GROUP TRUST BOARD MEETING IN PUBLIC A G E N D As3-eu-west-1.amazonaws.com/files.royalfree.nhs.uk/Trust... · 2018-05-21 · GROUP TRUST BOARD MEETING IN PUBLIC1 The next meeting of

GROUP TRUST BOARD MEETING IN PUBLIC1

The next meeting of the group trust board will take place on Wednesday 23 May 2018 at 1.00pm in the boardroom, 2nd floor, Royal Free Hospital.

Dominic Dodd Chairman

A G E N D A

ITEM LEAD PAPER

ADMINISTRATIVE ITEMS

2018/54 Apologies for absence – A Panniker D Dodd

2018/55 Declaration of interests D Dodd 1.

2018/56 Minutes of meeting held on 25 April 2018 D Dodd 2.

2018/57 Matters arising report D Dodd 3.

2018/58 Record of items discussed at the Part II board meeting on 25 April 2018

D Dodd 4.

QUALITY, PATIENT SAFETY AND EXPERIENCE

2018/59 ‘Safety Lessons of the week; Integrating governance, risk and

improvement” –Dr Alan McGlennan, medical director, Chase

Farm Hospital

C Streather Verbal

2018/60 Patients’ voices M Basterfield Verbal

2018/61 Go see visits Emma Kearney 5.

FINANCE AND PERFORMANCE

2018/62 Financial performance report C Clarke 6.

2018/63 Operational performance report P Ridley 7.

GOVERNANCE AND REGULATION: REPORTS FROM BOARD COMMITTEES – DISCUSSION BY EXCEPTION ONLY

2018/64 Chair’s and chief executive’s report D Dodd /D Sloman

8.

2018/65 Quality improvement and leadership committee (26 March and

27 April 2018)

J Owen 9.

2018/66 Clinical standards and innovation committee (9 April 2018) A Schapira 10.

2018/67 Group services committee (10 May 2018) W Goldwag 11.

2018/68 Population health and pathways committee (24 April 2018) J Tugendhat 12.

2018/69 Audit committee (11 and 18 May 2018) M Basterfield Verbal

2018/70 Board code of conduct E Kearney 13.

1 In accordance with the Health & Social Care Act 2012, all Trust Board meetings must be held in public. All decisions which require the board’s collective approval can only be made at a Trust Board (or a Part II meeting held in closed session to discuss confidential matters).

OTHER BUSINESS

2018/71 Questions from the public D Dodd

2018/72 Any other business D Dodd

2018/73 Date of next meeting – 27 June 2018 D Dodd

Paper 1

Register of interests – trust board 23 May 2018 1

REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS

Executive summary

The trust constitution requires trust board members to declare interests which are relevant and material to the NHS board of which they are a member. The register of interests is presented at each board meeting.

The entry for the group chief finance officer has been amended to show her directorship of the Royal Free property services company. There are no other changes since the last meeting.

Action required

Board members are asked to provide an update if they have any changes in interests since the last meeting.

Board members are asked to declare any interests which are relevant to matters on the board agenda.

The board is asked to ratify the register, subject to any further changes made.

Public Patient and Carer involvement

The register will be made available to the public.

Report From Dominic Dodd, chairman Author(s) Alison Macdonald, board secretary Date 15 May 2018

Report to Date of meeting Attachment number

Trust Board 23 May 2018 Paper 1

Version 22 Updated 4/5/18

Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public.

REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD

Board Member and position

Directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies)

Ownership or part-ownership of private companies, business or consultancies likely or possibly seeking to do business with the NHS

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS

A position of authority in a charity or voluntary organisation in the field of health and social care

Any connection with a voluntary or other organisation contracting for NHS services

Research funding/grants that may be received by an individual or their department

Interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the Trust must be declared)

Dominic Dodd, Chair 8/4/16

Director of UCLPartners

1

Member of NHSI’s Chairs’ Advisory Group. Unpaid position.

Nil Nil Trustee, The King’s Fund. Unpaid position

Nil Nil

Non-executive directors

Stephen Ainger Non-executive director 5/1/16

Chair Downshire Hill Residents’ Association.

Director of ATL trust fund.

