Administrator

Within Clinical Directorates the management team of General Manager, Clinical Director and Head of Nursing are responsible for the dissemination and monitoring of compliance to Trust policies in their areas. The Head of Nursing is responsible for the coordination of adult safeguarding in the directorate including overseeing investigations and ensuring that relevant staff are in attendance at applicable meetings. Governance and Assurance NBT has a number of policies in place to promote best practice in safeguarding. These policies include:

Organisational Strategies that Support Safeguarding Adults Policies and procedures In place Review Completion CG 15 Safeguarding Adults Policy Yes Under review March 2013 Training Strategy Yes Under review April 2013 CP 7 J Deprivation of Liberty Safeguards Policy Yes Under review May 2013 Recruitment and Selection Policy and Guidance Yes Under review April 2013 CP 7 K Restriction and Restraint Policy (Adults) No In development May 2013 CP 7I Policy for Assessment of Mental Capacity and Best Interests

Yes Under review April 2013

CG 43 Policy and procedure for raising concerns over services. Whistle Blowing Policy

Yes Complete Complete

The implementation and effectiveness of the policies and procedures is overseen by the Safeguarding Adults Operational Group. The Operational Group reports directly to the Overarching Safeguarding Board and to the Safeguarding Adults Boards (SAB) in Bristol and South Gloucestershire (a reporting structure is shown at the end of the paper).Attendance at the Bristol and South Gloucestershire Safeguarding Boards is now managed within the Safeguarding Team.

NBT Southmead Hospital was recently inspected by CQC which included a review of standard 7 (safeguarding) with a finding of compliance. In feedback there was recognition of the high compliance with training and the importance placed on safeguarding the only areas noted as a concern regarding standard 7 where in relation to staff awareness of the “whistleblowing policy” and compliance with CRB checks.

Training Safeguarding training for adults has been mandatory in NBT since 2009. The training is provided internally by the Safeguarding Manager, Safeguarding Adult Lead and the Learning and Development Team. There are 3 levels of training provided currently.

Level 1: Basic awareness training for all staff at induction Level 2: Intermediate training for staff with regular contact with patients Level 3: Advanced training for senior clinicians and on-call managers

As Safeguarding encompasses a wide range of legal responsibilities and types of patient the training sessions include coverage of:

Mental Capacity Act, Deprivation of Liberty Caring for patients with a Learning disability Caring for patients with Dementia Addressing issues around dignity

Compliance figures for training: -

Level Target Actual RAG 1 90% 84% (To February 2013) Amber 2 90% 84% (To February 2013) Amber 3 90% Training being updated – will be launched in April 2013

(Refresher training for all levels of Safeguarding training is required after 3 years).

Work is currently underway to address the drop in compliance with levels 1 & 2 with an extra 350 people trained in January and February 2013 and an expectation that compliance will be reached in the next reported figures in April. Level 3 training sessions are planned for later in the year and will also bring the Trust into compliance. Safe Recruitment All staff employed within the Trust since 2009 have been subject to a Criminal Records Bureau (CRB) Check. For staff employed before 2009, Human Resources have a plan to ensure all those staff obtain and/or renew their CRB checks. This is being rolled out on a risk assessed priority basis. Serious Case Reviews (SCRs), Internal Safeguarding incidents Serious Case Reviews take place where there are major concerns about adult protection working or system failures or where there is a death of a vulnerable adult. Any professional can request a serious case review by the Safeguarding Board. South Gloucestershire Local Authority completed the SCR for Winterbourne View in October 2012. It contained no specific recommendations for NBT however considerable work is now being undertaken by both SAB’s to formulate work plans for the implementation of all recommendations and for the dissemination of learning. Learning from the SCR has been added to the training programme in NBT.

Activity

Activity 2012/13 Q1 Q2 Q3 Q4 Total Adult safeguarding referrals 10 15 37 40 102 Serious case reviews 0 0 0 0 0

Deprivation of Liberty Safeguards During 2012/13 there were 82 applications by the Trust for DoLS. NBT has been commended by the local authorities DOLS teams for its exemplary work in this area.

Achievements Appointments and roles The trust has recruited to the new post of Adult Safeguarding Lead to support the continued increase in activity in this area and to provide a strategic lead. All the strands of safeguarding have been amalgamated under the leadership of the Deputy Director of Nursing to streamline and direct the safeguarding agenda. Intranet Dedicated intranet pages are now in place to support staff with adult safeguarding and the use of the Mental Capacity Act. Activity There has been a continued increase in activity for adult safeguarding across the year. This is believed to be a reflection of continued awareness raising and accurate recording and not indicative of increased instances of adult abuse.Focused work between safeguarding and tissue viability including cross referencing in new policies has taken place to ensure that grade 3 & 4 pressure ulcers are referred to safeguarding. Adult Safeguarding Databases Work has taken place in 2012 developing the Safeguarding and DOLS database’s to facilitate the monitoring of referrals and activity. These are now complete and available via a central Adult Safeguarding shared management drive. Links with HR Focused work has taken place on embedding links with Human Resources, the whistle-blowing process and the disciplinary process. HR staff training needs have been reassessed and they are now required to complete level 2 training instead of level 1. Flow charts have been developed to assist HR staff with reporting adult safeguarding concerns. South West Safeguarding Leads Forum NBT have worked with Northern Devon Healthcare Trust to establish a South West Safeguarding Leads Forum which met for the first time in February 2013. The aim of this group is to share best practice, work on joint approaches and as a form of peer group supervision. Partnership Working NBT has taken over the role of chair of the training subgroup for Bristol Safeguarding Adults Board. Regular meetings have been set up with partners to monitor activity and promote closer working relationships. The Trust safeguarding team are also undertaking a rolling programme of training to the South Gloucester social workers about safeguarding within NBT. Specialist Training The adult safeguarding team have undertaken specialist training in the areas of suicide prevention, action planning, forced marriage and the law and restraint. NBT specific Level (3) Adult Safeguarding Training with be launched in April 2013. Key areas of work for 2013/2014 1. Complete the review of safeguarding policies ensuring they are in line with the opening of the new

hospital next year. 2. Launch and implement level (3) Adult Safeguarding training for those staff who require specialist

training in this area 3. Further embed the operational safeguarding processes within the Clinical Directorates. 4. Develop information for patients and carers; leaflets and electronic on the Trusts Intranet Pages. 5. Promote working relations between the Trust and the Independent Mental Capacity Advocacy

(IMCA) services with the aim of increased referrals to an IMCA. 6. Once the policies are ratified the training programme will be reviewed and updated to reflect the

new policies

7. Promotion of joint working with University Hospitals Bristol including the sharing of best practice,

development of joint working practices and shared processes. 8. Development of Adult Safeguarding Supervision Policy 9. Further highlight and develop the Trust Adult Safeguarding service.

Safeguarding Assurance and Reporting Structure

The Safeguarding Adults (Operational) Group also reports to the Safeguarding Adults Board (SAB) for Bristol and South Gloucestershire Local Authorities respectively. The Trust Safeguarding Committee (which meets quarterly) receives reports from the monthly/bi-monthly meetings of the sub-groups. The Trust Safeguarding Committee reports to the Governance and Risk Management Committee (GRMC), which reports to the Trust Board.

Trust Safeguarding Committee

MembershipChair – MNOChairs of Sub GroupsEducation RepSimon Wood/Security RepIT AnalystEquality RepNon-Executive

MembershipNamed ProfessionalsDirectorate RepsPartner AgenciesTrainerOperational Reps





Overarching Committee with Responsibilities for;• Strategic Planning / Horizon Scanning• Board Assurance• CQC Outcomes – Monitoring• Identifying / Resolving Trust Issues• Reporting Trustwide Themes• Risk Assessment• Holding Sub-Groups to Account• Maintaining Actions Plans

SafeguardingChildren Group

SafeguardingAdults Group

Dementia Steering Group

LD GroupMH Operational

Group

Appendix 2

Report to Trust Board – March 2013 Agenda Item

Report Title Dementia Report to Trust Board


Prepared by Gareth Howells – Deputy Director of Nursing


Appendices (2) - The NBT Dementia Pathway

For Information

Review of Dementia Care In February 2013, a peer review of Dementia Care at NBT was completed. Overall the review concluded significant progress had been made with tangible changes, a proactive approach delivering the national CQUIN, an impressive framework is in place to ensure carers are identified and action is required to ensure embedding and sustaining the progress made in 2012/13. Ensuring best practice ins embedded in every setting remains the goal and the challenge.

Creating a culture of Compassionate Dementia Care

This is based on the DoH vision to create a culture of compassionate care in the NHS and will form the basis of the updated NBT Dementia Strategy – (on display at meeting)

North Bristol NHS Trust Dementia Development Plan

Version (10) of the North Bristol NHS Trust Dementia Plan has been updated in February 2013 and incorporates the feedback from the peer review of Dementia Care at North Bristol NHS Trust.

Dementia Awareness Training

The training matrix for Dementia Training has been completed. Level (1) training, is now mandatory for all staff and to date 6100 NBT staff (Clinical and Non- clinical) have received Level (1) Dementia Awareness Training during. Level (2) training has been developed and has commenced in December 2012. Level (3) Training is currently being developed.

The Dementia Champion role

To date 120 North Bristol NHS staff have received specific training to undertake the role of the Dementia Champion. The Dementia care website is operational and supports Dementia Champions in the delivery of their role; http://sharepoint/sites/trustwide/Dementia/Pages/default.aspx

Dementia Volunteer Role The support volunteer role has been successfully implemented on Thirteen wards across the Trust. A roll out plan for the rest of the Trust will be progressed in 2013/2014.

The National Dementia CQUIN 2012/13

This relates to the initial assessment of all patients over 75 who are admitted as an emergency, assessing them for any cognitive impairment, and ensuring an appropriate referral is are made should it be required. The cQUIN states this must be achieved in 90% of cases, and while early indications identify NBT as achieving this, the final outcome will be available at the end of the fourth quarter of 2012/13.

Family carers are being supported

The Bristol Carers Charter was published in April 2012 and the NBT Carers Support scheme introduced January 2012. This will be evaluated during March 2013.

Creating a Dementia friendly environment

A report will be provided to the April 2013 Trust Redevelopment Board, relating to the creation of a supportive physical environment for people with Dementia in the new hospital.. Information has been provided previously, and this update will incorporate best practice as described by the King’s Fund’s ‘Enhancing the Healing Environment’ programme.

Development of a Specialist Dementia Nurse role

Following the peer review, support has been received from NHS Bristol to fund a Specialist Nurse in Dementia Care. Details of this role are currently being finalised.

Priority Standards for 2013/14

In 2013-14 North Bristol NHS Trust will continue to implement all eight South West Dementia Standards, but specifically focussing on - Standard 5 – The nutrition and hydration needs of people with a dementia are well met; and Standard 7 - The hospital and wards ensure quality of care at the end of life.

Action Required


Key Risks: Developing the cross community frail elderly pathway including those patients with dementia in the context of the implementation of the national cQUIN

Impact on Patients: ‘Frail Elderly’ patients may be denied access to appropriate care and treatment.


CQC Outcomes Outcome 1: Respecting & involving Outcome 2: Consent Outcome 4: Care and welfare Outcome 7: Safeguarding from abuse


Financial Issues: Considered throughout. Other Legal/ regulatory


Appendix 3

Report to Trust Board – March 2013 Agenda Item

Report Title Learning Disability - Report to Board


Prepared by Alison West – Senior Nurse Clinical Service Development/Gareth Howells – Deputy Director of Nursing


For Information

Executive Summary:

The Learning Disability Strategy 2012 – 2015 was ratified in June 2012.

Aim: People with a Learning Disability (LD) will receive equal access to personalised health care from all NBT services. Aligned to Monitor Compliance Framework 2012/13. Easy Read version of LD Strategy published in October 2012

Early identification of patients with LD is increasing

LD screening tool developed and being embedded on inpatient wards. From December 2012 100% of people with a LD who are admitted to NBT have an assessment of their specific LD needs assessed within 48 hours of admission. The Trust LD Operational Group is reviewing the process of identification of LD patients through ED. This is in response to Winterbourne view and will be completed in April 2013.

Reasonable adjustments are being made for LD patients.

Demonstrated through continuous improvement monthly audits of LD risk assessments and care plans.

Easy read information is available to patients

NBT easy read information available in the following topic areas: Complaints, X-Ray, Going to Hospital, Healthy eating, LD Nurse Service, Anaesthetic, Pre Assessment, Discharge and Medication.

Pictorial menu’s to be ready July 2013 and all are available on the NBT LD Website: http://www.nbt.nhs.uk/patients-carers/coming-hospital/learning-disability-nurses.

Family carers are being supported

Carers Strategy published December 2011. Carers Support scheme introduced January 2012. Evaluation March 2013.

Staff receive training in LD awareness

LD Awareness included within induction and safeguarding mandatory updating and E learning module launched March 2013.

LD competencies have been developed for all new qualified nurses and midwives within their preceptorship programme and LD Advisors recruited and trained, with on-going development support being provided.

Since March 2012 LD and Mental Capacity Act (MCA) training has been delivered to all rotating doctors in training.

Targeted training package for employed medical staff has now been developed and will be implemented through Consultants Mandatory Training working party.

People with LD and their families/carers are involved in planning and development of NBT health services.

The LD Liaison Nurses network widely with LD community groups and organisations and use feedback to inform NBT developments. Carer liaison workers have been recruited as members to the Patient Experience Group and representatives from SG and Bristol LD Partnership Boards are members of the NBT LD Operational Group.

LD audit and analysis is used within routine public reports.

Fortnightly reports are received for all Outpatient DNA’s by patients with a LD. These are subsequently followed up by the LD Specialist Nurses. LD Consent process audited May 2012. Action plan progressed and reported to overarching Safeguarding Committee. Continuous improvement audits of Consent Form No 4 by safeguarding team to be implemented April 2013.

LD Patient stories are reported within Board Reports since March 2012.

LD Confidential enquiry due to report 26th March 2013.

Action Required


Key Risks: Poor understanding of Mental Capacity Act may mean legislation not adhered to.

Impact on Patients: LD patients may be denied access to appropriate care and treatment.


CQC Outcomes Outcome 1: Respecting and involving Outcome 2: Consent to care and treatment Outcome 4: Care and welfare of people Outcome 7: Safeguarding people from abuse

NHS Constitution Considered as applicable

Equality Issues: Considered throughout

Financial Issues: Other Legal/ regulatory Issues


1

Report to Trust Board – March 2013 Agenda Item 6.3

Report Title Safeguarding Adults - Report to Board


Prepared by Gareth Howells – Deputy Director of Nursing


Appendices Appendix 1 - Safeguarding Adults Annual report

Appendix 2 – Dementia Report

Appendix 3 – Learning Disability report

For Information & Assurance

Executive Summary:

To provide the Trust Board with an overview of the activities and work relating to the safeguarding of adults and provide a work plan for 2013/14:

Safeguarding Adult work is evolving in accordance with national guidance. Whilst significant progress has been made over the year, there is growing activity in this area and a need to further develop the systems, processes and training to support clinical staff in practice.

The Trust established a new post of Adult Safeguarding Lead to support the continued increase in activity in this area and to provide a strategic lead.

The years activity records clearly indicates a significant increase in adult safeguarding cases which is deemed to be an improvement and a recognition that staff awareness is increasing.

Staff training compliance has decreased in the last quarter of the year however plans are in place to remedy this.

Safeguarding policies will be updated by May 2013 to bring them into line with current legislation and fit for purpose for the new hospital.

The Learning Disability report highlights activity and progress over the last quarter. Patients with a learning disability are able to access our services and have their needs met. The dementia report provides assurance of on-going action and development of the Trusts dementia action plan and independent assurance following recent Peer Review.

Action Required

The Trust Board is asked to note the contents of this report and the progress to date.

Key Risks: Poor understanding of Mental Capacity Act may mean legislation not adhered to.

Impact on Patients: LD patients may be denied access to appropriate care and treatment.

Trust Objectives Services exemplary of quality & safety,

CQC Outcomes Outcome 7: Safeguarding people from abuse

NHS Constitution Considered Equality Issues: Considered throughout

Financial Issues: Legal/ regulatory Issues


Appendix 1

KEY FACTOR NBT 2012

National Average

Score 2012

Position in respect of other Acute Trusts 2012 top 3

note 1 - scores in italics are better when lower

note 2 - single figures are %, decimal figures are scored out of 5

bottom 3

Core clinical

Women & Children

Surgery Medicine FacilitiesOther Execs

Musculo NeuroSouth

Glos CHSInfo Mgt Renal

Change since 2011 * Respondents

117 84 37 35 33 26 24 22 18 17 15

KF1% of staff feeling satisfied with the quality of work

and patient care they are able to deliver71% No Change 78% Worst 20% 68 70 78 71 77 - 74 70 61 36 100

KF2% of staff agreeing that their role makes a difference

to patients 88% No Change 89% Worse than average 87 91 94 82 89 75 73 95 94 87 93

KF3 Work pressure felt by staff 3.21 - 3.08 Worst 20% 3.17 3.31 3.36 3.41 3 3.08 3.15 3.24 3.37 3.39 2.93

KF4 Team working 3.63 No Change 3.72 Worst 20% 3.59 3.7 3.85 3.73 3.49 3.82 3.64 3.43 3.3 3.49 3.41

KF5 % of staff working extra hours 71% No Change 70% Worse than average 70 69 78 59 69 73 75 91 65 71 79

KF6% of staff receiving job-relevant training, learning or

development in last 12 months78% - 81% Worse than average 78 88 76 73 80 67 74 73 78 58 77

KF7 % of staff appraised in last 12 months 92% No Change 84% Best 20% 87 94 81 97 100 92 92 95 94 88 100

KF8% of staff having well structured appraisals in last 12

months34% No Change 36% Average 31 34 22 49 48 42 26 36 18 24 29

KF9 Support from immediate manager 3.49 No Change 3.61 Worst 20% 3.37 3.64 3.42 3.56 3.39 3.68 3.57 3.3 3.19 3.05 3.64

KF10% of staff receiving health and safety training in last

12 months75% No Change 74% Average 71 81 74 80 78 54 83 91 83 53 64

KF11% of staff suffering work-related stress in last 12

months 43% Worse 37% Worst 20% 47 52 51 42 39 32 25 41 39 63 20

KF12% of staff saying hand washing materials are always

available 52% No Change 60% Worse than average 53 59 54 47 45 35 58 59 56 29 53

KF13% of staff witnessing potentially harmful errors, near

misses or incidents in last month38% No Change 34% Worst 20% 39 38 38 44 42 15 29 50 33 31 60

KF14% of staff reporting errors, near misses or incidents

witnessed in the last month 91% Worse 90% Better than average 89 90 100 80 92 - - - - - -

KF15Fairness and effectiveness of incident reporting

procedures3.44 No Change 3.5 Worse than average 3.48 3.44 3.33 3.47 3.39 3.36 3.4 3.56 3.56 3.17 3.63

KF16% of staff experiencing physical violence from

patients, relatives or the public in last 12 months 16% - 15% Worse than average 12 12 16 37 12 8 29 33 6 0 33

KF17% of staff experiencing physical violence from staff

in last 12 months 2% - 3% Better than average 1 0 3 0 13 8 4 5 0 0 0

KF18% of staff experiencing harassment, bullying or

abuse from patients, relatives or the public in last 12 months

28% - 30% Better than average 19 29 41 51 19 20 43 29 29 18 33

KF19% of staff experiencing harassment, bullying or

abuse from staff in last 12 months 26% - 24% Worse than average 30 20 32 18 32 48 13 24 13 44 33

STAFF PLEDGE 1: To provide all staff with clear roles and responsibilities and rewarding jobs.

STAFF PLEDGE 2: To provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed.

STAFF PLEDGE 3: To provide support and opportunities for staff to maintain their health, well-being and safety.

KF20% of staff feeling pressure in last 3 months to attend

work when feeling unwell 30% No Change 29% Average 29 28 23 33 26 42 30 40 17 53 23

KF21% of staff reporting good communication between

senior management and staff23% - 27% Worse than average 15 24 22 18 21 27 25 32 22 24 47

KF22% of staff able to contribute towards improvements

at work67% No Change 68% Worse than average 64 74 73 63 70 73 67 68 56 53 60

KF23 Staff job satisfaction 3.5 No Change 3.58 Worst 20% 3.36 3.55 3.54 3.56 3.44 3.56 3.63 3.62 3.49 3.13 3.56

KF24Staff recommendation of the trust as a place to work

or receive treatment3.4 No Change 3.57 Worst 20% 3.36 3.38 3.13 3.27 3.54 3.64 3.33 3.33 3.22 3.39 3.87

KF25 Staff motivation at work 3.8 No Change 3.84 Worse than average 3.59 3.93 4.05 3.76 3.65 3.86 3.9 4 3.83 3.69 4.09

KF26% of staff having equality and diversity training in

last 12 months40% Better 55% Worst 20% 34 39 39 47 39 30 41 43 33 29 43

KF27% of staff believing the trust provides equal

opportunities for career progression or promotion89% No Change 88% Average 83 95 86 90 79 95 93 88 100 82 -

KF28% of staff experiencing discrimination at work in last

12 months 9% No Change 11% Better than average 12 5 6 9 9 16 8 14 0 18 13

Overall Staff Engagement 3.61 No change 3.69 Worse than average 3.5 3.69 3.63 3.56 3.51 3.77 3.63 3.71 3.49 3.53 3.93

* Note : Change since 2011 survey indicates whether there has been a statistically significant change in the staff survey results

times in top 31 7 7 5 5 7 6 8 10 3 12

times in bottom 37 1 7 7 5 10 2 9 9 18 6

STAFF SATISFACTION

EQUALITY AND DIVERSITY

STAFF PLEDGE 4: To engage staff in decisions that affect them and the services they provide, individually, through representative organisations and local partnership working arrangements. All staff will be empowered to put forward ways to deliver safer services for patients and their families.

HR&D

15

92

77

2.8

3.78

67

86

93

33

3.76

60

20

53

7

-

3.5

0

0

14

0

21

47

73

3.85

3.62

3.71

64

100

7

3.76

19

2

better and

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any

meeting.

1

Report to: Trust Board : March 2013 Agenda item: 6.4 Date of Meeting: 28 March 2013

Report Title: Staff Attitude Survey Results - 2012

For information discussion assurance approval Status: x x

Prepared by: Robert Baker, Associate Director, Human Resources & Development

Executive Sponsor (presenting): Harry Hayer, Director of Organisation, People & Performance

Appendices (list if applicable): Appendix 1, Directorate SAS Performance Executive Summary:

To provide Trust Board with details of :

Directorate performance following the National Staff Attitude Survey that was undertaken between September and December 2012.

Actions agreed at the March TMT

Action Required: 1) Trust Board is requested to NOTE the attached paper and appendix and 2) ENDORSE the proposed course of action to address the key issues. Key Risks: Financial and performance-related risks

Impact on Patients: The measurement of the Trust’s workforce’s attitudes and engagement are indicators which directly affect the provision of patient care and treatment

Impact on Staff: The measurement of the Trust’s workforce’s attitudes and engagement are indicators which monitor the levels of staff morale and motivation

Link to Trust Objectives: High quality patient care; Creating a strong financially sustainable organisation; A great place to work

Care Quality Commission outcomes:

CQC Outcomes 12,13,14

NHS Constitution: Underpins Staff and Patient NHS Constitution Pledges

Financial Issues: Considered and outlined within the report and appendices Attached

Legal/regulatory Issues: The Trust must ensure that it meets the requirements of employment law, statutory legislation and statutory public sector equality duty (Equality Act 2010) and has a statutory duty to empower, engage and support staff (NHS Act 2006) and demonstrate evidence of this.

Equality Issues considered: To meet Trust’s equality objectives.


meeting.

2

National Survey Directorate Scores : 2012 The Department of Health report on the National Staff Attitude Survey provides a basis for this report. 820 staff were sampled throughout the Directorates, and the response rate was 54%. This is above the national average for Acute Trusts in England. 1. National Survey and Directorate Scores : 2012 (Appendix 1) 1.1 Appendix 1 provides a summary of Trust results for 2012. 1.2 The column marked ‘Change since 2011 *’ indicates changes in results from 2011 to 2012

that are ‘statistically significant’. 1.3 Appendix 1 also illustrates the scores for each Directorate in comparison to the overall NBT

scores and national average scores. 1.3 The top 3 performing Directorates against each Key Factor, and bottom 3 scoring

Directorates are highlighted (relative to other directorates). Total appearances in top and bottom 3 are totalled at the foot of the page.

1.4 The overall ‘staff engagement’ indicator is measured in the national survey by combining

the scores of three key findings 22, 24 and 25. These key findings relate to the following aspects of staff engagement :

Staff ability to contribute towards improvements at work Staff recommendation of the trust as a place to work or receive treatment Staff motivation at work

1.5 The NBT score for staff engagement slightly worsened from 3.62 in 2011 to 3.61 in 2012

(not statistically significant), and was ‘worse than average’ when compared to benchmark Trusts.

2. Actions to address the key issues : Trust Management Team 2.1 The Trust Management Team has discussed at length the national survey results and has

agreed the following initial set of actions :

Articulate and share throughout Directorates ‘what good looks like’. Use the Trust values as the foundation and leaders to role model appropriate

behaviours

Identify in more detail, promote and share what higher performing directorates do well.

Select and roll out resilience and self assessment tools for directorates and staff to use.

As we approach 2014 and the opening of the new hospital, provide staff with as much information as possible on the changes for them.

All directorates to share staff survey results with staff and discuss what can be done to

further improve working lives.


meeting.

3

3. Next Steps

March/April 2013 – Discuss possible actions in partnership working with staff side organisations

April 2013 – report to Workforce Governance & Strategy Committee (WGSC) – to

consider recommendations from TMT and staff side organisations

June 2013 – progress report to TMT and Trust Board

A number of the factors, including those relating to Health and Safety, to be the remitted to the appropriate committee for ownership.

March 2013

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed

section' of any meeting. 1

Report to: TRUST BOARD Agenda item: 6.5 Date of Meeting: THURSDAY 28th MARCH 2013

Report Title: Monitor’s new Regulatory Framework

For information discussion assurance approvalStatus: X

Prepared by: Bill Boa, Interim Director of Finance Executive Sponsor (presenting): Bill Boa, Interim Director of Finance Appendices (list if applicable): Executive Summary: The attached slides were presented by Monitor at a Regional Engagement Event on 12 March 2013. The presentation was part of the national engagement process launched by Monitor to gather views on the new Regulatory Framework. Monitor’s new role will focus on 5 key areas:

Supporting Foundation Trust Governance Pricing NHS Services Supporting Choice and Competition Enabling Integrated Care Ensuring Continuity of Services

The New Regulatory Framework requires all providers of NHS Health Care to be licenced. NHS Trusts are exempt from this requirement but are expected to meet similar standards. Any NHS Trust providing Commissioner Requested Services (CRS) under the Trust failure regime will be required to hold a licence. The obligations of the licence cover General conditions and specific conditions relating to the 5 key areas noted above. The Regulatory Framework identifies two key types of service:

Commissioner Requested Services (CSR) – services the commissioner believes will need to be protected if a provider fails

Location Specific Services (LSS) – services for which there is no alternative provider and which, once a provider has failed, must be kept running.

CRS are defined within contracts and licences and LSS are defined by Commissioners and the Administrators. Monitor is consulting on proposals to reduce the Financial Risk Ratings to 4 levels and to two target measures:

Liquidity Ratio Capital Service Capacity

The application of the proposed Financial Risk Ratings will lead to the Trust being rated as a 1 for Capital Service Capacity requiring the Trust to achieve a rating of 4 for liquidity days in order to achieve an overall rating of 2.5 which may round to a rating of 3. The proposals are not clear about rounding protocols and whether PFI costs will adjusted for in this particular rating calculation. The Trust has responded to raise a series of queries and concerns about the proposal.



Governance Ratings are largely unchanged in measurement but Monitor is seeking views on the following proposals:

Removal of certain outcome triggers such as Healthcare Acquired Infections Using a broader range of more judgmental measures from various sources Requiring Trusts to undertake a formal Governance Review every three years

The Cooperation and Competition panel will become the Cooperation and Competition Directorate of Monitor. The Directorate will take its powers from section 3 of the provider licence and concurrent powers in relation to the Competition Act 1998 and the Enterprise Act 2002. The Directorate is required to advise the Office of Fair Trading on any merger involving a Foundation Trust. Action Required: The Trust Board is asked to note the information in the enclosed slides. The Trust will need to assess compliance against the proposed licence conditions in the early part of 2013/14. Key Risks: The application of the proposed Financial Risk Ratings

will lead to the Trust being rated as a 1 for Capital Service Capacity requiring the Trust to achieve a rating of 4 for liquidity days in order to achieve an overall rating of 2.5 which may round to a rating of 3. The Trust has responded to raise a series of queries and concerns about the proposal.

Impact on Patients: Patient rights further enshrined in Provider Licence. Impact on Staff: Awareness and education requirements for licencing

requirements Link to Trust Objectives: The Trust will become an NHS Foundation Trust Care Quality Commission outcomes:

The Care Quality Commission will provide judgemental assessments to inform the Governance ratings of Foundation Trusts.

NHS Constitution: No conflict with NHS Constitution and certain patient rights are now captured within the Provider Licence arrangements.

Financial Issues: The requirement for Foundation Trusts to undertake a three yearly Governance review is likely to introduce an additional cost for external assurance. There are no immediate financial impacts for the Trust.

Legal/regulatory Issues: The Provider Licence is a key regulatory tool. The Competition Act 1998 and Enterprise Act 2002 underpin the regulatory framework for Monitor.

Equality Issues considered:

22/03/2013

Monitor’s new regulatory framework

Setting the scene

2

The challenges you’re facing

322/03/2013

Meeting the challenges

Need for:

•strategic long-term planning•system reconfiguration

22/03/2013

Francis implications

Increased focus on culture and qualityMonitor and CQC already working closely together to share information and act jointlyWill look to see what further improvements can be madeRecommendation to transfer some of Monitor’s role to CQC ultimately a decision for GovernmentWould not affect Monitor’s role as health sector regulator for pricing; choice and competition, enabling integrated care; and ensuring the continuity of servicesWorking closely with DH, CQC, NTDA, NHSCB ahead of Government response (March)

22/03/2013

New regulatory framework…

Supporting FT

Governance

Ensuring continuity of services

Enabling integrated

care

Supporting choice and competition

Monitor protects and promotes interests of people who use health care services

through:

Pricing NHS Services

622/03/2013

Our new ways of working

Our provider teams now have same regional structure as CQC, NHS CB & NTDA

• Midlands & East of England• North• South• London

22/03/2013

What we will cover today

• The provider licence and how we prioritise action

• The Risk Assessment Framework, and how it works and your views on it

• An overview of the competition framework and how it applies to providers and commissioners

• Answer your questions

22/03/2013

The NHS provider licence and enforcement

9

What is a licence?

1022/03/2013

Exemptions

All providers of NHS health care services need a licence

Licence replaces FTs ToA

These providers are exempt

NHS Trusts

Primary medical and dental care providers

However

Primary medical and dental care only initially exempt

Exclusion of nursing and continuing care from de minimus limit to be reviewed in April 2015.

CRS providers need a licence

All providers expected to meet similar requirements

Except for those providers

Who do not require CQC registration

Beneath de minimus limit of £10 million NHS turnover (excluding nursing and continuing care initially)

11

What are the obligations on licensees?

Apply to all licensees

Relevant to licensees providing

services under national tariff

Apply to NHS foundation trusts

Apply to providers of CRS

designated services

General

Pricing Foundation trust Continuity of Services

Choice & competition

Integrated care

1222/03/2013

What do you need to do now about the licence?

Respond to requests to confirm that details are correct, so that we correctly issue the licence to youPlan to review your compliance against the

licence, ready for April 2013

1322/03/2013

What is enforcement?

1422/03/2013

Deciding what to do

• Intelligence and information – may suggest potential problem

• Prioritise – then might consider formal, informal, no action

– Might decide to open a formal investigation (which may lead to enforcement action)

– Or might decide informal action is better

– Or no action at all

1522/03/2013

Prioritisation

Should Monitor consider action?

Likely costs

Are the likely costs proportionate to likely

benefits?

Consider:Costs for MonitorBurden imposed

Likely benefits

Consider:Direct benefits for patients

Indirect benefits for patients

Also consider:Prospects for success?

Best placed to act?

Objective is to make sure Monitor acts where it can bring benefits to patients

1622/03/2013

Monitor’s licence enforcement powers

Discretionary requirements

Enforcement undertakings

Additional powers for FTs

Licence revocation (likely to be used only in exceptional circumstances)

1722/03/2013

An overview of Monitor’s proposed Risk Assessment Framework

18

How financially viable are providers of key NHS services?

Are FTs taking sufficient steps to secure compliance with their

governance condition?

What is the role of the Risk AssessmentFramework?

Financial risk at

providers of key

services

Oversee governance

of FTs

Is there a risk of a breach of the licence•do we need more information?•should we open an investigation?

1922/03/2013

Our assessment of financial risk at licensees is guided by the services they provide

All NHS services

Commissioner Requested Services

Location specific services

Commissioner Requested Services (CRS) •Services commissioners believe would need protecting should a provider fail financially•Defined in contracts and licences

Location Specific Services (LSS)•Once a provider of CRS has failed financially (or is about to) LSS are those that must be kept running and no alternative providers exists•Defined by commissioners and the Administrator

• Current mandatory services will be CRS until commissioners can review

• Monitor will assess financial risk at CRS providers only2022/03/2013

Monitor will assess financial risk atCRS providers prospectively…

Forward plan

Quarterly financial

information

Material financial

event

Monitor collects forward plan information from CRS providers and calculates a risk rating

Updates this risk rating each quarter on a year-to-date basis

Re-calculates financial risk to reflect any material financial event (e.g. large transactions, profits warnings)

2122/03/2013

… and use a 4-point risk rating

Medium Risk

Monthly monitoring

Risk rating

4

2

1

3

High riskPotential licence breach and

investigation

No evident risk

Quarterly monitoring

Regulatory implications

High risk Potential licence breach and

investigation

2222/03/2013

Liquidity ratio (days)

Weight

Can the provider meet immediate cash

requirements, e.g. paying suppliers & salaries

Definition

Capital service capacity (times)

Continuity of Services Risk Rating

Working capital balance x 360

Annual operating expenses

Revenue available for Debt Service

Annual debt service

Metric

… derived from short- and medium-term indicators of financial sustainability

Can the provider meet medium-term financing

requirements, e.g. PDC dividends, interest

payments, debt paymentsand PFI obligations?

2322/03/2013

Governance: summary of approach

Monitor oversees FT governance through the licence

FT governance condition reflects (i) existing requirements and (ii) our experience of FT governance to date

If the framework triggers governance concerns, we may request further information and/or investigate

2422/03/2013

Governance: proposed approach

Governance rating

Regular governance reviews

Forward plan reviews

Corporate governance statement

Do we need more

information?

Should we open an

investigation?

Monitor proposes using a series of inputs to trigger possible consideration of a breach

2522/03/2013

In generating a governance rating, we will lookat up to six key areas …

CQC concerns

Access

3rd party reports

Staff & patienttrends

Financial risk

Outcomes

Warning notices or civil/ criminal actions

Meeting national standards

Meeting national standards - including MRSA, C.Diff

e.g. Healthwatch, Patient groups, auditors, commissioners, HSE, ombudsman, coroners

e.g. friends & family test, staff turnover, staff absenteeism

Poor financial planning/management

Sample triggersArea of focus

2622/03/2013

… with the rating indicating the degree of our concern and any action we are taking

No evident concerns

Concern identified – need for further information identified

Potential breach of the governance condition identified -investigation underway

Material governance issue – regulatory action possible or under consideration

Breach of the governance condition with formal action taken by Monitor

Rating Description

2722/03/2013

Actions following concerns: investigation, prioritisation & enforcement

22/03/2013

Financial Risk to Continuity of Services

Governance (Foundation trusts only)

• Request & review reforecasts/replans − investigate local factors & stress test – is there a risk

to services? • Require the CRS provider to work with commissioners

and/or engage financial or governance expertise

Possible actions to addressArea of concern triggered

• Does investigation reveal a governance issue‒ how big is it / is regulatory action necessary?

• Actions may include e.g. requiring governance improvements, ensuring care quality issues are fixed

• Evidence of delivery likely to be sought

Breakout sessions

22/03/2013

Financial Risk

Governance oversight

(Foundation trusts only)

We are looking for some feedback on five topics…

… but also welcome your views on any other areas of the proposed framework you have

Moving from 5 metrics to two

Assessing risk on a prospective basis

Using a broader range of more judgemental inputs

Potentially removing outcomes (inc.HCAIs) from our framework

Requiring 3-year governance reviews

The work of the Cooperation and Competition Directorate

30

Cooperation & competition

Introduction • Cooperation & Competition Panel to become the Cooperation &

Competition Directorate of Monitor.

A brief overview of the new competition framework as it applies to: • Providers; and, • Commissioners.

Mergers, JVs and asset transfers.

Questions in the panel Q&A.

22/03/2013

Competition Framework: Providers

Provider Licence• Section 3:

- C1 – relating to the rights of patients to make choices- C2 – relating to (i) agreements/arrangements (ii) conduct which

have/has the effect of preventing, restricting or distorting competition

We will also have concurrent powers in relation to the Competition Act 1998 and the Enterprise Act 2002.

We have published draft formal guidance on enforcement of the provider licence and we expect to publish substantive guidance on the Choice and Competition conditions.

22/03/2013

Competition Framework: Providers

In preparation for substantive guidance, the CCP is publishing a number of papers on the application of the competition rules to:• Integrated Care (*published); • Unilateral Conduct;• Agreements; • Clinical Networks.

The CCP has also published advice and working papers on various subjects e.g. • Referral Management;• How competition between hospitals improves quality and

integration of services.

22/03/2013

Competition Framework: Commissioners

The Commissioner Regulations impose requirements on the NHS CB and CCGs to ensure:

• Good practice in relation to the procurement of health care services for the purposes of the NHS (e.g. in relation to transparency, proportionality, non-discrimination, etc);

• The protection of patients’ rights to make a choice regarding their NHS treatment; and,

• Prevention of anti-competitive behaviour by commissioners.

22/03/2013

Competition Framework: Commissioners

We will be publishing guidance for commissioners.

Our Level Playing Field Review will be laid before Parliament at the end of March.

As with providers, we will also have concurrent powers in relation to the Competition Act 1998 and the Enterprise Act 2002.

22/03/2013

Mergers, JVs and Asset Transfers

The term merger can relate to mergers, acquisitions, JVs and other transactions between NHS service providers that result in two previously independent organisations (or parts of organisations) coming under common management or control.

• E.g. University Hospitals Bristol FT & North Bristol NHS Trust.

22/03/2013

Mergers, JVs and Asset Transfers

Responsibility divided between the Office of Fair Trading (OFT) and Monitor:• The OFT is responsible for the investigation of mergers involving

FTs; and,• Monitor is responsible for the investigation of Trust-Trust mergers.• Monitor is, however, required (under the HSC Act 2012) to advise

the OFT on the effect of the mergers involving FTs on benefits for patients. - See for example, our advice to the OFT on Poole Hospital FT and

Royal Bournemouth and Christchurch Hospitals FT.- We expect the OFT to take responsibility for FT-Trust mergers

going forward. The OFT is expected to make an announcement about its approach in the coming weeks. We would also provide advice on benefits in these cases.

22/03/2013

Informal advice

We are more than happy to provide advice on an informal (non-binding) basis, advice about procurement and conduct issues and also potential merger situations.

If in doubt, please contact us to discuss.

Contacts: • [email protected] - Up to 31st March 2013.• [email protected] - From 1st April 2013.

22/03/2013



Report to: Trust Board Agenda item: 7.1 Date of Meeting: 28 March 2013

Report Title: SHRP and Move Highlight Reports

For information discussion assurance approvalStatus: X

Prepared by: Martin Warren, Project Manager/Sue Evans Head of Commissioning Support

Executive Sponsor (presenting): Mike Coupe, Director of Strategy and Planning Appendices (list if applicable): 130226 SHRP/130228 Move Highlight Report Executive Summary: The Southmead Hospital Redevelopment Programme Board (SHRP) and Move

highlight reports are attached. Action Required: Trust Board is requested to:

Note the progress and the issues identified.

Key Risks: See highlight report. Impact on Patients: Improved quality of environment. Trust Objectives: Meets the following objectives:

Services will be leading edge and provided in high quality environments

To be a strong financially healthy organisation Care Quality Commission outcomes:

Outcome 10, Safety and suitability of premises applies

NHS Constitution: Principle 7 is particularly relevant to this proposal: The NHS is accountable to the public, communities

and patients that it serves Patient and public: Quality of care and environment Staff: Have a good working environment; Have healthy and safe working conditions

Financial Issues: Covered within Strategic Objective no. 5 - Strong, financially healthy organisation and related risks.

Equality issues: Addressed through overall design of new hospital Legal/regulatory Issues: None

V:\Trust Board 2013\Public Papers\March 2013 - PUBLIC\07.1 SHRP Highlight Report -v3 (mdw td) final.docx

Southmead Hospital Redevelopment Project Highlight Report

Date: 26 Feb 2013 Author: Martin Warren

Period: 01-28 Feb 2013 Report Number: 105

SRO: Mike Coupe Status summary: Construction is on programme overall. Good quality build.

G

Key Issues: o Equipment list including substitutions being jointly reviewed with Carillion o The detailed analysis of the commercial agreements reached with Carillion (which includes cost neutral variations) will be provided to the Trust

Board once the financial information has been received from Carillion. To date, only cost information on asbestos is available. o The cost of legal fees associated with variations is a best estimate based on experience from elsewhere and covers NBT and The Hospital Company

legal costs. These cost estimates will be refined once further information has been received from Carillion on the variations. Time, quality, risk and financial control update

Time Quality

Construction and fit out is on programme overall. Permanent lights are on in some zones and rooms finished and locked

Design Review: 100% of structural and envelope reviewable design data (RDD) received and reviewed along with 99% of mechanical and electrical design (MEP), 92% interior design and 75% landscape

Automated guided vehicles (AGV) design development progressing together with users

Internal and external wayfinding and signage progressing

RAG

NBT generally very happy with quality of construction and finishes

A further meeting is to be arranged to discuss the emergency department corridor

The draft report from the British Research establishment (BRE) peer review of the fire strategy is expected in March 2013.