Nil Nil Nil Nil Nil Nil

Mary Basterfield Non-executive director 8/3/18

Flatberg Ltd (property management)

Chief finance officer, UKTV

Trustee, National Cancer Research Institute and UCL Union.

1 The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.











Wanda GoldwagNon-executive director

• Chair of the Office of Legal Complaints (OLC)

• Lay Member QC Appointments Panel

• Advisor SmedvigVenture Capital

Director, Goldwag Consultancy Ltd

Nil Nil Adopted sister is chief pharmacist of Barnet Enfield and Haringey Mental Health Trust

Nil I have a shareholding via Smedvig Capital in Antidote Technologies Ltd the clinical trial matching platform

Jenny Owen, Non-executive director 6/4/16

Nil Nil Nil Board member of Housing and Care 21

Vice chair of Alzheimer’s Society

Member of General Advisory Council King’s Fund

Housing 21 and Care 21

Alzheimer’s Society

Nil Nil

Akta Raja Non-executive director 1/1/17

• Enhabit Ltd • Geneff Ltd • Thornriver

Management Ltd • Riverside Homes

Ltd • Ansor Ltd (not

currently trading)












Professor Anthony Schapira Non-executive director 13/5/16

Upper Hampstead Walk Residents’ Association. AHV Schapira Ltd

Non-executive director, Ministry of Justice

Nil Nil Parkinson’s Disease Society Research Strategy Group

Nil Medical Research Council, Wellcome Trust, Parkinson’s Disease Society and other charitable sources of research funding

Nil

James Tugendhat

Non-executive director

Director of BHFS One Ltd and BHFS Two Ltd




Executive directors

Board Member and position Date of latest amendment/confirmed correct








Caroline Clarke Deputy group chief executive & chief finance officer 21/2/18

Director RFL Property Services Company

Nil Nil Director

Royal Free Charity (1/4/16)

Trustee, Overcoming MS

Trustee, Healthcare Finance Managers Association

Nil Nil

Deborah Sanders Group chief nurse 1/9/17

Nil Nil Nil Board member, The Royal Free Hospital Nurses’ Home of Rest Trust

Trustee, Royal Hospital for Neuro-disability

Nil Nil Nil

Kate Slemeck, RFH chief executive 7/4/16

Nil Nil Nil Chair of NHS Elect Advisory Committee Chair of NHS Providers COO Network

Husband works for Canon who provide the trust’s managed print service.

Nil Nil



Chris Streather

Group chief

medical officer

Nil Nil Nil Nil Unpaid advice to

ZPB on e-

rostering which

will contribute to

a report

commissioned

from them by

Allocate. It

involved two

meetings and

reviewing a

document and

Health Education

England (HEE)

also were

involved. The

trust has a

contract with

Allocate, but not

ZPB, for whom

this work was

done.

Nil Nil



Board Member and position Date of latest amendment/confirmed correct


State when directorship commenced

Ownership or part-ownership of private companies, business or consultancies likely or possibly seeking to do business with the NHS State when interest acquired

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS State when interest acquired


State when position accepted


State when position accepted


State when funding/grant commenced


State when interest acquired

David Sloman Group chief executive 15/11/16

Director, UCLPartners2

Accountable Officer for North Middlesex University Hospital NHS Trust (September 2017)

Nil Nil London Procurement Partnership board member.

Relative who works for Haringey CCG

Provider SROfor NCL STP and chair of digital programme board

Member of London health and social care strategic partnership board

Nil Nil

2 The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.



Non-voting directors









David Grantham

Group director of

Workforce and

OD

7/4/16

Nil Nil Nil Board Member

and Treasurer

London

Healthcare

People

Management

Academy –

March 2013

Chair of NHS

Employers

Medical

Workforce

Forum – August

2010

Board Member Health Education North and East London (HENCEL) – July 2014 Board Member and Treasurer London Streamlining Programme(s) – March 2014

Nil Nil

Emma Kearney

Group director of

corporate affairs

and

communications

Director, EK

Consulting Ltd


Andrew Panniker

Group director of

capital and

estates

Nil Nil Nil Nil Director, Royal

Free Charity

Development Co

Nil Nil

Peter Ridley

Group director of

Planning

Nil Nil Nil Nil Nil Nil Nil











Steve Shaw

Chief executive

BH

Nil

Glenn

Winteringham

Chief information

officer

3/5/17

Nil Nil Nil Nil Nil Nil Nil

Paper 2

1

MINUTES OF THE TRUST BOARD

HELD ON 25 APRIL 2018

Present

Mr D Dodd Mr S Ainger Ms M Basterfield Ms C Clarke Ms W Goldwag Ms J Owen Ms A Raja Prof A Schapira Ms K Slemeck Sir David Sloman Dr Chris Streather Mr J Tugendhat

Chairman Non-executive director Non-executive director Group chief finance officer and deputy group chief executive Non-executive director Non-executive director Non-executive director Non-executive director Chief executive – Royal Free Hospital Group chief executive Group chief medical officer Non-executive director

Invited to attendMr D Grantham Ms E Kearney Ms E McManus Mr A Panniker Mr P Ridley Dr S Shaw Mr G Winteringham Mrs J Dewinter Ms A Macdonald

Group director of workforce and organisational development Group director of corporate affairs and communications Group chief transformation officer Group director of capital and estates Group director of planning Chief executive – Barnet Hospital Group chief information officer Lead governor Board secretary (minutes)

Others in attendance

Ms L McKenna Ms C Cushen Ms A Taylor Ms A Smolec Ms L Francis Ms Y Carter Dr D Mack

Matron (for item 2018/59) Therapy lead (for item 2018/59) Physiotherapist (for item 2018/59) Ward manager (for item 2018/59) QI coach (for item 2018/59) Head of infection prevention and control nursing(for item 2018/63) Microbiology consultant and infection prevention and control doctor(for item 2018/63)

2018/54 APOLOGIES FOR ABSENCE AND WELCOME Action

Ms D Sanders Group chief nurse

The chairman welcomed those present to the meeting.

2018/55 DECLARATION OF INTERESTS

There were no further changes advised and the report on the register of interests was noted.

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2

2018/56 MINUTES OF MEETING HELD ON 21 MARCH 2018

The minutes were accepted as an accurate record of the meeting, subject to the following amendment:

2018/42 National staff survey results 2017

Amend spelling of Ms Raja’s name and change word ‘department’ for ‘director’.

2018/57 MATTERS ARISING REPORT

The chairman asked the group director of workforce to confirm when a further report on the gender pay gap would be presented to the board and this was confirmed as July 2018.

The matters arising report was noted.

Director of workforce and estates

2018/58 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 21 MARCH 2018

The report was noted.

2018/59 ‘KEEP ME MOBILE’ QUALITY IMPROVEMENT PROJECT, LARCH WARD, BARNET HOSPITAL

Lindsey McKenna (matron), Claire Cushen (therapy lead), Abbi Taylor (physiotherapist), Anna Smolec (ward manager) and Liz Francis (QI coach) were in attendance for this item.

Ms Francis made some introductory comments, explaining that the starting point for the project had been to reduce delayed discharges and an important part of this was preventing patients being ‘deconditioned’. The aim had been set of having 95% of patients who were medically well enough, out of bed and having their lunch at the table. The team then described how clinical staff including therapists, nurses and healthcare assistants had worked together on this project. It had also been important to get medical staff on board as patients and their families sometimes needed to hear the message from the doctor of how important it was for them to get up. A risk averse approach which kept patients in bed to avoid falls also had to be overcome. The ward had also worked closely with the Charity which had funded new chairs and equipment to support the project. It was felt that asking all the ward staff to sign a pledge to support the project had also been central to its success. The outcome measures were the percentage of eligible patients sitting out to lunch, length of stay, decreased number of delayed patients and the number of falls. So far, the length of stay and delays data was encouraging and falls did not appear to have increased. Ms Smolec, ward manager, expressed how proud she was of the way the ward team had embraced the project, noting particularly the enthusiasm of the healthcare assistants who took a particular pride in making sure all the patients they were caring for who were well enough were assisted out of bed in the morning.