RAG

Top Risks Score Mitigation

Pathology scheme delayed or revised Solution to sterile services provision during phase 2 of PFI Third party delays and costs to PFI

If DSC not relocated by May 2014, Trust will be faced with

delay payment to Carillion

16 16 12 12

Rapid decision making on solutions, negotiations with Carillion Assessment report to March Redevelopment Programme Board. Monthly reviews of all 3rd party property agreements. Aim to

complete all docs by end June 2013 Suitable properties for disablement services centre, wheelchairs

and communication aid services being reviewed Financial controls

Unidentified asbestos estimate of £200k anticipated and allowed for in budget. All other agreed Variations at NIL cost to date.

G G

V:\Trust Board 2013\Public Papers\March 2013 - PUBLIC\07.1 SHRP Move Highlight Report -v2 (se td) final.doc

Highlight Report

Date: 26 Feb 2013 Author: Sue Evans

Period: 01-28 Feb 2013 Report Number: 6

SRO: Sasha Karakusevic Status summary: Overall project is making good progress

G

Key Issues: o IM&T – Patient entertainment procurement processes must start immediately. Staffing issues of concern but being addressed. o FM – interface with themes re workforce requirements and timetable for sign off is of concern as timetables do not align. o People and Services – Staff are very eager to know where they will be based in the future – this is a source of anxiety amongst staff.

Time, quality, risk and financial control update

Time Quality

Overall the programme is on target The commissioning programme has been presented to Carillion and

is on target for agreement by the end of March 231 Move Leads have been recruited and 184 trained. 2 further

training sessions have been arranged. Progress made on IM&T workstream, but concerns raised about

procurement support for patient entertainment which is now the main risk for IM&T projects

Regular interface with FM and Theme clinical leads in place A robust approach at PMO level to monitoring performance against

the agreed critical path is essential to meeting the programme.

RAG

A further meeting is to be arranged to discuss the ED corridor

The quality of the finishes in the new building and on show in the mock up rooms has been appreciated by Move Leads, Foundation Trust members and other visitors

Staff have been enthused by the Move Lead training and have pledged to share this with colleagues

Voting has closed for site naming competition winner to be announced in May

RAG

Top Risks Score Mitigation Significant workload due to wide business as usual agenda will

impact staffs' availability to deliver move programme Themes are not able to deliver sufficient service changes before the

move The need for swift procurement following Patient Entertainment's

sign off in March will not be met Location of Sterile Services Department (SSD)

12

12

12

16

Close monitoring of Move Leads by Move Co-ordinators and early escalation of problems

Support of Theme Leads through Project Management Office, clear expectations of move requirements set out and monitored by board.

Get agreement in place for IT procurement support and advice. May require additional funding.

Option appraisal to be developed and considered by Redevelopment Programme Board recommended way forward to Move Project Board.

Financial controls

On target to meet budgetary requirements for year end

G G



Report to: Trust Board Agenda item: 7.3 Date of Meeting: Thursday 28 March

Report Title: FT / Acute Services Review – Clinical Summit Feedback Letter

For information discussion assurance approval Status: x

Prepared by: Acute Services Programme Team Board Sponsor: Harry Hayer, Director of Organisation, People & Performance Appendices: Clinical Summit Feedback Letter

Executive Summary: The attached letter provides initial feedback to over 100 clinicians and senior managers who attended the Clinical Summit as part of the Acute Services Review held on 28 February 2013. Action Required: Trust Board is requested to NOTE the attached letter

Key Risks: N/A

Impact on Patients: The Acute Services Review is designed to provide better

patient care

Impact on Staff Clinical staff will be heavily involved in the review Link to Trust Objectives: All Care Quality Commission outcomes:

N/A

NHS Constitution: N/A Financial Issues: N/A Legal/regulatory Issues: N/A Equality Issues considered N/A

Bristol Acute Services Review Page 1 of 3

Bristol Acute Services Review Cabot Suite,

The Courtyard, BRI Old Building,

Lower Mauldlin Street Bristol, BS2 8HW

Tel 0117 342 3421774 Email: [email protected]

Sent via email to all Clinical Summit invitees 12 March 2013 Dear colleague Re: Clinical Summit feedback It has been just over a week since the Clinical Summit where many of you learned more about the Bristol Acute Services Review and the challenges we are together trying to address and most importantly got actively involved in starting to shape the solution for the future. It was very powerful to have over 110 clinicians and healthcare professionals joining forces to debate and discuss what needs to change and where improvements should be made to ensure we design services that are high quality, best in class and financially sustainable for the long-term. As your time is so valuable we wanted to ensure we maximised the use of it and therefore the main focus of the event was workshop based where attendees worked in groups to answer the following questions:

1. What factors and data sources should we look at to determine which services we will review in more detail during the next stage of the acute services review?

2. What does good look like from the perspective of patients, clinicians / all relevant professionals and commissioners across the following four pathways:

Maternity, paediatrics and NICU

Urgent and emergency

Elective

Tertiary

3. Thinking radically, how could we best deliver care across these four pathways to the populations of Bristol, North Somerset and South Gloucester? What needs to change to achieve this?

Thank you to those of you who attended for your energy and honesty during the discussions; the feedback from each of the tables was extensive. PwC, who facilitated the event on our behalf, has been collating the detailed feedback which we will share with you soon via the two Trust intranet sites.

mailto:[email protected]


However, here is a flavour of some of the key themes coming out of the event thus far:

Attendees were engaged and showed a strong appetite for radical transformation to deliver sustainable services for the long-term;

There was a real enthusiasm shown for collaborative working between the two Trusts, but also attendees felt it was very important that all stakeholders within the health economy (primary care, community services, patients, voluntary etc) were involved and engaged in the next stage of the review;

Attendees were very keen that the next stage of the review focused on pathways as well as individual specialities;

There was a strong request for there to be transparency in decision making as the review progresses.

These themes show a strong message from clinicians that the Acute Services Review needs to be radical, needs to look at how pathways can be improved and must engage and involve the wider system in undertaking this work. Taking this feedback on board, the Programme Board for the Acute Services Review - which is accountable to both Trust Boards - is taking stock to make sure the next stage of the Review takes the views of clinicians that were so strongly expressed in the summit into account. However, whilst the Programme Board takes a short period of reflection, it is important that the momentum we have collectively established is maintained. As such, we are moving forward with establishing the factors and data sources that should be used to determine what services should be reviewed in detail as part of the next stage of the Review based on the feedback provided by those attending the summit. Whilst many factors were considered to be important by those attending the event, there were eight categories that were consistently suggested, these are:

Demand for services

Duplication

Quality

Potential for innovation

Patient experience

Opportunities for reconfiguration

Workforce and skills

Clinical efficiency We are working with the healthcare team at PwC to isolate the key indicators within each of these categories, prioritising those variables that are most representative of the overarching category and taking into account availability of data and the need to move relatively quickly. Based on the outputs of this discussion at the Clinical Summit, we have agreed the following factors to assess which areas should be focused on:

Demand for services: Income (as a proxy for activity and profitability)

Duplication: Profiling of services offered on both sites


Quality: HSMR, RTT

Potential for innovation: Levelling up opportunities (as a proxy for doing things differently)

Patient experience: Complaints

Opportunities for reconfiguration: Profiling of current reconfiguration plans

Workforce and skills: Workforce benchmarking

Clinical efficiency: Length of stay benchmarking We are currently collecting data and deciding how to weight the relative importance of each indicator; once this is done we will move quickly to agree which services we will focus on based on what you have told us. We will share the outcome of this with you in the near future and will keep you fully informed of the shape of the next stage of the review and how you can be involved moving forward. Your input and commitment to the review is important, and whilst we recognise your time is pressured as we all try to manage many priorities, we would ask you to try and make time for the next stage of the review as it progresses. This may involve attending a workshop or a small engagement event, or joining a larger event like the clinical summit again. We all know that challenging times are ahead. Let us take the opportunity that the Bristol Acute Services Review has given us to ensure we shape and develop our services to sustain the challenges in front of us and ensure we can deliver high quality, safe and affordable services to the people of Bristol and surrounding areas long into the future. For more information, or if you have any questions please email [email protected] or call 0117

342 1770.

With kind regards,

Dr Chris Burton Dr Sean O’Kelly Medical Director Medical Director North Bristol NHS Trust University Hospitals Bristol NHS Trust

Sue Jones Alison Moon Director of Nursing Chief Nurse North Bristol NHS Trust University Hospitals Bristol NHS Trust

mailto:[email protected]


section' of any meeting.

Report to: Trust Board Agenda item: 8.1 Date of Meeting: 28th March 2013

Report Title: Revenue and Capital Budgets for 2013/14

For information discussion assurance approval Status:

X Prepared by: Nigel Baker, Deputy Director of Finance Board Sponsor: Bill Boa, Interim Director of Finance Appendices: Yes

Executive Summary:

This budget is proposed in the context of the Trust’s medium term financial plan and Foundation Trust application. In 2013/14 the Trust is planning for a surplus of £5.6m. The key elements of the budget are as follows:

A £2.9m recurrent surplus brought forward from 2012/13 notwithstanding the forecast

surplus of £7.0m for the year. A total 2013/14 surplus of £5.6m, the full year impact of which is £8.3m recurrently. Inflation funding of £14.4m offset by a national efficiency savings requirement of

£19.2m. Negotiations with Commissioners are continuing with activity plans likely to be set

broadly at recurrent outturn plus some minimal growth and clearance of waiting list backlogs. Over-performance will be at risk to the Commissioners ie a PbR compliant contract. NBT are also seeking support for system change monies to enable improvement in patient flow to support achievement of the 4 hour wait target.

A resulting requirement for £24.3m efficiency savings. £12.5m new hospital transitional costs funded by the NHS Commissioning Board. Capital spend of £44m is planned. The new hospital will be handed over to the Trust in March 2014 so the resulting asset

and liability are included in the closing Balance Sheet, net of impairment of £157m. Total impairments will be £181m in 2013/14. The overall Financial Risk Rating is assessed as a 3.

This budget is in line with the Long Term Financial Model (LTFM) and meets the financial objectives of the Trust. Action Required:

The Trust Board is asked to approve revenue and capital budgets for 2013/14.

Key Risks: Final outcome of contract negotiations, particularly with

regard to penalties and CQUINS;

Commissioner activity reduction plans requiring reduction in capacity;

Achievement of savings target;

Cost pressures in excess of the sum set aside eg for consequences arising from meeting recommendations of the Francis report.

Impact on Patients: Delivery of year one of the medium term financial plan secures the patient benefits identified in the Integrated Business Plan of the Trust.

Trust Objectives: To be a strong financially healthy organisation.


None

NHS Constitution: This budget supports compliance with the NHS Constitution.

Financial Issues: Yes

Equality Issues: No

Other Legal/regulatory Issues: Yes

NORTH BRISTOL NHS TRUST

REPORT TO TRUST BOARD 28th MARCH 2013

REVENUE AND CAPITAL BUDGETS FOR 2013/14 1. Introduction

The budget for 2013/14 has been prepared in the context of:

a. the Operating Framework for 2013/14 published by the Department of Health; b. the Payment by Results (PbR) tariffs for 2013/14 published by the Department of

Health; c. commissioner financial plans; d. the Trust’s medium term financial plan.

The Operating Framework sets out the key planning assumptions and delivery expectations.

The key financial changes are:

that costs will increase by 2.7% overall; a national efficiency target of 4%; the above two items result in an expected net tariff reduction of 1.3%; the amount that can be earned from CQUINs schemes is 2.5% of income.

The key operational changes are:

that 18 week referral to treatment (RTT) performance is at specialty level rather than overall;

significant reductions (30%) in expected levels of c difficile.

Commissioners have received an increase of 2.6% in allocation for 2013/14. However, most Commissioners have sought to commission at 2012/13 outturn level adjusted by the expected tariff reduction with some specific growth items additionally funded.

The key contractual agreements with the main Commissioners are not yet concluded.

The budget as proposed takes account of:-

Activity levels have been agreed with Commissioners at the level of recurrent demand other than for some specific areas of growth such as renal services, HIV, NICE approved drugs and some other specialist services. To achieve this requires general areas of growth to be absorbed by activity reduction schemes.

The following service transfers:-

The transfer of breast and urology services to NBT from University Hospitals Bristol (UHB);

The transfer of ENT, head and neck and oral surgery from NBT to UHB.

A maximum additional payment above tariff of 2.5% dependent on the achievement of quality standards under the CQUINS scheme. We have budgeted to achieve 80% of the total.

Consideration of capital budget proposals by the members of the Capital Planning and

Monitoring Group. 2. The financial position brought forward from 2012/13

A summary of the 2012/13 outturn projection is set out in the table below.

2012/13 Outturn Forecast Recurrent

Non-recurrent Total

£m £m £m

Income (513.3) (11.3) (524.5)

Expenditure 510.4 7.2 517.5

Surplus for NHS accountability (2.9) (4.1) (7.0)

A £7.0m surplus is forecast for 2012/13, but this is largely due to one-off factors amounting to £4.1m so the recurrent underlying position in 2012/13 carried forward is a £2.9m surplus.

3. 2013/14 income and expenditure changes The income and expenditure changes planned in 2013/14 are shown in

source and application of funds statement (Appendix 1) income summary (Appendix 2) summary income and expenditure plan (Appendix 3)

The overall changes are as follows:

Recurring Non-recurrent Total£m £m £m

Brought forward recurring surplus (2.9)

Recurrent income changes (4.5)

Non-recurrent income (12.5)

Recurrent expenditure changes (0.9)

Non-recurrent expenditure 15.2

Projected surplus (for NHS accountability) (8.3) 2.7 (5.6)

There is significant non-recurring income and expenditure, largely associated with the new hospital. The key planned changes in 2013/14 are described in the sections below.

4.1 Tariff uplift and mandatory cost pressures

The cost of inflation and national mandatory cost pressures is estimated to be in line with the income from the tariff uplift of 2.7% (before the efficiency deduction). This is shown in the table below.

Income Expenditure Net increase increase impact

£m £m £m

Gross tariff uplift (14.4)

Pay increases 7.3Price increases 6.4Indexation of assets 0.6

Net (14.4) 14.3 (0.1)

4.2 Tariff reduction for efficiency

The 2.7% tariff uplift described in 4.1 above is prior to tariff reductions for efficiency that apply to all commissioner tariffs and contracts. This tariff reduction is 4% for PCT income. We have reviewed the likely inflation/deflation of other income sources and have set levels accordingly. The overall income reduction relating to expected efficiency improvements on this basis is £19.2m. The net impact of tariff reductions is a reduction of £4.8m.

4.3 Other tariff changes

Whilst the national expectation is for an overall 1.1% reduction from tariff changes the individual organisation impact is usually different. We have modelled the proposed new tariffs and this indicates that the NBT reduction will be less than this. Some of the changes are quite fundamental, e.g. the new maternity pathways and the unbundling of outpatient radiology, and commissioner acceptance is required.

The methodology for non-payment for avoidable readmissions which was introduced in 2012/13 requires Trusts and Commissioners to jointly review a sample of readmissions and identify when they could have been avoided, whether that be by actions of the Trust or community services. This will set a threshold for readmissions above which the Trust will not be paid. Based on evidence to date the expectation is that this will result in a lower level of unpaid readmissions. This gives a forecast benefit of £1.8m.

4.4 Additional local cost pressures

In addition to the inflationary pressures described in section 4.1 above, provision has also been made for recurrent cost pressures equivalent to 0.25% of expenditure.

4.5 Financial impact of activity and service changes The table below shows the overall impact of planned activity and service changes. This

shows income increasing on outturn by £3.4m and cost increasing by £1.1m, giving a net favourable impact on the Trust of £2.3m.

Income Expenditure Net impactchange change

£m £m £m

Recurrent demand over 2012/13 outturn (1.9) 0.0 (1.9)

Market share (2.3) 1.7 (0.6)

Net growth (4.5) 3.4 (1.1)

Transfers 5.3 (4.0) 1.3

Total (3.4) 1.1 (2.3)

It has been assumed that some of the shortfalls in elective activity in 2012/13 will be recovered in 2013/14 and Directorates have indicated that this can be done at minimal additional cost.

In general commissioners have sought to plan for minimal or zero growth in 2013/14. However we have made some specific projections of growth in certain areas of activity, e.g Renal, HIV, and Neurosurgery. These have been recognised by commissioners. We have included some gains in market share in some specialised services including major trauma and paediatric epilepsy.

The expectation from local commissioners is that demographic growth will be matched by QIPP. Growth and QIPP will inevitably fall in different specialties and we are awaiting details from commissioners so that capacity changes can be planned for. The service transfers of breast and urology from UHB to NBT, and ENT and oral surgery from NBT to UHB have been included

We have planned for a cost impact of 75% on income changes. Commissioners will also fund the increased spend on NICE drugs. The Trust is also seeking non-recurrent support from the Commissioners to fund the system changes we are implementing to improve patient flow and access performance.

4.6 CQUINs

The potential level of CQUINs is 2.5% of income and could contribute a further £1.8m net of additional costs of achievement.

4.7 Non recurrent items in 2013/14

The following income and costs largely relate to the new hospital scheme. There is no net effect on the Trust’s income and expenditure position from the new hospital funding, as shown in the table below. We have set aside £2.7m for various project costs to facilitate the pace and scale of change.

Income Expenditure Net impactchange change£000's £000's £000's

PFI support (12.5) 3.0 (9.5)Restructuring costs 3.6 3.6Accelerated depreciation 5.9 5.9

Total PFI support (12.5) 12.5 0.0

Non-recurrent project costs 2.7 2.7

Total non-recurrent items (12.5) 15.2 2.7

Reduction of the waiting backlog has not yet been agreed by commissioners and so this non recurrent income and cost has not been included in the budget at this stage.

4.8 Resultant requirement for efficiency savings in 2013/14 The table below sets out the requirement for efficiency savings of £24.3m based on the various drivers set out earlier in section 4.

Movement in Income and ExpenditureSection

reference £m

2012/13 recurrent surplus (for NHS accountability) 2 (2.9)

Tariff efficiency requirement 4.2 19.2

Other tariff changes 4.3 (1.8)

Cost pressures over tariff uplift 4.4 1.2

Net impact of activity and service changes 4.5 (2.3)

CQUINs 4.6 (1.8)

Non-recurrent items 4.7 2.7

Recurrent capital charges (excluding indexation on assets) 2.3

Recurrent contingency 2.0

2013/14 savings target 4.9 (24.3)

2013/14 projected surplus (for NHS accountability) (5.6)

4.9 Efficiency improvements identified against targets As set out above the total savings required in 2013/14 are £24.3m. Appendix 4 shows the

targets and amounts identified by Directorate. This shows that £23.1m of schemes have been identified but that after risk adjustment this reduces to £16.9m. Performance in identifying savings is variable across Directorates.

Following the 2012/13 performance where final savings achieved were significantly below target despite what appeared to be a good plan at the start of the year, the programme management office will carefully monitor delivery of schemes against planned implementation dates.

Directorates are completing quality impact assessments for each scheme which are being signed off by the Medical and Nursing Directors.

The graph below shows the phasing of the probability adjusted savings plans identified by Directorates. The top of each stacked bar is the current gap against the full target.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

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

£m

Month

2013/14 probability adjusted phased CRES plan and gap

Gap Plan

4.10 Phased Income and Expenditure The projected phased cumulative surplus is shown in the graph below

0

1

2

3

4

5

6

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

£m

Month

Cumulative net surplus

5. Capital expenditure. 5.1 The Trust’s expected capital expenditure and funding are shown in appendix 5. This shows a proposed plan for 2013/14 which requires Board approval and indicative plans for the period to 2015/16. Although the capital expenditure exceeds funding available in 2013/14 and 2014/15, the projected cash balance at March 2013 if £40m. The Trust Capital Planning and Monitoring Group (CPMG) have considered the detailed plan for 2013/14 and there will be ongoing discussion and review by this group throughout the year. 5.2 The key aspects of the expenditure plan are as follows. The vast majority of the schemes are related to the new PFI hospital which is due to

be handed over to the Trust in March next year. As well as Pathology and Learning & Research they include the new Breast Care Centre and Corporate Office provision.

There is still some uncertainty regarding the exact timing of a number of the schemes in 2013/14 including the new Pathology building.

There is also an element of uncertainty regarding the cost of some of the PFI enabling schemes and to reflect that a contingency has been calculated for each scheme and included in the plan. It is hoped that this will reduce as the schemes progress rapidly in 2013/14.

Slippage is relatively high in 2013/14 due to the proximity of the new hospital handover to the year end.

5.3 Capital expenditure in 2013/14 is financed from: Depreciation of the trusts owned assets; Cash surpluses from prior years – primarily from capital sources; A number of external contributions to the major building schemes (£5.7m in 2013/14) Leasing of medical equipment; Public Dividend capital of £1.7m which has been agreed can be accessed in

2013/14.

In future years receipts from the sale of the Frenchay land are critical to the overall liquidity of the Trust.

6. Cash and Statement of Financial Position (Balance Sheet) 6.1 The table below shows that the projected cash position at the end of 2012/13 is £40m and this increases slightly during the year to £44.3m. The excess of capital expenditure over funding is temporarily offset by a rise in capital creditors at the end of the year of £8.8m but this will reverse in 2014/15, meaning the underlying cash position is £35.5m. Appendices 7 and 8 show the full forecast cashflow statement as well as a monthly analysis.

2012/13 2013/14£m £m

Opening cash balance 28.3 40.0

Surplus 7.0 5.6Net change in working capital (0.8) 10.7Capital plan in-year surplus/(deficit) 6.9 (10.6)Loan repayments (1.4) (1.4)Net increase/(decrease) in cash 11.7 4.3

Closing cash balance 40.0 44.3

6.2 The graph below shows how cash fluctuates throughout the year. There is a steep increase in cash in September when we anticipate receiving the transitional income from the National Commissioning Board of £12.5m. Net cash then drops in the final quarter of the year reflecting the profile of capital expenditure which is weighted heavily towards the final 3 months.