The group chief executive noted that the team were looking to share their learning with other areas and said that he would be very interested to hear how

Paper 2

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they got on. Ms Owen, non-executive director, noted the patient’s story at the end of the presentation which was very powerful affirmation of the importance of helping patients to keep mobile. She asked whether there were space constraints and Ms Smolec responded that there were tables in the middle of the bed bays where patients could have their lunch. She added that this gave a more ‘normal’ and sociable atmosphere to being in hospital.

Ms Basterfield, non-executive director asked whether ‘keep me mobile’ was embedded and whether the ward had all the support they needed. Ms McKenna responded that this was effectively ‘business as usual’ for the ward and everybody could see the benefits.

The chairman thanked the Larch ward team for attending and sharing their very patient focused project with the board.

2018/60 GO SEE VISITS

Ms Raja, non-executive director, reported back on her visit to the haematology and oncology ward. During the visit she had met Keith Hunt, complementary therapy coordinator, who described the massage service that was available to patients undergoing chemotherapy. She had received very positive feedback from the visit, patients described the service’s patient focus and receiving an excellent experience.

The group director of workforce and OD had visited the pharmacy departments at Barnet Hospital and Chase Farm Hospital. Both departments were very busy and keen on staff development. They were well engaged with improvement work such as the multi-agency discharge events (MADE). They had mentioned the cramped space for staff and patients attending for prescriptions. The Chase Farm department had noted that they provided a service to other organisations outside the trust which bought income in.

The chairman asked colleagues how they felt the new go see system was working. The consensus was that it was successful and useful. Ms Goldwag, non-executive director, suggested that rather than fixing a set interval for repeat visits (currently two months) six months would be better as changes were likely to have been occurred. The chairman was happy for colleagues to decide when to carry out a return visit.

2018/61 PATIENTS’ VOICES

The group director of workforce and OD read out a complaint from the daughter of a patient relating to aspects of her care at Barnet Hospital in her last days of life; these were pain control, a failure of staff to recognise the distress suffered both by the patient and her family, failure to administer prescribed medication and a lack of clarity regarding medical responsibility. The complaint had been investigated and a full response sent. This acknowledged that staff had not always recognised that the patient was in pain rather than just agitated and the palliative care team would be arranging some training for staff. The response explained the need to move the patient regularly in order to prevent pressure ulcers and noted that other family members had been appreciative of the care provided but apologised to the daughter that the ward team had been unable to meet her expectations.

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The compliment was from the family of a patient who had died on a ward at the Royal Free Hospital. This described care being of the highest calibre and the utmost respect been shown to the patient and their family. All the patient’s needs had been anticipated and the patient was made as comfortable in their las days as if they had been at home.

Ms Owen, non-executive director, noted that these were two contrasting pictures of end of life care and wondered whether it would be timely for the board to receive an update. The chief medical officer suggested that this could be presented alongside the next learning from deaths review which would be in July 2018 and this was agreed.

Mary Basterfield, non-executive director, would present the patients’ stories item next time.

Group chief medical officer

Mary Basterfield

2018/62 LEARNING FROM DEATHS (QUARTER 2 REVIEW)

The group chief medical officer presented this report which was the second report since the new learning from deaths review process had been introduced. It was reassuring to note that both cases of avoidable death had already been identified and fully investigated through the trust’s serious incidents process. Discussions were still taking place with hospital unit colleagues about the best way to undertake the reviews; with the aim that this would be part of normal clinical business. The palliative care team were being brought into the process and a patient representative was also being sought.

Ms Owen, non-executive director, was concerned that if reviews took more time to complete, there would be an adverse impact on relatives. She also asked about the learning from reviews.

The group chief medical officer undertook to include the actual learning from deaths in future reports, which would be derived from the serious incidents investigation reports. He would also ensure that the time taken to conclude investigations was kept under review.

The board noted the report and agreed to the submission of the learning from deaths (LfD) return.


2018/63 DIRECTOR OF INFECTION PREVENTION AND CONTROL REPORTS:QUARTERLY REPORT (Q4) AND ANNUAL PROGRAMME

Ms Y Carter, head of infection prevention and control nursing, and Dr D Mack, microbiology consultant and infection prevention and control doctor were in attendance for this item.

Ms Carter noted that in 2017/18 there had been 82 cases of attributable C. diff, 14 above the threshold set by Public Health England and a higher number than in 2016/17. However, despite the higher overall number, the number of cases due to lapses of care (seven) was the same as in 2016/17. The Public Health England threshold for 2018/19 was 65, a reduction of one on the previous year. The focus next year would be on embedding the deep clean schedule and antimicrobial stewardship, to reduce the trust’s use of antibiotics which was high compared with others. An antimicrobial stewardship business case was currently being worked on. There would also be a need to reduce gram negative

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bacteraemias. Finally she drew attention to the letter from the NHS England executive director of nursing and national director for infection prevention and control, congratulating the Royal Free London for being one of 59 trusts in England which achieved a 10% or greater reduction in E. coli bloodstream infections – the RFL reduction had been 14.3%.

Dr Mack noted that carbapenemase producing enterobacteriaceae (CPE) was a new issue and more cases were being seen locally. Screening and surveillance were being increased.

Regarding influenza, there had been more cases and over a more extended period than in previous years. He noted that the quadrivalent (QV) flu vaccine had been purchased for next year.

Mr Ainger, non-executive director, asked about the large increase in CPE and whether additional funding had been agreed for the deep cleaning.

Dr Mack responded that the increased number of CPE cases was due to the introduction of the enhanced microbiology laboratory testing at Barnet Hospital which had previously only been done at the Royal Free Hospital. Ms Carter responded that the cost of deep cleaning was included in budgets; the issue was that bed pressures meant that it was difficult in the winter months to release ward areas for deep cleaning.

The Board confirmed that the report provided sufficient information to provide assurance of sustained compliance with the Hygiene Code, accepted the report as adequate assurance that IPC requirements were being managed appropriately and in line with legislation and approved the work plan for 2018/19.

2018/64 FINANCIAL PERFORMANCE REPORT

The group chief finance officer presented this report, noting that at the end of March, the trust reported a deficit of £22.4m for the year, which was £5.1m favourable against plan. This reported position was before the impact of sustainability and transformation funding (STF). Better than planned performance was due to winter pressures income, CQUIN funding and other net non-recurrent benefits. This would qualify the trust to receive STF funding, potentially £11.4m plus an additional £11m. If this occurred the trust would almost break even.

The group chief finance officer noted that the 2017/18 financial plan included delivery of £44.7m of financial improvement programme (FIP) savings. At the end of March, the trust delivered £44.1m of FIP. The trust had started the year with an underlying deficit of £123m, which FIP delivery had improved to £92m. The group chief executive suggested that congratulations were due to the organisation for achieving a £30m reduction in the underlying deficit, in year one of the four year financial recovery plan.

The cash balance at the end of March was £43.7m. Although this appeared relatively healthy and better than planned due to winter funding and STF the board noted that the majority of the surplus cash would be used to fund the redevelopment of Chase Farm in 2018/19 and 2019/20.

The board noted the current financial position of the trust.

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2018/65 OPERATIONAL PERFORMANCE REPORT

The group director of planning presented this report. He noted that cancer performance for February 2018 was reported at 84.4% and that the March position was 83.5% but was still being validated. He could not confirm whether or not the trust had achieved compliance for the quarter. The main concern was the backlog which was currently 123 against a target of 47. The cancer target and backlog was being closely managed.

Regarding referral to treatment time (RTT) the March position was 83.1%. Performance had not improved significantly because priority and organisational focus was being given to cancer and A&E. However the trust remained committed to treating all patients who had waited more than a year for treatment, and to preventing new patients passing the 52 week threshold. However further work was required to prevent ‘tip ins’ (long waiters being identified late on the pathway making it difficult to treat them within the 18 week and 52 week targets). There were currently 33 patients who had waited more than 52 weeks and every effort was being made to bring their treatment forward. The chairman asked that data from clinical harm reviews be incorporated into this report. The group director of planning responded that independent clinical review was taking place and to the end of March 2018 no case of medium or significant harm had been identified; all reviews had concluded that there was either no harm or low harm.

The group chief executive noted that there was a national and local focus away from RTT and towards cancer and A&E. However the trust would reduce long waiting patients to 20-30 by the end of April.