0

10

20

30

40

50

60

70

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

£m

2013/14 cumulative monthly cash balance

6.3 Appendix 6 shows the forecast statement of financial position. There are a number of significant points to note for the position at 31st March 2014: It is anticipated that the new PFI hospital will be made available to the Trust in

March 2014, and therefore it is included as an addition to non-current assets net of an anticipated impairment of £157m;

The full value of the asset of £428m is shown as a PFI liability in order to comply with accounting for the PFI as on-balance sheet, in accordance with IFRIC 12 (service concession arrangements);

The net effect of this and previous asset write-downs results in a negative net asset balance of £3.1m. This significantly reduces dividends payable in 2013/14;

Other movements of note include a rise in capital creditors of £10.1m and other creditors of £5.7m. The £5.7m relates to external contributions to the capital programme.

6.4 The overall financial risk rating for 2013/14 is 3. (See Appendix 9).

7. Financial risks The key risks inherent in the budget are:-

Final outcome of contract negotiations, particularly with regard to penalties and CQUINS;

Commissioner activity reduction plans requiring reduction in capacity, and failure to release cost to the level required when activity and income reduces;

Failure to achieve the savings target; Cost pressures in excess of the sum set aside, e.g. for consequences arising from

meeting the recommendations of the Francis report.

If these risks materialise, the Trust will need to find offsetting mitigations, e.g. reducing discretionary spend and delaying developmental investments.

8. Summary and recommendations

This report sets out a budget plan for 2013/14 that achieves the short term financial objectives of the Trust, and is consistent with the medium term strategy. This will be another challenging year with the need to deliver a further £24m of savings. It is an achievable plan provided we do the following:-

Step up the rate of productivity improvement; Deliver savings as planned; Engage with Commissioners on demand management plans; Pro-actively take out capacity as demand falls or is managed down; Take opportunities for growth or transfer where they exist and are affordable to the

relevant commissioners; Control our costs.

This budget paper has been reviewed by the Finance Committee and it is recommended that the budget be approved. Given that the budget has been drawn up prior to the final resolution of SLA values and in particular contract terms, it may be necessary to bring a revised budget and certainly an update on the implications of the final contractual position, back to the Board.

INDEX OF APPENDICES

1. Statement of Sources and Applications of Funds

2. Projected Income 2013/14

3. Income and Expenditure Account Summary

4. 2013/14 Savings Identified by Directorate

5. Capital Expenditure Plan 2012/13 to 2015/16 6. Forecast Balance Sheets

7. Forecast Cash Flow Statement 8. Monthly Cash Flow Forecast 2013/14

9. Forecast Financial Risk Ratings

Appendix 1Statement of Sources and Applications of Funds

Recurrent changes

Non recurrent changes Total

£m £m £mForecast 2012/13 recurrent (surplus) (2.9) (2.9)

Income changes Gross tariff uplift (14.4) (14.4) CQUINS (4.0) (4.0) Tariff reductions for efficiency savings 19.2 19.2 Other tariff changes (1.8) (1.8)

Activity and service changes 2013/14 market share changes (2.3) (2.3) 2013/14 recurrent growth over 2012/13 outturn (4.5) (4.5) 2013/14 recurrent demand over 2012/13 outturn (1.9) (1.9) 2013/14 service transfers 5.3 5.3 NICE (1.2) (1.2)

Other income 1.0 1.0 PFI support (12.5) (12.5)

Total income changes (4.5) (12.5) (17.0)

Expenditure changes

Generic cost pressures (inflation etc) 12.5 12.5 CQUINS 2.2 2.2 Other cost pressures 1.2 1.2

Activity and service changes 2013/14 market share changes 1.7 1.7 2013/14 recurrent growth over 2012/13 outturn 3.4 3.4 2013/14 service transfers (4.0) (4.0) NICE 1.2 1.2

Costs associated with other income changes 0.2 0.2 Contingency 2.0 2.0 Non-recurrent project costs 2.7 2.7 PFI costs 12.5 12.5 Savings required 2013/14 (24.3) (24.3)

Depreciation 2.8 2.8 Interest receivable (0.0) (0.0) Interest payable (0.1) (0.1) Dividend 0.2 0.2

Total expenditure changes (0.9) 15.2 14.3

Projected 2013/14 I&E (surplus) / deficit (8.3) 2.7 (5.6)

12/13 forecast outturn to 13/14 planAdv / (fav)

Appendix 2Projected Income 2013/14

Patient care activity income

Other income Donations

Total income

£m £m £m £m

Projected paid outturn 2012/13 (446.0) (78.5) (0.3) (524.8)

Non-recurring income (1.2) (10.1) 0.0 (11.3)

Recurrent 2012/13 outturn (444.8) (68.4) (0.3) (513.6)

Changes in 2013/14

Gross tariff uplift (12.5) (1.8) (14.4)

CQUINS (4.0) 0.0 (4.0)

Tariff reductions for efficiency savings 17.8 1.4 19.2

2013/14 market share changes (2.3) 0.0 (2.3)

2013/14 recurrent growth over 2012/13 outturn (4.5) 0.0 (4.5)

2013/14 recurrent demand over 2012/13 outturn (1.9) 0.0 (1.9)

2013/14 other tariff changes (1.8) 0.0 (1.8)

2013/14 service transfers 5.3 0.0 5.3

NICE (1.2) 0.0 (1.2)

Other income 0.0 1.0 (0.5) 0.5

PFI support 0.0 (12.5) (12.5)

Total changes (5.1) (11.9) (0.5) (17.5)

Total 2013/14 income (449.9) (80.3) (0.8) (531.0)

Appendix 3

Recurring change

2012/13 to

RecurringNon

recurring Total 2013/14 RecurringNon

recurring Total£m £m £m £m £m £m £m

Income

Income from activities (444.8) (1.2) (446.0) (5.1) (449.9) 0.0 (449.9)Other operating income (68.4) (10.1) (78.5) 0.6 (67.8) (12.5) (80.3)Donations Income (0.3) 0.0 (0.3) 0.0 (0.3) (0.5) (0.8)

Total Income (513.6) (11.3) (524.8) (4.5) (518.0) (13.0) (531.0)

Expenditure

Pay 335.4 3.5 338.9 (5.1) 330.4 6.5 336.9Non Pay 155.0 (2.5) 152.5 1.3 156.3 2.8 159.1

Total Expenditure 490.4 1.0 491.4 (3.8) 486.6 9.3 495.9

EBITDA (23.1) (10.3) (33.4) (8.3) (31.4) (3.7) (35.1)

Depreciation 16.0 6.2 22.2 2.8 18.8 5.9 24.7Interest receivable (0.1) 0.0 (0.1) (0.0) (0.1) 0.0 (0.1)Interest payable 1.7 0.0 1.7 (0.1) 1.6 0.0 1.6Dividends on PDC 4.7 0.0 4.7 (2.6) 2.1 0.0 2.1PFI impairment 0.0 0.0 0.0 0.0 0.0 156.8 156.8Other impairment 0.0 22.8 22.8 0.0 0.0 24.5 24.5

Retained (surplus) / deficit (0.9) 18.7 17.8 (8.2) (9.0) 183.6 174.5

Add back items for NHS accountability

PFI impairment 0.0 0.0 0.0 0.0 0.0 (156.8) (156.8)Other impairment 0.0 (22.8) (22.8) 0.0 0.0 (24.5) (24.5)IFRIC 12 adjustment (0.5) 0.0 (0.5) 2.8 2.3 0.0 2.3Donated assets (Depreciation) (1.8) 0.0 (1.8) 0.0 (1.8) 0.0 (1.8)Donated assets (Income) 0.3 0.0 0.3 0.0 0.3 0.5 0.8

Net (Surplus) / Deficit for NHS accountability (2.9) (4.1) (7.0) (5.4) (8.3) 2.7 (5.6)

Income and Expenditure Account Summary

2012/13 outturn forecast 2013/14 plan

Appendix 4

2013/14 Savings identified by Directorate

Total Probability ProbabilityGross Adjusted adjusted

Directorate Savings Target (2013/14

) Savings Savings

gap

% of Target % of Target

£m £m £m £m £m £m % £m £m £m £m £m % £m

Core Clinical Services 5.4 0.0 2.2 1.0 0.2 3.4 63% 0.0 2.0 0.6 0.0 2.6 48% 2.8Medicine 2.7 0.0 2.7 0.4 0.0 3.0 112% 0.0 2.1 0.2 0.0 2.3 86% 0.4Musculo-skeletal 2.1 0.0 2.4 0.2 0.6 3.1 151% 0.0 1.9 0.1 0.1 2.1 102% (0.0)Neurosciences 1.5 0.0 0.8 0.6 0.2 1.6 106% 0.0 0.6 0.3 0.0 1.0 64% 0.5Renal 0.9 0.0 0.6 0.2 0.0 0.8 85% 0.0 0.5 0.1 0.0 0.6 66% 0.3South Glos Community HS 0.6 0.2 0.0 0.5 0.0 0.7 119% 0.2 0.0 0.3 0.0 0.5 84% 0.1Surgery 2.6 0.0 2.5 1.2 0.0 3.7 142% 0.0 2.2 0.6 0.0 2.8 108% (0.2)Women and Children's Health 2.3 0.0 1.5 0.7 0.1 2.3 102% 0.0 1.2 0.4 0.0 1.6 69% 0.7

Clinical Directorates 18.1 0.2 12.5 4.9 1.1 18.7 103% 0.2 10.5 2.6 0.2 13.5 75% 4.6

Facilities 1.6 0.0 0.7 0.5 0.0 1.2 73% 0.0 0.6 0.2 0.0 0.8 50% 0.8Chief Executive 0.1 0.0 0.1 0.0 0.0 0.1 116% 0.0 0.0 0.0 0.0 0.0 81% 0.0Clinical Governance 0.2 0.0 0.1 0.0 0.0 0.1 95% 0.0 0.1 0.0 0.0 0.1 85% 0.0Finance 0.4 0.3 0.1 0.0 0.0 0.3 78% 0.3 0.0 0.0 0.0 0.3 77% 0.1Human Resources 0.4 0.2 0.1 0.2 0.0 0.5 126% 0.2 0.1 0.1 0.0 0.4 96% 0.0IM&T 0.7 0.0 0.5 0.2 0.0 0.7 102% 0.0 0.4 0.1 0.0 0.5 66% 0.2Operations 0.1 0.0 0.1 0.0 0.0 0.1 91% 0.0 0.1 0.0 0.0 0.1 73% 0.0

Non-clinical Directorates 3.5 0.5 1.7 0.9 0.0 3.0 87% 0.5 1.3 0.4 0.0 2.2 64% 1.2

Central Projects 2.7 0.0 1.4 0.0 0.0 1.4 50% 0.0 1.2 0.0 0.0 1.2 43% 1.5

Total 24.3 0.7 15.6 5.7 1.1 23.1 95% 0.7 13.0 3.0 0.2 16.9 70% 7.4

In-p

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Total

Gross Savings Recurrent & Non Recurrent

Probability Adjusted Savings Recurrent & Non Recurrent Im

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d

Mo

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In-p

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Total

Imp

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Appendix 5Capital Expenditure Plan 2012/13 to 2015/16

Lead Director

Forecast outturn 2013/14 2014/15 2015/16

Total 2012/13 to

2015/162012/13

£m £m £m £m £m1. Expenditure

Pathology M Coupe 0.5 7.9 14.9 0.0 23.3Learning and Research M Coupe 1.7 7.3 0.5 0.0 9.5PFI enabling schemes M Coupe 0.5 8.7 8.1 0.8 18.2IM&T B Boa 4.9 7.5 1.7 6.1 20.2Medical equipment C Burton 2.5 8.9 2.0 2.0 15.4Routine expenditure CPMG 2.4 1.3 1.2 1.4 6.2Other CPMG 1.0 2.4 7.1 2.2 12.6Contingency M Coupe 0.0 4.7 2.4 0.2 7.2Slippage 0.0 (4.9) 1.1 2.5 (1.3)

Total expenditure 13.6 43.7 38.9 15.1 111.3

2. Funding

Depreciation B Boa 20.2 22.0 13.6 13.1 68.9PDC B Boa 0.0 1.7 0.0 0.0 1.7Land sales - Frenchay M Coupe 0.0 0.0 6.5 10.8 17.3Land sales - other M Coupe 0.0 0.0 1.2 1.5 2.7External contributions:HPA - Pathology M Coupe 0.0 2.9 2.0 0.0 4.9UoB - Learning & Research M Coupe 0.0 1.8 0.1 0.0 1.9Macmillan - Breast Care Centre M Coupe 0.0 1.0 0.0 0.0 1.0Fundraising B Boa 0.3 0.8 0.3 0.3 1.7Leasing B Boa 0.0 3.0 0.5 0.0 3.5

Total funding 20.5 33.2 24.2 25.7 103.6

Loan Repayment B Boa (0.5) (0.5) (0.5) (0.5) (2.1)

Net capex surplus / (deficit) 6.4 (11.1) (15.3) 10.1 (9.9)

Note: Whilst the capital expenditure exceeds the funding available in 2013/14 and 2014/15, the projected cash balance at March 2013 is £40m.

Appendix 6

Forecast outturn March

2013

Movement 2013/14

Plan March 2014

£m £m £m

TOTAL NON-CURRENT ASSETS 188.5 272.0 460.5

Current AssetsInventories 6.5 0.0 6.5 Trade and other Receivables 23.3 0.0 23.3 Cash in hand and at bank 40.0 4.3 44.3 Current assets 69.8 4.2 74.0 Total Assets 258.2 276.4 534.6

Current LiabilitiesNHS trade payables (5.8) 0.0 (5.8)Non-NHS Trade Payables (51.4) (10.1) (61.5)Other Liabilities 0.0 (5.7) (5.7)DH Loans (1.4) 0.0 (1.4)PFI Liability 0.0 (5.8) (5.8)Provisions for liabilities and Charges (0.9) 0.0 (0.9)Total current liabilities (59.5) (21.6) (81.1)Net Current Assets/(Liabilities) 10.3 (17.4) (7.1)Non-current assets less net current liabilities 198.7 254.7 453.4

Long Term Creditors (2.1) 0.0 (2.1)DH loans (22.4) 1.5 (20.9)PFI Liability (9.5) (422.6) (432.1)Provisions for Liabilities & Charges (1.5) 0.0 (1.5)

TOTAL NET ASSETS/(LIABILITIES) 163.3 166.4 (3.1)

CAPITAL & RESERVESPublic Dividend Capital 211.7 1.7 213.4 Income and expenditure account brought forward (132.3) 0.0 (132.3)Income and expenditure account - current year 0.0 (174.5) (174.5)Revaluation reserve 83.8 6.4 90.2

TOTAL CAPITAL & RESERVES 163.3 (166.4) (3.1)

Forecast Balance Sheets

Appendix 7

Forecast Plan2012/13 2013/14

£m £m

Total Operating Surplus 31.4 35.0

Decrease in stock 1.0 0.0 Decrease in Debtors 1.4 0.0 Increase in Creditors 1.3 7.0 (Decrease) in Provisions (3.5) 0.0 Net Cash Inflow from Operating Activities 31.6 42.0

Interest received 0.1 0.1 Interest paid on Long Term Loan (1.1) (1.1)Net Cash Outflow from Returns on Investment and Servicing of Finance (1.0) (1.0)

Cash payments for Capital Purchases (12.9) (34.9)Dividends paid (4.6) (2.1)Net Cash Inflow Before Financing 13.1 4.0

PDC Received 0.0 1.7 Loans Repaid (1.4) (1.4)Net Cash (Outflow) / Inflow From Financing (1.4) 0.3

Increase in Cash 11.7 4.3

OPENING CASH BALANCE 28.3 40.0

CLOSING CASH BALANCE 40.0 44.3

Forecast cashflow statement

Appendix 8

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total for Year£m £m £m £m £m £m £m £m £m £m £m £m £m

Opening cash balance 40.0 39.9 40.8 39.5 37.2 39.4 52.6 53.1 54.0 49.5 46.4 43.5 40.0

IncomeNHS SLA income 36.0 36.0 36.0 36.0 36.0 36.0 36.0 36.0 36.0 36.0 36.0 36.0 432.0Other NHS income 0.1 0.1 (0.7) (1.5) 2.1 2.8 3.2 3.6 (1.4) 1.9 2.3 5.3 17.9Transitional Income 12.5 12.5Other income 5.4 5.6 5.6 5.7 5.8 5.7 5.8 5.8 5.5 5.7 5.4 5.9 67.8Interest received 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1HPA capital Contribution 2.9 2.9UoB capital contribution 1.8 1.8Macmillan capital contibution 1.0 1.0Public Dividend Capital 1.7 1.7Total income 41.6 41.8 40.9 40.2 43.9 58.6 45.0 45.4 40.1 43.6 43.8 52.9 537.7

ExpenditurePayroll (16.2) (16.6) (16.4) (16.1) (16.3) (16.0) (16.6) (16.7) (15.9) (16.9) (16.9) (16.9) (197.6)Tax/NI/Superann (10.7) (11.4) (11.7) (11.6) (11.4) (11.5) (11.3) (11.7) (11.7) (11.2) (11.9) (11.9) (138.0)Non-pay (13.3) (12.7) (13.1) (13.7) (12.4) (13.7) (13.6) (12.7) (13.5) (14.1) (12.6) (13.1) (158.4)Capital (1.5) (0.2) (1.0) (1.2) (1.7) (1.9) (3.0) (3.4) (3.5) (4.4) (5.3) (8.0) (34.9)Dividends (1.0) (1.0) (2.1)Loan Repayment (0.7) (0.7) (1.4)Loan Interest Repayment (0.5) (0.5) (1.1)Total Expenditure (41.6) (41.0) (42.2) (42.5) (41.7) (45.4) (44.5) (44.5) (44.7) (46.7) (46.6) (52.2) (533.5)

Closing cash balance 39.9 40.8 39.5 37.2 39.4 52.6 53.1 54.0 49.5 46.4 43.5 44.3 44.3

Monthly cash flow forecast 2013/14

Appendix 9Forecast financial risk ratings

Forecast Score

Plan Score

Mar-13 Mar-14Financial Metrics - Indicators used to derive financial risk rating

EBITDA margin 3 3

EBITDA % achieved 4 5

Net return after financing 4 3

I&E Surplus margin (net of dividend) 2 3

Liquid Ratio 4 3

Weighted Average 3.4 3.2 Overall FRR 3 3

Risk Rating Thresholds Weighting 5 4 3 2 1

EBITDA margin 25 11 9 5 1 <1EBITDA % achieved 10 100 85 70 50 <50

Net return after financing 20 3 2 -0.5 -5 <-5

I&E Surplus margin (net of dividend)

20 3 2 1 -2 <-2

Liquid Ratio 25 60 25 15 10 <10

Calculation Methods

EBITDA margin

EBITDA % achieved

Net return after financing

I&E Surplus margin Net surplus excluding impairments as a percentage of total income

Liquid Ratio

Restriction Where any one factor has a score of 1, the overall score cannot exceed 2Where any two factors have a score of 2, the overall score cannot exceed 2

Earnings before Interest, Tax, Dividends and Amortisation as apercentage of Total Income

EBITDA achieved as a percentage of planned EBITDA

Surplus excluding dividends and financing costs as a percentage ofaverage net assets excluding financing transactions

Net current assets less stock plus a working capital facility of 30 daysexpressed as the number of days of costs covered by this sum

1

Report to: Trust Board Agenda item: 8.2.1 Date of Meeting: 19th March 2013

Report Title: Activity and Performance Report

For information discussion assurance approval Status:

Prepared by: Alison Moroz and Daniel Bates Board Sponsor: Sasha Karakusevic Appendices:

Executive Summary: The Trust continues to achieve the admitted and non-admitted standard at Trust level. Validation of incomplete pathways is nearing completion and will enable the Trust to report a full dataset for March. Due to non-elective pressures cancelled operations remained above target during February. It has not been possible to rebook all patients within 28 days. A review of the booking process is underway. The Trust failed to achieve 2 cancer standards in February. This was principally related to pressure on activity and late referrals. The position for January has been revised due to receipt of late referrals. In February the Trust achieved 91.2% on the 4 hour admission standard. Although this is still below the 95% standard it represents an improvement. The position in March has deteriorated. Action Required: Note the report and ensure that actions, particularly regarding incomplete pathways, are undertaken by directorates.

Key Risks: The standards are underpinned by the NHS Constitution.

Failure to achieve them has an impact on patient care, reputation, staff, contract income and the Foundation Trust application process

Impact on Patients: The standards are designed to identify and support the delivery of high quality care for patients. The core standards are a right defined in the NHS Constitution. Therefore, non-delivery represents a failure to provide the required standard of care.