The board noted the current operational performance of the trust. 2018/66 CHAIR’S AND CHIEF EXECUTIVE’S REPORT

The group chief executive informed the board that since the board papers had been circulated the trust had been informed that there was the possibility of a five week delay on the completion of the construction of Chase Farm Hospital. However this was still in discussion.

The chairman then congratulated Judy Dewinter on her re-election to the council of governors by such a sizeable majority (securing the votes of 10% of the entire electorate and 44% of all the votes cast in the election) and on her reappointment as lead governor.

The board noted the report.

2018/67 QUALITY IMPROVEMENT AND LEADERSHIP COMMITTEE

Ms Owen, chair of the committee, highlighted the following points from the recent meeting:

• The committee had received an update on dementia work – which was making good progress

• The committee had looked at the results of the staff survey and reviewed the action plan. The committee had noted the work the trust was doing on clinical practice groups (CPGs) and quality improvement (QI) which should have a positive impact on staff experience and discussed whether

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any additional work was needed in response to local issues.

• The committee noted some lack of progress on delivering actions agreed to improve performance on the workforce race equality standards (WRES) and the need to accelerate this now.

• The committee noted that a disability standard was being introduced along the same lines as WRES and discussed what the trust needed to do in response to this.

• The committee noted that a tracking tool was being developed to enable progress to be tracked.

The board noted the report from the committee.

2018/68 CLINICAL STANDARDS AND INNOVATION


2018/69 GROUP SERVICES COMMITTEE

The board noted the report from the committee regarding the March meeting. The April meeting had covered the same themes.

2018/70 POPULATION HEALTH AND PATHWAYS COMMITTEE


2018/71 AUDIT COMMITTEE


2018/72 USE OF TRUST SEAL

The board noted the report detailing the occasions on which the seal had been used.

2018/73 QUESTIONS FROM THE PUBLIC

There were no questions. 2018/74 ANY OTHER BUSINESS

There was no other business.

2018/75 DATE OF NEXT MEETING

The next trust board meeting would be on 23 May 2018 at 1300 in the boardroom, 2nd floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 23 May 2018……………………………. Dominic Dodd, chairman

Paper 3

Matters arising – trust board 23 May 2018

Trust Board Matters arising report as at 23 May 2018

Actions completed since last meeting of the Trust Board

MinuteNo

Action Lead Complete Board date/agenda item

Outstanding

FROM TRUST BOARD HELD ON 25 APRIL 20182018/612018/62

Patients’ voicesLearning from deaths review

Presentation on end of life care – to be presented alongside next learning from deaths review

The group chief medical officer undertook to include the actual learning from deaths in future reports, which would be derived from the serious incidents investigation reports. He would also ensure that the time taken to conclude investigations was kept under review.


Next report scheduled for July 2018

FROM TRUST BOARD HELD ON 21 MARCH 20182018/43 Gender pay gap

Ms Owen, non-executive director, said that she would like to see a very focused plan of three items with clear outcomes defined. The group chief executive commented that it was necessary to fully understand the data in order to arrive at an action plan, but an action plan would be brought back to the board in due course.

Group director of workforce and OD

To be scheduled for the July 2018 board meeting.

Paper 4

Confidential trust board meeting update – trust board May 2018

ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 25 APRIL 2018

Executive summary

Decisions taken at a confidential trust board are reported where appropriate at the next trust board held in public. Those issues of note and decisions taken at the trust board’s confidential meeting held on 25 April 2018 are outlined below. The board discussed the trust’s financial position and performance report, although a detailed discussion also took place within the public part of the meeting. The following matters were also discussed at the meeting:

• 2018/19 annual plan – this has now been submitted and a public version will be published during May 2018

• Group goals – a suite of reports was received reconfirming the group goals and identifying group and hospital unit priorities for the next year. The governance and delivery arrangements were also presented. These are summarised in the chairman and chief executive’s report.

• Outline business case for the sale of Queen Mary’s House and Pond Street Plot D • Information governance – the board was provided with assurance that the trust would be

compliant with two new regulatory information governance requirements : the NHS Data Security and Protection requirements and the General Data Protection Regulation (GDPR)

• The board received a report from a review commissioned by the group chief executive of the trust’s financial improvement programme (FIP). This confirmed that the programme and governance were robust.