Impact on Staff High workload in areas affects staff in several areas. Link to Trust Objectives: 1 and 2 Care Quality Commission outcomes:

Performance indicators

NHS Constitution: Access to services. Financial Issues: Risk on income received. Legal/regulatory Issues: Yes Equality Issues considered N/A

2

The performance associated with the dashboard is as follows: 1. RTT 18 week a. Admitted and non-admitted pathways within 18 weeks. For non-admitted patients

the standard was achieved for all specialties. – validations for February are close to completion. Both targets have been met

Non- admitted pathways

Nspec National Spec exp < 18 weeks >= 18 weeks Grand Total

% < 18 Weeks

100 General surgery 869 22 891 97.5% 101 Urology 333 7 340 97.9% 110 Trauma and orthopaedics 936 100 1036 90.3% 120 ENT 400 10 410 97.6% 130 Ophthalmology 2 2 100.0% 140 Oral & Maxillo Facial Surgery 172 3 175 98.3% 143 Orthodontics 52 52 100.0% 150 Neurosurgery 165 3 168 98.2% 160 Plastic surgery 755 33 788 95.8% 171 Paediatric surgery 21 21 100.0% 190 Pain management 181 6 187 96.8% 300 General medicine 493 3 496 99.4% 301 Gastroenterology 37 1 38 97.4% 303 Haematology (clinical) 55 55 100.0% 313 Clinical immunology & allergy 48 1 49 98.0% 320 Cardiology 322 13 335 96.1% 330 Dermatology 342 3 345 99.1% 340 Respiratory 157 2 159 98.7% 361 Nephrology 144 3 147 98.0% 370 Medical Oncology 47 47 100.0% 400 Neurology 460 14 474 97.0% 401 Clinical Neuro-Physiology 76 1 77 98.7% 410 Rheumatology 100 2 102 98.0% 420 Paediatrics 61 61 100.0% 421 Paediatric neurology 20 20 100.0% 430 Geriatric medicine 18 18 100.0% 502 Gynaecology 780 780 100.0% 710 Mental illness 76 8 84 90.5% 711 Child & Adolescent psych 1 1 100.0% 800 Clinical Oncology 15 15 100.0%

822 Chemical pathology 1 1 100.0%

Total 7139 235 7374 96.8% A number of specialties failed to achieve the standard for admitted patients. Trauma and Orthopaedics are working to achieve the standard by the end of Q1 2013/14. Nuerosurgery is working to achieve the standard in April. Oral and Maxillofacial surgery were affected by high levels of cancellations in January and February.

3

Admitted pathways

Aspec National Spec exp 18 weeks 18 weeks+ Grand Total

% < 18 Weeks

100 General surgery 414 46 460 90.0% 101 Urology 226 3 229 98.7% 110 Trauma and orthopaedics 410 106 516 79.5% 120 ENT 77 2 79 97.5% 140 Oral & Maxillo Facial Surgery 73 13 86 84.9% 150 Neurosurgery 93 13 106 87.7% 160 Plastic surgery 412 39 451 91.4% 190 Pain management 5 5 100.0% 300 General medicine 80 80 100.0% 301 Gastroenterology 18 18 100.0% 313 Clinical immunology & allergy 8 1 9 88.9% 320 Cardiology 43 43 100.0% 340 Respiratory Medicine 9 9 100.0% 361 Nephrology 69 69 100.0% 400 Neurology 14 1 15 93.3% 421 Paediatric neurology 18 18 100.0% 430 Geriatric medicine 30 1 31 96.8% 502 Gynaecology 271 12 283 95.8% 710 Mental illness 12 1 13 92.3% Total 2273 247 2520 90.6% b. Incomplete pathways – performance continues to improve and February’s

performance is 80%. Specialities are being monitored on a daily basis and performance has continued to improve during March. It is expected that March performance will be close to 90%.

c. The service transfers of Head and Neck, Breast and Urology take place on March 25th.

2. Cancer

Since the January report the position has deteriorated for the month of January. This is due to a number of late referrals and a resulting increase in shared breaches. A review of these processes is being undertaken to identify delays and potential improvements to current systems, although it is acknowledged that due to the complexity of individual cases not all breaches are avoidable. For February performance, the validations are not yet complete and therefore the draft position is shown on the balanced scorecard.

3. Cancelled operations

There are 56 same-day cancellations which means that the 0.8% target has not been met. 26 of these cancellations were within orthopaedics and are primarily driven by issues regarding bed availability.

4

16 of the total number of same day cancellations have not been re-booked within 28 days. This performance is an improvement from the January position but further improvements in performance are dependent on implementation of the 4 hour recovery plan.

4. Emergencies

In February performance delivery against the four hour indicator at Trust level was 94.0%, below the national standard of 95%. This gives a year to date position of 93.4%. The percentage for Frenchay was 91.2% giving a year to date of 90.4%. The resultant pressure has led to 330 over 15 minute ambulance handover delays for the month. This picture continues to reflect the delays in initiating flow across our assessment units, the number of delays we have in the system resulting in a variation in discharge, an increased reliance on escalation capacity and transfer of patients across site and directorate. The recovery plan is being implemented. In particular the ‘Green to Go’ system is leading to improved identification and resolution of delays to complex discharge. Twice weekly conference calls are now in place with Trust, local authority and health partners to review and action plan all patients on the list. The CARE project is being implemented and the number of patients in hospital over 14 days has reduced. It is proving difficult to accelerate the implementation of 7 day working in the assessment unit. This is principally due to a lack of available staff. Performance during March has been poor. High volumes of attendances and high admission rates have occurred. This has occurred at a time of significant staffing shortages. It has not been possible to keep all of the planned escalation beds open resulting in increased pressure in the system.

5

Apr-12 M ay-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 M ar-13 YTD 11/12 Q1 Q2 Q3 Q4

Admitted 18 weeks 90% 90.0% 90.1% 90.5% 90.2% 91.0% 90.3% 91.8% 91.8% 91.8% 90.1% 90.6% 90.7% 91.3% 90.2% 90.5% 91.7%

Non Admitted 18 weeks 95% 97.8% 97.4% 97.1% 97.6% 97.4% 96.5% 97.6% 97.8% 97.8% 97.7% 96.7% 97.4% 97.7% 97.5% 97.2% 97.7%

Incomplete 18 weeks 92% 73% 67% 61% 60% 59% 57% 63% 68% 72% 75% 80% 66% 88% 66% 59% 67%

TWW GP Referrals > 93% 96.4% 95.4% 94.6% 95.2% 96.0% 96.2% 95.9% 95.9% 95.5% 95.8% 95.9% 95.7% 93.9% 95.6% 95.1% 95.9%

TWW Breast Symptoms > 93% 100.0% 100.0% 97.3% 100.0% 92.5% 95.2% 100.0% 97.8% 94.7% 88.2% 100.0% 97.1% 97.8% 99.2% 99.2% 99.4%

62 Day First Treatment from GP Referral

> 85% 88.0% 86.2% 89.3% 83.5% 86.9% 78.1% 79.9% 85.7% 84.9% 82.3% 79.8% 84.2% 88.1% 88.1% 83.9% 83.8%

62 Day First Treatment from Consultant Screening

> 90% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 62.5% 87.5% 83.3% 85.7% 33.3% 89.1% 95.9% 100.0% 90.9% 80.6%

62 Day First Treatment from Consultant Upgrade

> 90% 100.0% 100.0% 66.7% 100.0% 75.0% 60.0% 50.0% 100.0% 100.0% 91.7% 100.0% 84.4% 95.2% 80.0% 78.6% 81.8%

31 Day First Treatment from Diagnosis

> 96% 98.9% 96.7% 96.0% 96.2% 92.9% 91.5% 91.4% 95.6% 96.0% 95.7% 96.7% 95.1% 97.7% 97.7% 93.2% 93.8%

31 Day Secondary AntiCancer Drug Treatment

> 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day Secondary Surgery Treatment

> 94% 97.4% 100.0% 98.6% 95.3% 86.4% 95.2% 98.2% 98.6% 90.8% 93.4% 94.6% 95.3% 97.8% 98.7% 92.1% 97.2%

31 Day Secondary Radiotherapy Treatment

> 94% 100.0% 100.0% No cases No cases No cases 100.0% 100.0% No cases No cases 100.0% No cases 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day Secondary Palliative Care

> 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% No cases 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

31 Day Secondary Active M onitoring

> 94% 100.0% 100.0% 100.0% 100.0% 100.0% No cases 100.0% 100.0% 100.0% No cases No cases 100.0% 100.0% 100.0% 100.0% 100.0%

Cancelled Ops for non-clinical reasons < 0.8% 0.7% 0.4% 0.8% 0.4% 0.5% 0.8% 1.0% 0.6% 0.7% 2.2% 1.2% 0.8% 0.6% 0.6% 0.6% 0.8%

Cancelled Ops rebooking within 28 days > 95% 86.2% 84.2% 71.9% 81.8% 76.9% 72.2% 71.7% 83.9% 77.4% 72.7% 71.4% 75.5% 89.3% 80.0% 76.2% 76.5%

QUARTERLY PERFORMANCEYEARLY PERF

TARGET

NATIONAL MEA

SURE

RTT

18

Weeks

Cancer

LOCAL

MONTHLY PERFORMANCE

Cancelled

Ops

NATIONAL

6


A&E 4 hour wait (SM D , F R E & YA T E)

> 95% 93.4% 92.2% 92.5% 94.7% 96.5% 94.9% 92.1% 96.2% 91.5% 89.6% 94.0% 93.4% 94.4% 91.6% 95.0% 92.7%

A&E 4 hour wait SM D > 95% 99.9% 99.5% 99.9% 100.0% 100.0% 99.9% 99.9% 100.0% 100.0% 99.9% 100.0% 99.9% 100.0% 99.8% 100.0% 100.0%

A&E 4 hour wait F R E > 95% 90.5% 88.3% 88.6% 92.0% 94.7% 92.4% 88.4% 94.5% 88.2% 85.1% 91.2% 90.4% 92.0% 87.9% 92.8% 89.8%

A&E Unplanned reattendance rate T OT A L

< 5% 4.8% 4.7% 4.9% 4.6% 4.1% 4.7% 3.9% 4.0% 4.6% 4.1% 4.0% 4.4% 4.2% 4.8% 4.5% 4.2%

A&E Unplanned reattendance rate SM D

< 5% 5.3% 5.4% 4.4% 4.8% 3.3% 4.5% 4.2% 3.2% 4.1% 3.2% 4.1% 4.3% 4.5% 5.0% 4.2% 3.8%

A&E Unplanned reattendance rate F R E

< 5% 4.8% 4.7% 5.3% 4.7% 4.6% 5.0% 4.2% 4.5% 4.9% 4.8% 4.0% 4.7% 4.1% 4.9% 4.8% 4.5%

A&E Left dept without being seen T OT A L

< 5% 2.8% 3.4% 3.1% 2.5% 1.9% 3.0% 2.2% 1.5% 2.2% 1.8% 1.7% 2.4% 2.8% 3.1% 2.5% 2.0%

A&E Left dept without being seen SM D

< 5% 1.2% 2.2% 1.8% 1.3% 0.6% 2.2% 0.9% 1.0% 0.6% 0.7% 0.6% 1.2% 1.4% 1.8% 1.4% 0.8%

A&E Left dept without being seen F R E

< 5% 3.6% 4.3% 4.0% 3.3% 2.5% 3.7% 2.9% 1.9% 2.8% 2.4% 2.2% 3.1% 3.3% 4.0% 3.2% 2.5%

A&E Initial assessment 95th percentile (15 mins) T OT A L

< 15 89 108 87 80 69 73 73 63 68 94 62 82 96 97 74 67

A&E Initial assessment 95th percentile (15 mins) SM D

< 15 80 98 9 47 28 84 55 27 0 109 37 109 101 100 84 55

A&E Initial assessment 95th percentile (15 mins) F R E

< 15 89 107 87 80 69 73 72 63 68 93 62 81 96 96 73 67

A&E Time to treatment median (60 mins) T OT A L

< 60 55 64 58 59 43 55 46 39 40 42 41 49 63 59 52 42

A&E Time to treatment median (60 mins) SM D

< 60 43 60 55 58 43 59 50 42 37 48 37 49 35 53 53 43

A&E Time to treatment median (60 mins) F R E

< 60 70 79 72 71 51 62 52 44 46 47 48 57 77 74 61 47

A&E Ambulance Handover times > 15 mins

0 399 636 581 539 435 421 417 305 607 749 330 5419 4064 1616 1395 1329

Overall Elective LOS < 3.90 3.55 3.31 4.00 3.51 3.80 3.32 3.70 3.66 4.47 2.91 3.84 3.64 3.75 3.28 3.57 3.90

Elective Pre-op LOS < 0.3 0.09 0.11 0.09 0.16 0.07 0.09 0.07 0.10 0.18 0.05 0.07 0.10 0.23 0.09 0.10 0.11

Overall Emergency LOS < 5.26 5.94 5.61 5.61 5.64 5.25 5.53 5.51 5.82 5.31 5.75 5.72 5.61 5.43 5.79 5.45 5.55

Acute Emergency LOS < 4.6 5.03 4.86 4.81 4.88 4.41 4.76 4.69 5.01 4.70 5.02 5.00 4.77 4.80 4.90 4.70 4.75Length of Stay

NATIONAL MEASURE

TARGET

LOCA

L MEASURE

Emergency

7


6 Week Diagnostic Waits > 99% 99.9% 99.7% 99.4% 99.7% 99.8% 99.7% 99.7% 99.5% 99.2% 98.8% 99.0% 99.0% 99.9% 99.7% 99.7% 99.5%

Revascularisation - 11 weeks 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

C&B Sufficient appointment slo ts

> 96% 98% 98% 98% 98% 98% 99% 98% 98% 98% 99% 98% 98% 97% 98% 98% 98%

18 Week Direct Access Audio logy

> 95% 100% 100% 100% 100% 100% 97% 99% 99% 100% 100% 100% 100% 100% 100% 99% 99%

High Risk TIA > 60% 61% 61% 60% 81% 77% 97% 81% 86% 71% 72% 81% 75% 73% 61% 85% 80%

Stroke M anagement 90% on Stroke Unit

> 80% 74% 75% 70% 85% 79% 91% 82% 91% 94% 90% 94% 84% 83% 73% 85% 89%

Delayed Transfers < 2% 2.32% 3.07% 2.82% 1.92% 1.99% 1.47% 2.58% 2.91% 2.29% 2.74% 2.24% 2.40% 2.71% 2.72% 1.79% 2.58%

Daycase Rates > 72.7% 75.0% 75.4% 75.3% 74.4% 75.6% 74.9% 76.1% 75.3% 75.0% 77.7% 74.8% 75.4% 74.0% 75.4% 75.1% 75.8%

QUARTERLY PERFORMANCE

NATIONAL MEA

SURE

LOCAL

Other

TARGET

MONTHLY PERFORMANCE YEARLY PERF

Trust Board Infection Report February 2013

0

2

4

6

8

10

12

14

16A

pr-

10

May

-10

Jun

-10

Jul-

10

Au

g-10

Sep

-10

Oct

-10

No

v-10

De

c-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-11

Sep

-11

Oct

-11

No

v-11

De

c-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-12

May

-12

Jun

-12

Jul-

12

Au

g-12

Sep

-12

Oct

-12

No

v-12

De

c-12

Jan

-13

Feb

-13

Mar

-13

case

s C.Difficile Cases: Trust Attributable

Trust Attributable CDiff SHA Performance Target

Apr 10 to Feb 2013

0

1

2

3

4

5

Ap

r-10

May

-10

Jun

-10

Jul-

10

Au

g-10

Sep

-10

Oct

-10

No

v-10

De

c-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-11

Sep

-11

Oct

-11

No

v-11

De

c-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-12

May

-12

Jun

-12

Jul-

12

Au

g-12

Sep

-12

Oct

-12

No

v-12

De

c-12

Jan

-13

Feb

-13

Mar

-13

case

s

MRSA Cases: Trust Attributable

Trust Attributable MRSA Gateway Limit

Apr 10 to Feb 2013

0

2

4

6

8

10

12

14

Ap

r-10

May

-10

Jun

-10

Jul-

10

Au

g-10

Sep

-10

Oct

-10

No

v-10

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-11

Sep

-11

Oct

-11

No

v-11

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-12

May

-12

Jun

-12

Jul-

12

Au

g-12

Sep

-12

Oct

-12

No

v-12

Dec

-12

Jan

-13

Feb

-13

Mar

-13

case

s

MSSA Cases: Trust Attributable

Trust Attributable MSSA SHA Performance Target

* validated from Jan 2011 Apr 10 to Feb 2013

0

5

10

15

20

25

30

Ap

r-10

May

-10

Jun

-10

Jul-

10

Au

g-10

Sep

-10

Oct

-10

No

v-10

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-11

Sep

-11

Oct

-11

No

v-11

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-12

May

-12

Jun

-12

Jul-

12

Au

g-12

Sep

-12

Oct

-12

No

v-12

Dec

-12

Jan

-13

Feb

-13

Mar

-13

case

s

ECOLI Cases: Trust Attributable

Trust Attributable E.Coli SHA Performance Target

* validated from Jun 2011 Apr 10 to Feb 2013

50%

60%

70%

80%

90%

100%A

pr-

10

May

-10

Jun

-10

Jul-

10

Au

g-10

Sep

-10

Oct

-10

No

v-10

Dec

-10

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-11

Sep

-11

Oct

-11

No

v-11

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-12

May

-12

Jun

-12

Jul-

12

Au

g-12

Sep

-12

Oct

-12

No

v-12

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Hand Hygiene Overall NBT Compliance

Compliance (Combined) Target

50%

60%

70%

80%

90%

100%

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

MRSA Pre-Elective Screening for BNSSG patients

Elective IP/DC Target

50%

60%

70%

80%

90%

100%

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

MRSA Non-elective Screening

Non-Elective in 24 hr Target Non-Elective

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under

a 'closed section' of any meeting.

1

Agenda Item 8.2.2 Report to Trust Management Team – March 2013

Title: Monthly Infection Control Report

Purpose of paper: To update Trust Board on Infection Control performance

To Note

Executive Summary: Q1 Q2 Q3 Jan Feb Mar

MRSA month R YTD

MSSA month YTD

E-coli month R R YTD R R

C.diff month R YTD R R

Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar

Hand Hygiene month

MRSA screening (elective) month

MRSA screening (emergency) month

Mandatory training month

A

MRSA

There were no cases of MRSA bacteraemia attributable to the Trust in February 2013.

Total five MRSA bacteraemia against target for the financial year of 6. Emergency MRSA screening is above target

MSSA

There were 6 MSSA bacteraemia in February 2013, 1 attributable to NBT. Total 24 cases against target for the financial year of 29 cases.

This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under

a 'closed section' of any meeting.

2

Clostridium difficile C.diff is an area of concern with end of year target breached in January. 5 CDiff cases attributable to the Trust in February. Year to date at the end of February is 67 cases against a target of 61. The Infection Prevention and Control Team analyse each case to determine

appropriate actions with continued focus on review of antibiotics and PPI prescribing.

The 2013/14 target will require a further reduction to a maximum of 42 cases.

. E-Coli

There were 13 cases of E-coli bacteraemia during February 2013 of which 5 were attributable to the Trust. There have been 70 cases reported to date in 2012/13. Rates of EColi infection have remained stable over the past 2 years.

Norovirus

In February there was 1 ward and 3 bays with restricted access due to confirmed Norovirus with 29 cumulative bed days lost.

Outbreaks

Work to improve the water systems on the neonatal intensive care unit is complete and NICU has returned to its refurbished ward space.

Mandatory Training Infection Control mandatory training compliance is 83% which is a reduction

from the previous month. Continued action is required from directorates to maintain training levels. A targeted approach is being taken for medical staff.

Hand Hygiene

Trust wide compliance was 95% (target 95%)

Action Required: Trust Management Team are asked to note the report and the Directorate actions required to maintain and improve infection control performance.

Key Risks:

Non achievement of DH C.diff trajectory of 61 Non achievement of DH MRSA bacteraemia trajectory of 6 Non achievement of MRSA emergency screening target which is set at 90% Infection control mandatory training compliance

Impact on Patients: Patients deserve the highest level of professional standards. CQC Outcome: Outcome 8 (regulation 12) Responsible Committee: Control of Infection Committee Presented by: Chris Burton Medical Director /DIPC Prepared by: Helen Richardson Assistant Director of Nursing

Table 1

Finance Report February 2013 - Summary Income & Expenditure Statement

Variation from

budgetIn-month variance

Plan Budget ActualAdverse /

(Favourable)Adverse /

(Favourable)£'000 £'000 £'000 £'000 £'000

Income

442,493 PCT Income 405,800 404,418 1,382 (382)79,123 Other Operating Income 69,648 68,844 804 352

521,616 Total Income 475,448 473,262 2,186 (30)

Expenditure

333,161 Pay 306,111 308,531 2,420 (195)154,035 Non Pay 136,517 140,062 3,544 216

Variance to planned savings (6,019) 6,019 367Reduce non-recurrent spend and release of provisions & contingency 7,632 (5,778) (13,410) (140)

487,196 444,241 442,815 (1,426) 249

34,420 Earnings before Interest & Depreciation 31,207 30,447 760 2196.43%

21,214 Depreciation & Amortisation on Purchased Assets 19,446 18,745 (701) (234)(50) Interest receivable (46) (81) (35) (4)

1,132 Interest payable on loans 1,038 1,038 0 05,124 PDC Dividend 4,697 4,697 0 0

7,000 Net Surplus / (Deficit) for NHS accountability 6,072 6,048 24 (20)1.28%

580 Below the line impact of IFRIC 12 531 531 0 01,500 Donated Assets 1,377 1,377 0 0

4,920 Net surplus for Monitor accountability 4,164 4,140 24 (20)0.87%

6,702 Impairments 919 919 0 0

(1,782) Retained Surplus / (Deficit) for accounting purposes 3,245 3,221 24 (20)0.68%

North Bristol NHS Trust

Position as at 28th February

Table 2

Overall Variance by Directorate for the Eleven Months Ended 28th February 2013

(Favourable) / Adverse

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 YTD

Core Clinical Services 89 90 700 115 670 157 (392) 17 (331) (358) 12 769

Medicine 175 175 (49) (511) 252 656 960 551 143 485 (207) 2,629

Musculo 17 17 99 1,908 346 946 755 730 346 158 428 5,749

Neuro 127 127 384 653 776 467 (325) 218 60 194 665 3,345

Renal (44) (44) (249) 273 55 176 142 (156) 22 (489) (382) (696)

South Glos Community HS 37 37 (56) 23 26 (43) (183) (26) (13) 7 (36) (228)

Surgery 82 81 54 664 353 639 232 128 270 664 1,114 4,281

Womens & Childrens 52 52 283 506 108 573 (384) 863 733 394 (151) 3,029

Facilities 16 16 6 130 133 (1) (13) 136 41 (44) (295) 124

Corporate Directorates (7) (7) 152 147 109 90 99 88 86 113 194 1,064

Other (554) (554) (948) (3,530) (3,256) (3,972) (833) (2,570) (1,346) (1,118) (1,362) (20,042)

Total (12) (13) 376 378 (428) (312) 58 (21) 11 6 (20) 24

= > 2 % adverse variance

= Adverse to plan by up to 2% adverse variance

= On plan or favourable

£000's

Analysis of activity over months 1 to 11 Table 3

April May June July August Sept. Oct Nov Dec Jan FebCumulative

YTDDaycases Activity 12/13 3,114 3,729 3,101 3,648 3,745 3,445 4,057 3,815 3,260 3,791 3,408 39,113

Activity 11/12 3,061 3,390 3,814 3,529 3,703 3,637 3,677 3,637 2,696 3,013 3,118 37,275% change since prior year 2% 10% (19)% 3% 1% (5)% 10% 5% 21% 26% 9% 5%

Elect IP Activity 12/13 1,034 1,209 1,024 1,253 1,208 1,162 1,271 1,254 1,082 1,089 1,145 12,731Activity 11/12 1,154 1,232 1,316 1,288 1,264 1,275 1,238 1,330 1,581 1,389 1,052 14,119% change since prior year (10)% (2)% (22)% (3)% (4)% (9)% 3% (6)% (32)% (22)% 9% (10)%

Non-Elect IP-S/stay Activity 12/13 2,066 2,185 1,997 2,100 2,218 2,129 2,257 2,110 2,100 2,185 2,006 23,353Activity 11/12 2,136 2,193 2,171 2,192 2,116 2,036 2,052 2,049 2,006 2,258 2,275 23,484% change since prior year (3)% (0)% (8)% (4)% 5% 5% 10% 3% 5% (3)% (12)% (1)%

Non-Elect IP-L/stay Activity 12/13 1,991 2,165 1,975 2,028 2,003 1,961 2,141 1,999 1,978 2,107 1,915 22,263Activity 11/12 1,979 1,999 2,008 1,963 2,029 2,017 1,930 2,012 2,001 1,968 1,975 21,881% change since prior year 1% 8% (2)% 3% (1)% (3)% 11% (1)% (1)% 7% (3)% 2%

OP-New Activity 12/13 8,520 10,527 8,863 10,043 9,626 9,257 10,533 9,900 8,082 9,534 8,619 103,504Activity 11/12 8,100 9,351 9,686 8,712 9,723 9,803 9,856 10,051 7,988 9,926 10,209 103,402% change since prior year 5% 13% (8)% 15% (1)% (6)% 7% (2)% 1% (4)% (16)% 0%

OP-FUp Activity 12/13 20,267 23,806 20,214 22,826 22,083 21,508 24,593 23,589 19,039 23,669 21,099 242,693Activity 11/12 19,865 22,193 23,299 20,637 22,821 22,600 22,462 23,787 19,128 21,230 20,182 238,203% change since prior year 2% 7% (13)% 11% (3)% (5)% 9% (1)% (0)% 11% 5% 2%

OP-Procedures Activity 12/13 1,000 1,355 1,225 1,304 1,187 1,106 1,380 1,337 940 1,398 954 13,186Activity 11/12 1,090 974 1,215 1,123 1,191 1,109 1,083 1,104 774 801 984 11,448% change since prior year (8)% 39% 1% 16% (0)% (0)% 27% 21% 21% 75% (3)% 15%

April May June July August Sept. Oct Nov Dec Jan FebTotal days 2011/12 30 31 30 31 31 30 31 30 31 31 29

2012/13 30 31 30 31 31 30 31 30 31 31 28

Workings days 2011/12 18 20 22 21 22 22 21 22 20 21 21

2012/13 19 22 19 22 22 20 23 22 19 22 20

Activity per day

April May June July August Sept. Oct Nov Dec Jan FebCumulative

averageDaycases (per working day) Activity 12/13 164 170 163 166 170 172 176 173 172 172 170 170

Activity 11/12 170 170 173 168 168 165 175 165 135 143 148 162% change since prior year (4)% 0% (6)% (1)% 1% 4% 1% 5% 27% 20% 15% 5%

Elect IP (per working day) Activity 12/13 54 55 54 57 55 58 55 57 57 50 57 55Activity 11/12 64 62 60 61 57 58 59 60 79 66 50 62% change since prior year (15)% (11)% (10)% (7)% (4)% 0% (6)% (6)% (28)% (25)% 14% (10)%

Non-Elect IP-S/stay (per day) Activity 12/13 69 70 67 68 72 71 73 70 68 70 72 70Activity 11/12 71 71 72 71 68 68 66 68 65 73 78 70% change since prior year (3)% (0)% (8)% (4)% 5% 5% 10% 3% 5% (3)% (9)% (0)%

Non-Elect IP-L/stay (per day) Activity 12/13 66 70 66 65 65 65 69 67 64 68 68 67Activity 11/12 66 64 67 63 65 67 62 67 65 63 68 65% change since prior year 1% 8% (2)% 3% (1)% (3)% 11% (1)% (1)% 7% 0% 2%

OP-New (per working day) Activity 12/13 448 478 466 456 438 463 458 450 425 433 431 450Activity 11/12 450 468 440 415 442 446 469 457 399 473 486 449% change since prior year (0)% 2% 6% 10% (1)% 4% (2)% (2)% 7% (8)% (11)% 0%

OP-FUp (per working day) Activity 12/13 1,067 1,082 1,064 1,038 1,004 1,075 1,069 1,072 1,002 1,076 1,055 1,055Activity 11/12 1,104 1,110 1,059 983 1,037 1,027 1,070 1,081 956 1,011 961 1,036% change since prior year (3)% (2)% 0% 6% (3)% 5% (0)% (1)% 5% 6% 10% 2%

OP-Procedures (per working day) Activity 12/13 53 62 64 59 54 55 60 61 49 64 48 57Activity 11/12 61 49 55 53 54 50 52 50 39 38 47 50% change since prior year (13)% 26% 17% 11% (0)% 10% 16% 21% 28% 67% 2% 15%

Pay Variance Analysis Table 3a

Directorate

Medical

£'000

Qualified Nursing

£'000

Healthcare

Assistants £'000

Other

£'000

Waiting List Payment

£'000

Total

£'000 Directorate

Medical

£'000

Qualified Nursing

£'000

Healthcare

Assistants £'000

Other

£'000

Waiting List Payment

£'000

Total

£'000

Core Clinical Services (530) (367) (123) 136 68 (816) Core Clinical Services (52) (102) (22) 7 7 (162)

Medicine 201 7 1,151 (63) 37 1,333 Medicine 6 30 108 12 5 162

Musculo (3) 192 296 (96) 162 551 Musculo 2 21 36 (8) 15 66

Neurosciences 60 116 901 (42) 96 1,131 Neurosciences 11 9 62 (40) 1 43

Renal (192) (4) (246) (46) 0 (488) Renal (6) (18) (28) (6) 0 (58)

South Glos Adult Community HS (16) 30 (49) (269) 0 (304) South Glos Adult Community HS (3) 4 (8) (52) 0 (59)

Surgery 502 422 286 (94) (89) 1,027 Surgery 34 57 19 16 (47) 79

Women and Childrens 370 (204) (199) 405 82 454 Women and Childrens 97 (71) (13) 49 5 67

Other Directorates (467) (467) Other Directorates 0 0 0 (330) 0 (331)

Total 392 192 2,017 (537) 356 2,420 Total 89 (70) 154 (354) (14) (195)

Month 1 to 11 2012/13 Month 11 2012/13

Adverse / (Favourable) Adverse / (Favourable)

Table 3b

Whole Time Equivalents (WTEs) Analysis

Worked WTE by Directorate Whole Time Equivalents

Worked Worked Worked Worked Worked Worked Funded VarianceSep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 WTE WTE

Core Clinical Services 2,024 2,022 1,964 1,929 1,929 1,890 1,989 (99)Medicine 978 985 1,016 1,013 1,038 1,033 1,001 32Musculoskeletal 440 458 470 444 446 445 447 (2)Neurosciences 512 527 543 518 519 512 494 18Renal Services 287 287 287 282 277 286 299 (13)South Glos Community Health Services 319 323 323 313 315 312 361 (49)Surgical Services 693 688 692 696 695 697 673 24Women and Childrens 1,296 1,317 1,320 1,316 1,328 1,335 1,334 1

Clinical Directorates Sub-Total 6,548 6,607 6,615 6,615 6,547 6,510 6,598 (88)

Chief Executive 25 25 25 26 27 25 24 1Clinical Fovernance 54 55 57 57 60 60 59 1Facilities 736 715 795 797 822 793 815 (22)Finance 132 132 130 129 132 131 134 (3)HR 251 246 242 246 239 239 240 (1)Information Management 208 205 209 209 220 217 214 3Operations 64 62 64 60 64 61 61 (0)Projects 24 21 22 21 23 23 24 (1)Ring Fenced Funding 50 50 42 50 50 50 50 0Central adjustment 70 0

Total 8,092 8,120 8,200 8,200 8,184 8,111 8,219 (108)

Current Month : Feb-13

7,500

7,600

7,700

7,800

7,900

8,000

8,100

8,200

8,300

8,400

8,500

Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

WT

Es

Month

TREND TOTAL WORKED AND FUNDED WTEs

Funded

Worked

NORTH BRISTOL NHS TRUST Table 4aSavings by Directorate as at February 20132012-2013

Total Probability ProbabilityGross Adjusted adjusted

Directorate Savings Target (2012/13) Savings Savings

gap

% of Target % of Target

£000 £000 £000 £000 £000 £000 % £000 £000 £000 £000 £000 % £000

Core Clinical Services 4,986 2,848 - - - 2,848 57% 2,848 - - - 2,848 57% 2,138 Medicine 4,426 1,915 - - - 1,915 43% 1,915 - - - 1,915 43% 2,511 Musculo-skeletal 2,178 761 42 2 - 805 37% 761 41 1 - 803 37% 1,375 Neurosciences 1,648 998 79 7 - 1,084 66% 998 64 3 - 1,066 65% 582 Renal 1,086 1,086 - - - 1,086 100% 1,086 - - - 1,086 100% (0) South Glos Community HS 377 377 - - - 377 100% 377 - - - 377 100% (0) Surgery 2,949 1,234 10 - - 1,244 42% 1,234 9 - - 1,243 42% 1,706 Women and Children's Health 2,961 2,554 - - 26 2,580 87% 2,554 - - 6 2,561 86% 400

Clinical Directorates 20,611 11,775 131 8 26 11,940 58% 11,775 114 4 6 11,899 58% 8,712

Facilities 1,554 1,286 - - - 1,286 83% 1,286 - - - 1,286 83% 268 Chief Executive 42 42 - - - 42 100% 42 - - - 42 100% - Clinical Governance 156 156 - - - 156 100% 156 - - - 156 100% - Finance 388 387 - - - 387 100% 387 - - - 387 100% 1 Human Resources 365 365 - - - 365 100% 365 - - - 365 100% - IM&T 1,002 300 - - - 300 30% 300 - - - 300 30% 702 Operations 182 152 - - - 152 84% 152 - - - 152 84% 30

Non-clinical Directorates 3,689 2,688 - - - 2,688 73% 2,688 - - - 2,688 73% 1,001

Central Projects 4,300 4,140 - - - 4,140 96% 4,140 - - - 4,140 96% 160

Contingency (3,600) - 0% - - - - - 0% (3,600)

Total 25,000 18,603 131 8 26 18,768 75% 18,603 114 4 6 18,727 75% 6,273

In-progress

Further

Total

Gross Savings Recurrent & Non Recurrent

Probability Adjusted Savings Recurrent & Non Recurrent

Implem

ented

Most Likely

In-progress

Further

Total

Implem

ented

Most Likely

Table 4aPhased CRES plan vs actual - Clinical Directorates

0

100

200

300

400

500


£000

's

Month

Core Clinical Services phased CRES plan vs actual

Forecast Actual Gap Plan

0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

Musculo-skeletal phased CRES plan vs actual


0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

Neurosciences phased CRES plan vs actual


0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

Renal phased CRES plan vs actual


0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

South Glos Community HS phased CRES plan vs actual


0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

Surgery phased CRES plan vs actual


0

50

100

150

200

250

300

350

400

450

500


£000

's

Month

Women and Children's Health phased CRES plan vs actual


0

100

200

300

400

500


£000

's

Month

Medicine phased CRES plan vs actual


Table 5

CAPITAL EXPENDITURE MONITORING REPORT 2012/13 - FEBRUARY 2013

March TBFull year CAPITAL EXPENDITURE PLAN Project Plan Actual Variance Forecast

Plan Director to February to February from plan outturn£'000 £'000 £'000 £'000 £'000

Expenditure

567 Cossham Renal Dialysis Unit M Coupe 567 463 104 5098,224 Pathology Ph IIA/Learning & Research M Coupe 6,624 611 6,013 1,363280 Childrens community services N Curtis 280 147 133 280

1,410 Frenchay site preparation M Coupe 800 271 529 325250 Directorate schemes S Karakusevic 200 328 (128) 374500 PPU Contingency M Coupe 300 0 300 0535 Riverside single sex works N Curtis 415 50 365 146

4,275 IM&T B Boa 3,669 4,024 (355) 5,2772,900 Medical equipment (excluding leasing) C Burton 2,175 1,712 463 2,512500 Facilities expenditure S Wood 440 874 (434) 974

1,003 Contingency CPMG 713 210 503 674300 Donated assets 225 274 (49) 359720 Other 713 518 195 757

21,464 TOTAL GROSS CAPITAL EXPENDITURE 17,121 9,482 7,639 13,550

Funding

21,339 Purchased assets depreciation (excl car park) 19,446 18,746 (700) 20,2801,200 PDC 0 0 0 0

0 Land sales 0 0 0 0300 Donations 225 274 49 300

22,839 Total funding 19,671 19,020 (651) 20,580

1,375 Surplus of capital funding 2,550 9,538 6,988 7,030

520 Capital loan repayments 260 260 0 520

855 Cash surplus from capital items 2,290 9,278 6,988 6,510

Table 6

VarianceMar-12 Plan Actual from plan Full year

Closing balance Plan£'000 £'000 £'000 £'000 £'000

Non Current Assets216,191 Property, Plant and Equipment 211,194 205,127 6,067 209,7271,463 Intangible Assets 1,101 962 139 1,200

217,654 Total non-current assets 212,295 206,089 6,206 210,927

Current Assets7,512 Inventories 7,512 7,245 267 7,51210,224 Trade and other receivables NHS 18,701 22,659 (3,958) 9,25011,741 Trade and other receivables Non-NHS 0 12,712 (12,712) 11,01528,300 Cash and Cash equivalents 36,823 32,953 3,870 33,54957,777 Total current assets 63,036 75,569 (12,533) 61,326

0 Non-current assets held for sale 0 0 0 057,777 Total Current assets 63,036 75,569 (12,533) 61,326

275,431 Total assets 275,331 281,658 (6,327) 272,253

Current Liabilities (< 1 Year)3,328 Trade and Other payables - NHS 8,421 5,669 (2,752) 5,82552,578 Trade and Other payables - Non-NHS 44,374 56,293 11,919 49,6291,420 Borrowings 1,420 1,420 0 1,4204,033 Provisions 2,667 256 (2,411) 2,667

0 Other liabilities 0 0 0 061,359 Total current liabilities 56,882 63,638 6,756 59,541(3,582) Net current assets/(liabilities) 6,154 11,931 (5,777) 1,785

214,072 Total assets less current liabilites 218,449 218,020 429 212,712

2,106 Trade and other payables 2,106 2,074 (32) 2,10632,717 Borrowings 32,007 32,630 623 31,2971,831 Provisions 1,831 2,066 235 1,831

177,418 TOTAL NET ASSETS 182,505 181,250 1,255 177,478

CAPITAL & RESERVES211,744 Public Dividend Capital 212,944 211,744 1,200 212,944

(117,507) Income and expenditure reserve (117,507) (117,507) 0 (117,507)0 Income and expenditure account - current year 3,245 3,221 24 (1,782)

83,181 Revaluation reserve 83,823 83,792 31 83,823

177,418 TOTAL CAPITAL & RESERVES 182,505 181,250 1,255 177,478

NORTH BRISTOL NHS TRUSTSTATEMENT OF FINANCIAL POSITION AS AT 28th February 2013

Table 7

Variancefrom plan

£'000 Plan ActualCash inflow

/(outflow)£'000 £'000 £'000

34,420Earnings Before Interest, Depreciation and Amortisation 31,207 30,447 (760)

Less effect of Donated Assets 0 0 0

0 (Increase)/Decrease in Stock 0 267 2671,700 (Increase)/Decrease in Debtors (3,882) (13,406) (9,524)

(1,647) Increase/(Decrease) in Creditors 3,264 6,068 2,804(1,366) Increase/(Decrease) in Provisions (1,366) (3,542) (2,176)

33,107Net Cash Inflow/(Outflow) from Operating Activities 29,223 19,834 (9,389)

50 Interest received 46 81 35(1,135) Interest Paid on Long Term Loan (580) (580) 0

(1,085)Net Cash Inflow/(Outflow) from Returns on Investment and Servicing of Finance (534) (499) 35

(21,429) Cash payments for Capital Purchases (18,094) (11,650) 6,4440 Cash receipts from Asset Sales 0 0 0

(5,124) Dividends paid / payable (2,562) (2,322) 2405,469 Net Cash Inflow Before Financing 8,033 5,363 (2,670)

Financing0 Donated Capital Receipts 0 0 00 Temp PDC Drawn Down 0 0 00 Temp PDC repaid 0 0 0

1,200 Permanent PDC Drawn down 1,200 0 (1,200)(1,420) Loans Repaid (710) (710) 0

(220) Net Cash Inflow From Financing 490 (710) (1,200)

5,249 Increase (decrease) in Cash 8,523 4,653 (3,870)

28,300 Opening cash balance 28,300 28,300 0

33,549 Closing cash balance 36,823 32,953 (3,870)

NORTH BRISTOL NHS TRUSTSTATEMENT OF CASH FLOWS AS AT 28TH FEBRUARY 2013

Full year Plan

Table 7a

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

EDITDA 2,953 2,880 2,866 2,876 3,102 2,833 2,998 3,746 2,835 2,488 3,008 2,293

Less donated asset income (non-cash) (300)

Movement in Stock (Increase)/Decrease

Movement on Debtors (Increase)/Decrease 15,106 (2,023) (2,036) (2,787) (3,896) 1,024 13,185 (563) 1,593 (2,843) (2,226) (683)

Movement on Creditors Increase/(Decrease) (5,422) 584 141 (346) (353) (53) (389) 282 (168) (683) 503 843

Movement in Provisions Increase/(Decrease)

Net Cash Inflow/(Outflow) from Operating Activities 9,886 1,442 971 (257) (1,147) 3,804 15,794 3,465 4,261 (1,038) 1,285 2,453

Interest received 4 8 8 8 8 8 8 8 8 8 8 8

Interest Paid on Long Term Loan (555) (533)

Net Cash Inflow(Outflow) from Returns on Investment and Servicing of Finance (551) 8 8 8 8 8 (525) 8 8 10 8 8

Cash payments for Capital Purchases (1,467) (1,500) (177) (976) (1,177) (1,651) (1,929) (2,995) (3,367) (3,497) (4,417) (5,309)

Cash receipts from Land Sales

Dividends paid (2,562) (1,046)

Net Cash Inflow Before Financing 5,306 (50) 802 (1,225) (2,317) 2,161 12,294 479 902 (4,525) (3,124) (2,849)

FinancingPDC Received 1,675 PDC RepaidDonated Capital receiptsTemp PDC Drawn DownTemp PDC RepaidLoans Repaid (710) (710)Net Cash Inflow From Financing 1,741 965

Increase (decrease) in Cash 7,047 (50) 802 (1,225) (2,317) 2,161 13,259 479 902 (4,525) (3,124) (2,849)

OPENING CASH BALANCE 32,953 40,000 39,950 40,752 39,527 37,210 39,371 52,630 53,109 54,011 49,486 46,362

CLOSING CASH BALANCE 40,000 39,950 40,752 39,527 37,210 39,371 52,630 53,109 54,011 49,486 46,362 43,513

NORTH BRISTOL NHS TRUSTCASHFLOW FORECAST FOR 12 MONTHS FROM 28TH FEBRUARY 2013

Table 8Debtors Graphs

-2

01435

26

-6

777 0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

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

£0

00

's

Month

ANALYSIS OF RECEIVABLES

InvoicesRaised

TotalReceivables

0

1,000

2,000

3,000

4,000

5,000

6,000

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-12 Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

£0

00

's

Month

NORTH BRISTOL NHS TRUST - AGEING ANALYSIS OF NON-NHS RECEIVABLES

Over 12 Months

6 to 12 months

3 - 6 Months

1 - 3 months

Less than 1 month

0

2,000

4,000

6,000

8,000

10,000

12,000

Feb-12

Mar-12

Apr-12 May-12

Jun-12 Jul-12 Aug-12

Sep-12

Oct-12 Nov-12

Dec-12

Jan-13 Feb-13

£0

00

's

Month

NORTH BRISTOL NHS TRUST - AGEING ANALYSIS OF NHS RECEIVABLES

Over 12 Months

6 to 12 months

3 - 6 Months

1 - 3 months

Less than 1 month

0

500

1,000

1,500

2,000

2,500

3,000

3,500

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

£0

00

's

Month

NORTH BRISTOL NHS TRUST - INVOICES OVER 3 MONTHS OLD

Over 3months

TABLE 9

Criteria Indicator Weight 5 4 3 2 1Year to

DateForecast Outturn

Underlying performance EBITDA margin % 25% 11 9 5 1 <1 3 3

Achievement of plan EBITDA achieved % 10% 100 85 70 50 <50 4 4

Net return after financing % 20% >3 2 -0.5 -5 <-5 4 4

I&E surplus margin % 20% 3 2 1 -2 <-2 2 2

Liquidity Liquid ratio days 25% 60 25 15 10 <10 4 4

100% 3.4 3.4

##

3 3 #

Weighted Average

Overriding rules

Overall rating

FINANCIAL RISK RATING North Bristol NHS Trust

Score (1-5) Achieved for each Criteria Per Month

Risk RatingsReported Position

Financial efficiency



Report to: Trust Board Agenda item: 8.2.3Date of Meeting: 28 March 2013

Report Title: Finance Report to the Trust Board for the eleven months

ended 28th February 2013 For information discussion assurance approval Status:

X Prepared by: Mark Ross, Financial Controller Board Sponsor: Bill Boa, Interim Director of Finance Appendices: Yes Executive Summary:

Draft accounts have been prepared for the 11 months to February. The position is broadly breakeven. Because of the more positive position in February,

largely on PCT income and pay we have not needed to use as much of our reserves as in previous months.

PCT income is favourable against plan in the month by £0.4m The pay position is £0.2m favourable in-month. Non pay is £0.2m adverse in the month and £3.5m year to date. Performance against the savings target continues to deteriorate. Action needs to continue to be taken to improve the underlying position – achieving

planned levels of income, controlling costs within budget and making required savings. Key operational improvement actions include:

Weekly meeting to plan theatre activity; Weekly orthopaedic meeting; Review of bed allocation to minimise risk of cancellation; Implementation of 4 hour recovery plan; Finalisation of Cerner recovery; Development of whole hospital performance measures.

These actions need to be clearly linked to activity and financial improvements via the

PMO scrutiny process. Action Required: The Trust Board is asked to note the report.

Key Risks: See above Impact on Patients: Failure of the Trust to achieve its target surplus will have

a negative impact on the Trust. Trust Objectives: Care Quality Commission outcomes:

None

NHS Constitution: Financial Issues: Yes Equality Issues: No Other Legal/regulatory Issues:

Yes



NORTH BRISTOL NHS TRUST

FINANCE REPORT TO TRUST BOARD

APRIL 2012 to FEBRUARY 2013

1. Summary Financial Performance

KPIs

Retained Surplus Before Impairment (£m) Amber

Capital Expenditure (£m) Green

Debt repayment (£m) Green

Better payment performance Amber

Financial risk rating Green

Year to date

Notes on scoring: Retained surplus. This is the bottom line on the Trust’s income and expenditure account excluding

impairment. Green is ahead of the £7m plan, amber is adrift in the year to date position but forecasting an outturn on plan, red is adrift in the year to date with a high risk of not achieving the year end plan.

Capital expenditure. This is capital expenditure compared with plan. Green is on plan or underspent,

amber is overspent in the year to date but forecasting an outturn on plan or underspent. Red is adrift in the year to date with a high risk of overspending the year end plan.

Debt repayment. Whether the trust is on track with making its debt repayments. Either green, red or

amber according to the level of risk. Payment performance. The total number of invoices paid within 30 days expressed as a % of the total.

Green is 95% or above, amber 80% to 95%, and red is below 80% Overall risk rating under the FT rating system. Green is a risk rating of 3 or above for the year to date and

plan. Amber is less than 3 year to date but a planned 3 or above. Red is a 2 or 1 risk rating year to date and plan. The calculation of risk rating scores is set in table 9.



2. Overall position

(1)

0

1

2

3

4

5

6

7

8

9

10

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

£m

Month

Retained Surplus (Before Impairment) Actual vs Budget

Plan Actual

£'000 % £000's %

Income (30) (0.1%) 2,186 0.5%

Pay (195) (0.7%) 2,420 0.8%

Non-pay 216 1.8% 3,544 2.6%

Variance to planned savings 367 n/a 6,019 n/a

Reduce non-recurrent spend and release of contingency (140) n/a (13,410) n/a

Depreciation & financing (238) (10.4%) (736) (2.9%)

Retained surplus (20) (1.9%) 24 0.4%

In month variance before impairment

Year to date variance before impairment

(Fav)/ adv(Fav)/ adv



2.1 Income The month 10 year to date PCT income position is calculated at £3.6m below our internal plan (excluding the QIPP target). After allowing for the QIPP target, the contractual adjustments and the estimated variance for month 11, a year to date position of £1.4m adverse is reported. The £1.4m compares with £1.8m at January. The improved position is due to backdated activity recording including NICU (£0.2m) and the re-allocation of activity between PCTs. This re-allocation has had a favourable impact on the variance as activity has moved from fixed to variable contracts.

BNSSG SWSCGOther

Commissioners

Adjustment for

NBT planTotal

£m £m £m £m £m

(Adv) / Fav (Adv) / Fav (Adv) / Fav (Adv) / Fav (Adv) / Fav

M10 variance against plan

excluding QIPP targets 0.5 (1.9) 4.4 (6.6) (3.6)

Variance against QIPP targets 3.3 3.3

M11 Estimate 0.0 (0.2) 0.4 (0.7) (0.5)

0.5 (2.1) 4.8 (4.0) (0.8)

Contract adjustment (0.4) (0.2) (0.6)

0.2 (2.1) 4.5 (4.0) (1.4)

The graph below shows the normalised (recurring) variance as well as the actual variance. The reason for the difference between the two is primarily due to the operation of the BNSSG contract. The normalised variance shows the income variance for the actual activity done. The actual variance reflects the BNSSG contract agreement that (with some exceptions) the agreed contract value will be charged irrespective of under or over performance.



(5,000)

(4,000)

(3,000)

(2,000)

(1,000)

0

1,000

2,000


£0

00

's

Month

Income Forecast vs Reported Variance Favourable / (Adverse)

Reported variance

Normalised variance

M10 Normalised forecast variance

M10 Forecast variance

2.2 Pay expenditure Cumulatively, the pay overspend is now £2.4m with a favourable movement in the month of £0.2m which is a significant improvement on recent months. This month has shown a reduction in expenditure. The two graphs below show actual expenditure and forecast variances.

24.0

25.0

26.0

27.0

28.0

29.0

30.0


£m

Month

Trust Total Pay

Actual 2011/12 Actual 2012/13



(3,500)

(3,000)

(2,500)

(2,000)

(1,500)

(1,000)

(500)

0

500


£0

00

's

Month

Pay Forecast vs Reported Variance Favourable / (Adverse) (No adjustments for normalising pay variances)

Reported variance


A breakdown of variances across staff groups is shown below and a more detailed analysis by Directorate in Table 3a.

Staff groups In-month % of total pay budget forvariance

£000's £000's

the year to date by staff group

Medical staff 89 392 0.5%

Qualified Nursing & Midwifery (70) 192 0.2%

Healthcare Assistants 154 2,017 8.7%

Waiting list initiatives (14) 356 n/a

Other staff (354) (537) (0.5)%

Total staff (195) 2,420 0.8%

Year to date variance (Fav) / Adv



0.00%

5.00%

10.00%

15.00%

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Cumulative Bank and Agency Nursing and Healthcare Assistants Spend as Percentage of Total Nursing Spend

Nursing Agency Spend

Healthcare Assistant Bank Spend

Qualified Nursing and Midwifery Bank spend

2.3 Non-pay expenditure The adverse variance this month is £0.2m and £3.5m year to date. While this is still an adverse variance, the level of non-pay spend in the last 3 months has dropped from the high levels we saw from July to November.

9.0

10.0

11.0

12.0

13.0

14.0

15.0

Apr

-11

Ma

y-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Fe

b-1

2

Ma

r-1

2

Apr

-12

Ma

y-12

Jun-

12

Jul-1

2

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Fe

b-1

3

£m

Month

Trust Total Non-Pay

Actual 2011/12 Actual 2012/13



(4,500)

(4,000)

(3,500)

(3,000)

(2,500)

(2,000)

(1,500)

(1,000)

(500)

0

500


£000

's

Month

Non-Pay Forecast vs Reported Variance Favourable / (Adverse)(No adjustments for normalising non-pay variances)

Reported variance


2.4 Efficiency Savings Savings are £6.0m below the plan to date – a worsening of £0.4m in the month. The graph below shows that while more savings were implemented during the month, we are still well short of the planned level for February. This is the position we have been in for most of the year. Focus is now on delivering the 2013/14 savings target.

0.0

0.5

1.0

1.5

2.0

2.5

3.0


£m

Month

Trust Total phased CRES plan vs actual


The second graph shows the overall probability adjusted forecast savings. The latest forecast is £6.3m below the target of £25m. This graph also shows that our gross savings total continues to be below the target. The forecast of £18.7m includes £2.1m of non-recurrent savings.



0

5

10

15

20

25

30

Apr‐12

May‐12

Jun‐12

Jul‐12 Aug‐12

Sep‐12

Oct‐12

Nov‐12

Dec‐12

Jan‐13

Feb‐13

Mar‐13

£m

Month

Total Trust Total CRES position

D) Further

C) In Progress

B) Most Likely

A) Implemented

Target

Gross Savings

3. Overall income and expenditure forecast As previously reported, there is now little risk that the Trust will not achieve its plan in the current year and focus is on securing the recurrent position in 2013/14. The graph below shows the recurring variance is adverse against plan (largely because of the use of non-recurring reserves and balance sheet provisions).

(11,000)

(10,000)

(9,000)

(8,000)

(7,000)

(6,000)

(5,000)

(4,000)

(3,000)

(2,000)

(1,000)

0

1,000

2,000


£000

's

Month

Trust Total Forecast vs Reported Variance Favourable / (Adverse)

Reported variance


Normalised variance M10 Normalised

forecast variance



4. Capital and balance sheet Spend in the month is £1.5m and the forecast outturn remains in line with what was reported last month largely through slippage on the large schemes.

-

2,500

5,000

7,500

10,000

12,500

15,000

17,500

20,000

22,500

Apr May June July August Sept Oct Nov Dec Jan Feb March

£'00

0

Month

Cumulative capital expenditure against plan

Planned spend Actual Spend

The trust is behind its cash plan for the current year by almost £4m. This has been caused by delays in collection of debtors although significant sums have been received in March. Debtors and creditors remain high compared with plan but as noted above we expect these values (particularly debtors) will drop significantly during March.

I&E movements

stock

Debtors

Creditors

Capital

PDC

Loans

Total variance

(12,000)

(10,000)

(8,000)

(6,000)

(4,000)

(2,000)

-

2,000

4,000

6,000

8,000

1£00

0

Cash flow variance against plan - February 2013

Payment performance has improved to 90% in the month, with a slight improvement in the year to date figures.



80.00

90.00

100.00

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-12

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

Nov

-12

Dec

-12

Jan

-13

Fe

b-1

3

%

Better payment practice code performance Paid within30 days

Target

In month

5. Financial risk ratings Table 9 shows an overall FRR of 3 with the forecast outturn a 3.



FINANCE TABLES INDEX Table 1 Summary Income and Expenditure Statement Table 2 Variance Analysis by Directorate - Year to Date Table 3 Activity Table 3a Pay Variance Analysis Table 3b Whole Time Equivalents (WTEs) Analysis Table 4 Savings by Directorate Table 4a Phased CRES plan vs actual - Clinical Directorates Table 5 Capital Expenditure & Funding Table 6 Balance Sheet Table 7 Current Year Cash Flow Table 7a Rolling Cash Flow Forecast Table 8 Debtors Graphs Table 9 Financial Risk Ratings



Report to: Report to Trust Board – March 2013 Agenda item: 8.2.4Date of Meeting: 28 March 2013

Report Title: Road to 2014 – Programme

Management Office (PMO) Implementation Report

For information

discussion assurance approval Status:

X

Prepared by: Ian Triplow

Executive Sponsor (presenting): Harry Hayer, Director of Organisation, People & Performance

Appendices (list if applicable): PMO Report Executive Summary: This report provides an update on the progress on the implementation of the themes and the performance of Directorates to provide assurance on the progress of the ‘Road to 2014 Transforming Services’ programme. A priority for the PMO this month has been to finalise a single Trust critical path and facilitating closing the CRES gap for Directorates and Themes. The critical path will ensure the alignment of the Operating Plan, FT, MOVE, IT, workforce planning and 13/14 budget setting and contracting. It will enable progress to be monitored on a month by month basis. The CRES close the gap workshop provided the opportunity for Directorates and Themes to further identify CRES schemes (a CRES Impact Assessment and Quality Impact Assessment process and documentation were introduced). Maturity continues to grow across the core PMO functions. Scrutiny continues to evolve. Measurement has now progressed is plan this month and the current emphasis is to identify a process to align, update and configuration control the affordability, workforce and activity spreadsheets with each other and with the bed, theatres and outpatients model. The PMO report highlights the financial pressures in the Directorates to achieve CRES and for Themes to fit within the new hospital affordability envelope.

Action Required: The Trust Board is requested to NOTE the PMO Report. Key Risks: Failure to deliver the ‘Road to 2014 Transforming Services’

Programme carries significant service delivery, financial, quality and workforce risks.

Impact on Patients: All of the themes relate directly to patient care: e.g. new hospital and service transfers.

Impact on Staff: All staff at NBT will be affected by the ‘Road to 2014 Transforming Services’ Programme.

Link to Trust Objectives: All

Care Quality Commission Outcomes:

All

NHS Constitution: Delivery of the programme will assist the Trust to meet its obligations under the NHS Constitution.

Financial Issues: The ‘Road to 2014 Transforming Services’ Programme is the primary driver to meet the Trust’s savings programme and affordability for the new hospital.

Legal/regulatory Issues: As relevant.

Equality Issues considered: Equality Impact Assessments will be conducted for all significant themes affecting patients and staff.



What progress has been made to date in bringing these workstreams into the PMO and Programme at NBT?

In year performance, activity & quality

Phase 2 – Affordability and Critical Path

Operating planComplete, cost and define

the operational plan for the new Hospital

Phase 3a -Transition Planning Development of the transition

plan to implement the operating plan changes required for a successful move to the new

Hospital

Phase 3a - Transition Plan Implementation

Implement the transition plan to implement the changes required for a successful move to the new

Hospital

Phase 3b - MOVE - Plan and implement the ‘move’ into the new hospital

£92m CRES saving over 3 years

Service Transfers

Business PlanningContinuous cycle of business planning to review and refresh the IBP & LTFM to meet the overall

Trust strategy, objectives & clinical strategy

Finance & Performance

Achieving delivery targets

Transformation

Successful move into the new Hospital

Viable FT

Non ‘new hospital’ plans

FT/Merger

Covered by current PMO functions Work in progress to bring these workstreams into the PMO function

Progress in implementation of PMO processes in NBT

2

PMO Team

The team is in place and functioning well. Continued development of the team and processes will continue to ensure that the executive review / and support functions are continually developed.

Integrated Project Support

The existing PMO support team (previously known as DSU) provides resource to themes. A bottom up resourcing model is being progress with full competency sign off to ensure the correct resource to complete work packages required.

Measurement

The measurement group is ensuring a single process for updating the key models which inform PMO scrutiny and ERM’s including an audit trail of changes that is reviewed.

Scrutiny

The scrutiny function continues to develop with each “lens”being reviewed to ensure accuracy of information for the reviews, as well as detailed questions prepared for the executive team. Feedback to the scrutiny team has been improved.

Matrix

The themes shared interdependencies and progress at the “Closing the Gap”workshop to ensure closer links to detail work. Continued inter-theme working is being developed.

Executive Review

The Executive Reviews have continued to mature and are now receiving a more consistent response and reassurance from themes to the work undertaken, planned and the key risks and discussions.

Implementation progress bar

Poor function Good function

Mar 13Feb 13

SELF-CERTIFICATION RETURNS

Organisation Name:


Monitoring Period:

February 2013

NHS Trust Over-sight self certification template

Returns to SHA by the last working day of each

2012/13 In-Year Reporting

Name of Organisation: Period: February 2013

Organisational risk rating

* Please type in R, AR, AG or G and assign a number for the FRR

Governance Declarations

Supporting detail is required where compliance cannot be confirmed.

Governance declaration 1

Signed by: Print Name:

on behalf of the Trust Board Acting in capacity as:

Signed by: Print Name:


Governance declaration 2

Signed by : Print Name :


Signed by : Print Name :


If Declaration 2 has been signed:

Target/Standard:

The Issue :

Action :

Target/Standard:

The Issue :

Action :

Target/Standard:

The Issue :

Action :

Target/Standard:

The Issue :

Action :

Target/Standard:

The Issue :

Action :

Governance Risk Rating (RAG as per SOM guidance) R

NHS Trust Governance Declarations :


Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any

contractual issues and compliance with CQC essential standards:

Key Area for rating / comment by Provider Score / RAG rating*

At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of the

Board Statements.

Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 2

Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.

Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand

written or electronic, you are required to print your name.

The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board Statements.

For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain

briefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail.

11. Plans in place to ensure ongoing compliance with all existing targets.

Normalised financial performance significantly off plan. A&E 4 hour waits above target.

Plans are in place to recover this but at present the Board is insufficiently assured.

For each statement, the Board is asked to confirm the following:

For CLINICAL QUALITY, that: Response

1 Yes

2 Yes

3 Yes

For FINANCE, that: Response

4 Yes

5 Yes

For GOVERNANCE, that: Response

6 Yes

7 Yes

8 Yes

9 Yes

10 Yes

11 No

12 Yes

13 Yes

14 Yes

15 Yes

Signed on behalf of the Trust: Print name Date

CEO Marie-Noelle Orzel

Chair Peter Rilett

The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the

annual plan; and the management structure in place is adequate to deliver the annual plan.

The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and

skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks,

and ensuring management capacity and capability.

The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards

in force from time to time.


The necessary planning, performance management and corporate and clinical risk management processes and

mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by

the board are implemented satisfactorily.

The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance

Toolkit.

The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,

ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or

plans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordance

with the election rules.

Board Statements

The board will ensure that the trust at all times has regard to the NHS Constitution.

The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,

likelihood of occurrence and the plans for mitigation of these risks.

February 2013

An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance

framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury

(www.hm-treasury.gov.uk).

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the

application of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with all commissioned

targets going forward.

The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the SOM's

Oversight Regime (supported by Care Quality Commission information, its own information on serious incidents, patterns

of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective

arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s

registration requirements.

The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on

behalf of the trust have met the relevant registration and revalidation requirements.

The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.

All current key risks have been identified (raised either internally or by external audit and assessment bodies) and

addressed – or there are appropriate action plans in place to address the issues – in a timely manner

Information to inform the discussion meeting

Unit Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Board Action

1 SHMI - latest data Score 95.9* 95.9* 95.9* 93.3** 93.3**Data reported in arrears - updated quarterly.

*Q4 - 11-12

**Q1 12-13

2Venous Thromboembolism (VTE)

Screening % 93.29 93.93 94.39 94 94 95 94 95 95 94 94

Reported one month in arrears

3a Elective MRSA Screening % 99.4 99.1 99 99.7 99.2 99.1 99.3 98.7 98.6 98.9 98.7 98.8

3b Non Elective MRSA Screening % 90.4 82.7 92.1 93 94.4 94.4 92.8 91.3 91.6 91.3 92.8 92.1

4Single Sex Accommodation

BreachesNumber 0 0 0 0 0 0 0 0 0 0 0 0

5Open Serious Incidents Requiring

Investigation (SIRI)Number 61* 5** 5 2 4 5 3 3 9 8 4 7

6 "Never Events" occurring in month Number 0 0 0 1 0 1 0 0 0 0 0 0

7 CQC Conditions or Warning Notices Number 0 0 0 0 0 0 0 0 0 0 0 0

8Open Central Alert System (CAS)

AlertsNumber 3 0 0 0 0 1 0 0 0 0 0 0

9RED rated areas on your maternity

dashboard?Number 5 2 4 5 8 6 7 4

10Falls resulting in severe injury or

deathNumber 3 3 4 1 0 5 2 1 5 2 3 0

11 Grade 3 or 4 pressure ulcers Number 1 1 1 0 4 2 0 2 3 3 2 1 Note: Figures are number of PU's not patients

12100% compliance with WHO surgical

checklistY/N N N N N N N N - 66.5% N - 89.4%*

% Compliance with Sign In, Time Out & Sign Out.

*includes all theatres minus endoscopy, pain clinic,

radiology and cath lab. Clincial validity of including those

areas under review.

13 Formal complaints received Number 84 68 59 94 56 74 73 81 62 42 80 73

14Agency as a % of Employee Benefit

Expenditure% 2.7% 3.0% 3.0% 3.0% 3.0% 2.9% 2.4% 2.7% 3.0% 2.9% 3.1% 2.9%

15 Sickness absence rate % 4.3% 3.8% 3.89% 3.81% 4.15% 4.13% 4.14% 4.41% 4.45% 4.17% 4.20% 3.9%

16Consultants which, at their last

appraisal, had fully completed their

previous years PDP

% 23.50% 44.40% 54.00% 59.00% 61.20% 70.00% Note: Data not available before August 2012


Insert Performance in Month

QUALITY

Criteria

Refresh Data for new Month

Criteria Indicator Weight 5 4 3 2 1Year to

Date

Forecast

Outturn

Year to

Date

Forecast

OutturnBoard Action

Underlying

performanceEBITDA margin % 25% 11 9 5 1 <1 3 3 3 2

Achievement

of planEBITDA achieved % 10% 100 85 70 50 <50 4 4 2 3

Net return after financing % 20% >3 2 -0.5 -5 <-5 4 4 2 3

I&E surplus margin % 20% 3 2 1 -2 <-2 2 2 2 2

Liquidity Liquid ratio days 25% 60 25 15 10 <10 4 4 4 4

100% 3.4 3.4 2.8 2.8

2 3

3 3 2 3

Overriding Rules :

Max Rating

3 No

3 No

2 No

2 Unplanned breach of the PBC No

2

3 3

1

2 2

* Trust should detail the normalising adjustments made to calculate this rating within the comments box.

Two Financial Criteria at "2"

One Financial Criterion at "1"

One Financial Criterion at "2"

PDC dividend not paid in full

Rule

Two Financial Criteria at "1"

Weighted Average

Overriding rules

Overall rating

Plan not submitted on time

Plan not submitted complete and correct

FINANCIAL RISK RATING

Insert the Score (1-5) Achieved for each

Criteria Per Month

Reported

Position

Normalised

Position*


Financial

efficiency

Risk Ratings

FINANCIAL RISK TRIGGERS

CriteriaQtr to

Jun-12

Qtr to

Sep-12

Qtr to

Dec-12Jan-13 Feb-13 Mar-13

Qtr to

Mar-13Board Action

1Unplanned decrease in EBITDA margin in two consecutive

quartersYes No No No No

2Quarterly self-certification by trust that the normalised

financial risk rating (FRR) may be less than 3 in the next 12

months

No No No N/a N/aQuarterly assessment, not applicable each month.

3Working capital facility (WCF) agreement includes default

clauseN/a N/a N/a N/a N/a N/a N/a

4Debtors > 90 days past due account for more than 5% of

total debtor balancesYes Yes Yes Yes Yes

This target is extremely challenging due to the relatively low

level of total debtors resulting from immediate payment of

monthly SLA sums from commissioners. To meet this criteria

debtors over 90 days need to be less than £400k, 0.08% of

annual turnover.

5Creditors > 90 days past due account for more than 5% of

total creditor balancesNo No No No No

6Two or more changes in Finance Director in a twelve

month periodNo No No No No

7Interim Finance Director in place over more than one

quarter endNo No No No No

8 Quarter end cash balance <10 days of operating expenses No No No No No

9 Capital expenditure < 75% of plan for the year to date No No Yes Yes Yes

Pathology phase 2, Learning and Research phase 2 and

Frenchay Community Hospital delayed start dates. Forecast is

now to spend 70% against original plan.

10 Yet to identify two years of detailed CIP schemes N/a N/a Yes Yes Yes

Introduced from Nov 12. CIP schemes for the next two years

are in various states of development due to the additional

complexity of developing the new hospital operating plan, and

will be firmed up by the end of March 2013.


Insert "Yes" / "No" Assessment for the Month

Historic Data Current Data

Refresh Triggers for New Quarter

See 'Notes' for further detail of each of the below indicators

Area Ref Indicator Sub SectionsThresh-

old

Weight-

ing

Qtr to

Jun-12

Qtr to

Sep-12

Qtr to


Qtr to

Mar-13Board Action

Referral to treatment information 50%

Referral information 50%

Treatment activity information 50%

Patient identifier information 50% Yes Yes Yes Yes

Patients dying at home / care home 50% YesReviews commissioned. Board Governance Memorandum reviewed and approved at February Board.Yes Yes Yes

1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a

1cData completeness: outcomes for patients

on CPA50% 0.5 N/a N/a N/a N/a N/a N/a

2aFrom point of referral to treatment in

aggregate (RTT) – admittedMaximum time of 18 weeks 90% 1.0 Yes Yes Yes Yes

2bFrom point of referral to treatment in

aggregate (RTT) – non-admittedMaximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes

2c

From point of referral to treatment in

aggregate (RTT) – patients on an

incomplete pathway

Maximum time of 18 weeks 92% 1.0 No No No NoWork to validate approximately 6000 spells

continues and should complete in March 13

enabling accurate reporting to resume.

2d

Certification against compliance with

requirements regarding access to

healthcare for people with a learning

disability

N/A 0.5 Yes Yes Yes Yes

Surgery 94%

Anti cancer drug treatments 98%

Radiotherapy 94%

From urgent GP referral for

suspected cancer85%

From NHS Cancer Screening

Service referral90%

3cAll Cancers: 31-day wait from diagnosis to

first treatment96% 0.5 No No Yes Yes

all urgent referrals 93%

for symptomatic breast patients

(cancer not initially suspected)93%

3eA&E: From arrival to

admission/transfer/dischargeMaximum waiting time of four hours 95% 1.0 Yes No No No

A revised action plan has been submitted to

commissioners and is being implemented. It

predicts compliance from the end of Q1.

Receiving follow-up contact within 7

days of discharge95% N/a N/a N/a N/a N/a

Having formal review

within 12 months95% N/a N/a N/a N/a N/a

3gMinimising mental health delayed transfers

of care≤7.5% 1.0 N/a N/a N/a N/a N/a N/a

3h

Admissions to inpatients services had

access to Crisis Resolution/Home

Treatment teams

95% 1.0 N/a N/a N/a N/a N/a N/a

3iMeeting commitment to serve new

psychosis cases by early intervention teams95% 0.5 N/a N/a N/a N/a N/a N/a

Red 1 80% 0.5 N/a N/a N/a N/a N/a N/a

Red 2 75% 0.5 N/a N/a N/a N/a N/a N/a

3kCategory A call – ambulance vehicle arrives

within 19 minutes95% 1.0 N/a N/a N/a N/a N/a N/a

Is the Trust below the de minimus 12 No No No No

Is the Trust below the YTD ceiling

Contractual

trajectory -

61

No No No No

Is the Trust below the de minimus 6 Yes Yes Yes Yes

Is the Trust below the YTD ceilingContractual

trajectory - 6Yes Yes Yes Yes

CQC Registration

A

Non-Compliance with CQC Essential

Standards resulting in a Major Impact on

Patients

0 2.0 No No No No

BNon-Compliance with CQC Essential

Standards resulting in Enforcement Action0 4.0 No No No No

C

NHS Litigation Authority – Failure to

maintain, or certify a minimum published

CNST level of 1.0 or have in place

appropriate alternative arrangements

0 2.0 No No No No

TOTAL 0.0 5.5 4.5 3.0 4.0 0.0 0.0RAG RATING : G R R AR R G G


YesNo Yes

Yes Yes

AMBER / RED = Score greater than or equal to 2, but less than 4

AMBER/GREEN = Score greater than or equal to 1, but less than 2

All cancers: 31-day wait for second or

subsequent treatment, comprising:

Cancer: 2 week wait from referral to date

first seen, comprising:3d

RED = Score greater than or equal to 4

No Yes Yes Yes

No No

N/a

Yes Yes

Yes No

Historic Data

Yes

Current Data

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate)

Eff

ective

ne

ss

Data completeness: Community services

comprising:

Pa

tie

nt

Exp

eri

en

ce

Qu

alit

y

0.5

1.01a

1bData completeness, community services:

(may be introduced later)

Category A call –emergency response

within 8 minutes3j

3f

Sa

fety

GREEN = Score less than 1

1.0

1.0

3a

3b All cancers: 62-day wait for first treatment:

1.0

Care Programme Approach (CPA) patients,

comprising:1.0

1.0MRSA4b

Clostridium Difficile4a

Refresh GRR for New Quarter

See 'Notes' for further detail of each of the below indicators


Historic Data Current Data

GOVERNANCE RISK RATINGS

Insert YES, NO or N/A (as appropriate) Refresh GRR for New Quarter

Overriding Rules - Nature and Duration of Override at SHA's Discretion

i) Meeting the MRSA Objective No No No

iv) A&E Clinical Quality Indicator Yes Yes

viii) Any other Indicator weighted 1.0 No No

Adjusted Governance Risk Rating 0.0 5.5 4.5 4.0 4.0 0.0 0.0

G R R R R G G

Breaches the indicator for three successive quarters.

referral to treatment information for a third successive quarter;

service referral information for a third successive quarter, or;

treatment activity information for a third successive quarter

N/a N/a

Novii) Community Services data completeness

Fails to maintain the threshold for data completeness for:

N/a

No

the category A 8-minute response time target for a third

successive quarter

either Red 1 or Red 2 targets for a third successive quarter

N/a N/a

Breaches either:

the 31-day cancer waiting time target for a third successive

quarter

the 62-day cancer waiting time target for a third successive

quarter

No No

Ambulance Response Times

Breaches either:

the category A 19-minute response time target for a third

successive quarter

Cancer Wait Times

No

The admitted patients 18 weeks waiting time measure for a

third successive quarter

The non-admitted patients 18 weeks waiting time measure for a


The incomplete pathway 18 weeks waiting time measure for a


Breaches:

No

NoNoNoii)

Greater than six cases in the year to date, and breaches the

cumulative year-to-date trajectory for three successive quarters

Greater than 12 cases in the year to date, and either:

Breaches the cumulative year-to-date trajectory for three

successive quarters

iii) RTT Waiting Times

vi)

Meeting the C-Diff Objective

v)

Reports important or signficant outbreaks of C.difficile, as

defined by the Health Protection Agency.

Fails to meet the A&E target twice in any two quarters over a 12-

month period and fails the indicator in a quarter during the

subsequent nine-month period or the full year.

Qtr to

Jun-12

Qtr to

Sep-12

Qtr to


Qtr to

Mar-13Board Action

1 Are the prior year contracts* closed? Yes Yes Yes Yes Yes

2Are all current year contracts* agreed and

signed?Yes Yes Yes Yes Yes

3Has the Trust received income support outside of

the NHS standard contract e.g. transformational

support?

Yes Yes Yes

Qn. introduced from Nov 12.

4Are both the NHS Trust and commissioner

fulfilling the terms of the contract?Yes Yes Yes Yes Yes

5Are there any disputes over the terms of the

contract?No No No No No

6Might the dispute require third party intervention

or arbitration?N/a N/a No No No

7 Are the parties already in arbitration? N/a N/a No No No

8 Have any performance notices been issued? No Yes No No No

Perf Notice in Q2. Escalated to Exception

Notice in Q3. ED performance improvement

trajectory agreed.

9 Have any penalties been applied? Yes No No No No

*All contracts which represent more than 25% of the Trust's operating revenue.

Current Data

Insert "Yes" / "No" Assessment for the Month


Criteria

CONTRACTUAL DATA

Information to inform the discussion meeting

Historic Data

Refresh Data for new Quarter

Mar-13

Milestone

DateDue or Delivered

MilestonesFuture Milestones Board Action

1 Refreshed & Signed off TFA Feb-13 On track to deliverRevised TFA submitted to SHA & TDA. Awaiting review & sign off.

2 First Draft refreshed IBP and LTFM Feb-13 On track to deliver

3 Refreshed BGAF & QGAF reviews Apr-13Will not be delivered on

time

Board Governance Memorandum reviewed and approved at February

Board. Quality Governance Framework review in progress. BGAF & HDD

reviews postponed.

4 Final IBP and LTFM Apr-13 On track to deliver

5 Commissioner Convergence Letter Apr-13Will not be delivered on

time

6 Historical Due Diligence part two Apr-13Will not be delivered on

time

7 Board to Board Apr-13Will not be delivered on

time

8 Application to DH May-13Will not be delivered on

time

9

10

Select the Performance from the drop-down list

TFA Milestone (All including those delivered)



Report to: Trust Board Agenda item: 8.2.5Date of Meeting: 25 March 2013

Report Title: Single Operating Model Returns – Feb 2013

For information discussion assurance approvalStatus: x x

Prepared by: Paul Cresswell, Trust Secretary Executive Sponsor (presenting): Marie-Noelle Orzel, Chief Executive Appendices (list if applicable): SOM Board Statements & appendices

TDA Oversight Action Plan Executive Summary: Key Changes in SOM since February Trust Board review The Governance Risk Rating has moved from a score of 3.0 (amber/red) to 4.0 (red) due to failure to achieve the 62 day cancer target. Quality Indicators;

SHMI has reduced from 95.9 to 93.3 (figure corrected from board paper last month). This was resolved for the January data prior to submitting to TDA on 1st March.

Compliance with WHO surgical checklist – last month a specific percentage was reported (as requested by the SHA at Oversight review) of 66.5%. This figure has since been reviewed in detail given its seemingly poor position. Detailed discussion has been undertaken involving the Director of Nursing, Medical Director and Clinical Director for Surgery about what this measure should include. This dialogue has also been shared with the TDA Quality lead and has resulted in the decision to exclude data relating to endoscopy, pain clinic, radiology and cath lab as there is a limited clinical basis for its inclusion.

Over the coming month benchmarking information from other trusts is being sought through the SW quality and safety programme. NBT is being transparent about the basis of reporting and will ensure there is both a valid clinical basis for the use of the WHO checklist and also a consistent approach with other organisations.

Maternity Red Risks – following the spike in numbers from 5 to 8 in November 12 detailed assurances have been sought and obtained from Maternity Services on what this actually means in terms of providing a safe service and how they can provide assurance on this. There is a lot of detail behind this but the key points are; There is no standardised approach to measurement of a ‘maternity

dashboard’ Different units measure in different ways. The dashboard is intended to act as an improvement tool, applying ‘stretch’

targets that are by their nature challenging. This differs to many targets which measure ‘compliance’ or ‘basic safe standards.’

Dashboard scores are rigorously reviewed monthly at Womens & Children’s Clinical Governance meetings. Adverse indicators are evaluated and potential causes tested, for example through the use of clinical audits. This drives subsequent improvement action.

In future Maternity Services will provide an exception report when the number increases month on month, as a routine output from their clinical governance processes.

Sickness Absence rate - dropped below 4% for the first time since June 2012.



TFA Progress is reported as “will not be delivered on time” as we now know that performance will not allow the ‘DH application’ in May 2013 as set out in the original TFA. The Trust Development Authority is fully aware of this position. Risk Rating Summary Financial Risk Rating (FRR): Overall (Normalised) Rating 2 - RED

January 13 – ratings of 3 apart from Normalised YTD of 2. February 13 – same as above.

Governance Risk Rating (GRR):Overall Rating 4.0 – RED

January 13 – 3.0 (Amber/Red) February 13 – 4.0 (Red)

2C – (RTT – patients on an incomplete pathway) – this remains red. Work to validate approximately 6000 spells continues and should complete in March 13 enabling accurate reporting to resume.

3B (All cancers: 62-day wait for first treatment) has reverted to red this month. 3E (A&E 4 hr waits) - after a ‘green’ rating in November 12 this reverted to ‘red’

in December 12, January 13 and February 13. The Board Performance report explains actions in place to improve this, referencing the key metrics that will help to track progress.

4A (Clostridium Difficile) is above YTD and annual trajectory and thus rated red. SOM Oversight Meeting with the TDA - Action Plan Following submission of the SOM, post board approval, an Oversight meeting with the TDA occurs in the first week of the month. This generates a range of actions to address which are followed up the next time. In order to bring transparency to this process and provide assurance to the Board on progress, the action plan at Appendix 2 has been drafted reflecting the discussion in early March. It has not been possible this month to provide updates but this will become a routine discipline from April Board onwards. Board Statements - Considerations

Statement 4 (The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months). Work is ongoing for the LTFM and IBP updates for FT project and Acute Services review. It is recommended that the current response of ‘yes’ should remain at this point.

Statement 6 (The board will ensure that the trust at all times has regard to the NHS Constitution). At the February board a comment was made by the Staff Side representative that the wording had changed from previous version of the SOM, which is correct. This does not reflect any diminished commitment from NBT. It purely reflects the fact that the original statement in the SOM was an incorrect copy of its equivalent within the Monitor Compliance Framework and this was corrected within the standard template issued by the Trust Development Authority that applies to all non Foundation Trusts.

Statement 11 - Based upon the adverse risk rating scores it is recommended that a response of ‘no’ remains in place.

Action Required: The Trust Board is requested to:

Discuss and approve responses to the 15 board statements, with particular attention to statements 4, 6 and 11, as outlined in the Executive Summary.

Review the SOM data and key changes as highlighted in the Executive Summary.



Agree the intended approach to providing assurance on progress of actions agreed with the TDA at the monthly oversight meeting.

Key Risks: Persistently adverse FRR or GRR ratings will undermine the Trust’s Foundation Trust application and/or potential merger. Specific risks are reflected in the SOM data items and narrative above.

Impact on Patients: None directly – this is a corporate return to facilitate scrutiny of the Trust by the SHA and TDA.

Impact on Staff As above Link to Trust Objectives: All Trust Big 5 objectives are relevant. Care Quality Commission outcomes:

Overall CQC compliance reflected in Governance Risk Rating ‘Quality’ section.

NHS Constitution: Reflected where relevant within SOM data Financial Issues: Reflected within SOM data Legal/regulatory Issues: SOM is required for all non-Foundation Trusts as part of

TDA pipeline. Equality Issues considered: N/A


meeting.

1

Report to: Trust Board : March 2013 Agenda item: 10.1 Date of Meeting: 28 March 2013

Report Title: Declarations of Interest 2012/13

For information discussion assurance approval Status: x

Prepared by: Paul Cresswell, Secretary to the Board

Executive Sponsor (presenting): Marie-Noelle Orzel, Chief Executive

Appendices (list if applicable): Declarations Executive Summary: Under the Standards of Business Conduct for NHS Staff, the Codes of Conduct and Accountability, the Professional Standards of Board Members and to help comply with the Bribery Act 2011 all members of the Trust Board must declare any relevant and material interest and those declarations must be recorded in the Public Minutes. The declarations (including ‘nil responses’) set out in the appendix have been made. In addition, Declarations of Interest, including nil returns, have been made by all Corporate Directors, Clinical Directors, General Managers, second-in line officers of the Trust and other relevant staff. These forms are available for inspection from the secretary to the Trust Board.

Action Required: Trust Board is requested to NOTE the declarations

Key Risks: Non-disclosure could lead to potential bribery actions against

both the Trust and individuals Impact on Patients: No direct impact on patients

Impact on Staff: Declarations protect staff against possible accusations or misunderstandings about the way services and goods are purchased

Link to Trust Objectives: Creating a strong financially sustainable organisation; A great place to work


CQC Outcome 12

NHS Constitution: Underpins Staff NHS Constitution Pledges

Financial Issues: Financial probity issues are the reasons for the report

Legal/regulatory Issues: The Trust must ensure that it meets the requirements of the Bribery Act

Equality Issues considered: To meet Trust’s equality objectives.


meeting.

2

NORTH BRISTOL NHS TRUST Appendix

TRUST BOARD 28th MARCH 2013

Declaration of Interest 2012/2013

BOARD MEMBER

INTEREST DECLARED

1. Mr Peter Rilett Chairman

1. Non-Executive Director of: Watts of Lydney Ltd Bordeaux Quay Ltd 2. Trustee of: St. Monica’s Trust 3.. Adviser to: Centaur Services Ltd 4. Chairman of Governors of: Bristol Grammar School

2. Mr Robert Mould Non-Executive

1. Trustee of: Hopes Place Charity

3. Mr Nick Patel

None

4. Mr Stephen Hughes Non-Executive Director

1. Trustee and Company Secretary of Great Western Air Ambulance Charity Ltd. 2. Partner of Bevan Brittan LLP, Solicitors

5. Professor Avril Waterman-Pearson Non-Executive Director

None

6. Mr Ken Guy Non-Executive Director

1. Trustee of:

Milestones Trust

2. Trustee of Penny Brohn Cancer Care


meeting.

3

3. Independent Member of Bristol City Council Audit Committee

7. Mr Mark Lawton Non-Executive Director

1. Finance and Commercial Director,

Babcock Support Services Ltd 2. Director, Debut Services (South

West) Ltd

8. Miss Marie-Noelle Orzel

Director of Nursing to June 2012 and Chief Executive from then

1. Wing Commander, Royal Auxiliary

Air Force

9. Mr. Stephen Webster

Director of Finance and Information to January 2013

None

10. Mrs Sue Jones Director of Nursing from June 2012

None

11. Dr Christopher Burton Medical Director

None

12. Mr Bill Boa

Director of Finance and Commercial Development from January 2013

1. Director and part owner of Foxwell

Associates Ltd 2. Wife is part owner of same company

3. Trustee of Arts in Hospital South

West

13. Mrs Ruth Brunt

Chief Executive to June 2012

1. None

Documents

Board paper March 2013 - Agenda Board... · NBT’s progression to Foundation status and development of the associated quality assurance frameworks would provide the assurance that