Action required

For the board to note.

Report From

D Dodd, chairman

Author(s)Date

A Macdonald, board secretary 3 May 2018



1

GO SEE VISITS

Executive summary

The board agreed to a new approach to go see visits at its December 2017 meeting, building on the previous programme of go see visits designed to increase visibility and engagement between trust leaders and governors with staff.

Go see visits are open to all group directors, including site chief executives, non-executive directors and governors. They will take place monthly and ‘visit’ all areas of the trust, including corporate support services. Prior to the visits, a fact sheet will be provided giving some key information about the areas. This will include information on staffing and where appropriate, patient or client feedback. The current sheet is in the process of being reviewed. Visits are not designed to be inspections, but opportunities to listen to staff and where appropriate, meet patients.

While non-executives will continue to be paired with governors, executive directors will visit a separate set of areas.

Three key questions will be asked:

1. What is working? 2. What is not working? 3. What would you like to change?

This information will be fed back verbally at the following trust board meeting. Logistically this will mean there is feedback from more than one area. This will be dealt with by a list of areas visited being circulated in the papers and the chairman asking for any specific areas to be highlighted.

Since the last meeting the following visits have taken place. Work has now commenced on organising the next set of visits.

Area DirectorICU nursing (QI area to reduce turnover) Mary Basterfield and Wale Bakare Endoscopy (RFH) Glenn Winteringham Gastroenterology –irritable bowel disease Pathway (QI area) Wanda Goldwag, Vineeta Manchanda, Anthony

Isaacs Emergency department (RFH) David Sloman ITU South (BH) David Sloman Pharmacy at Edgware Community Hospital David Grantham Maternity (RFH) Peter Ridley



2

Action required

The board is asked to note the report.

Report From Emma Kearney, director of corporate affairs and communications

Author(s) Alison Macdonald, board secretary Date 15 May 2018

Page | 1

Finance Report for M1 April

Executive Summary

The trust has submitted a deficit plan of £65.8m for the 2018/19 financial year.

In April the trust delivered an actual deficit of £12.3m. This was £0.6m worse than plan. Clinical income performance for April is currently assumed to be on plan. There is a risk that actual performance could be lower.

The financial plan for 2018/18 includes delivery of £45.4m financial improvement programme (FIP). At end of April, the trust delivered £1.1m of FIP.

The cash balance on 30 April was £41.9m. This continues to be high due to the Parcel B land

sale receipts being ring fenced for the Chase Farm capital redevelopment. The trust

anticipates that it will need to access working capital loans from September onwards. Focus

continues on reducing debt with clinical commissioning groups (CCGs) and NHS England

(NHSE) who account for the majority of the aged debt in order to minimize loan drawdown and

therefore interest charges.

Action required/recommendation

For information

Trust strategic priorities and business planning objectives

supported by this paper

Board assurance risk

number(s)

3. Excellent financial performance – to be in the top 10% of

relevant peers on financial performance

CQC Regulations supported by this paper

Regulation 13 Financial position

Risks attached to this project/initiative and how these will be managed (assurance)

Equality analysis

No identified negative impact on equality and diversity

Report from Group chief finance officer and deputy chief executive

Author(s) Senior Finance Team

Date 16-May-2018


Trust Board Part I 23 May 2018 Paper 6

Paper 6

The Royal Free London

Finance Report M01 FY19 TB Part 1

1

Paper 6

CFO Message

Plan for FY19 is

deficit of £65.8m

1 Trust submitted a deficit plan of £65.8m for FY19. The plan does no meet the required control total for FY19. The plan includes

delivery of £45.4m of FIP for FY19.

Delivered an actual

deficit of £12.3m for

April; £0.6m worse

than plan

2 In April the Trust delivered an actual deficit of £12.3m. This was £0.6m worse than plan. Key drivers for the adverse M1 variance

from plan are

• Lower than planned contribution from PPU activity

• Residual winter pressure costs

• Slippage in FIP schemes

Clinical income performance for April is currently assumed to be on plan. There is a risk that actual performance could be lower

than plan

Delivered £1.1m of FIP in M1

3 FIP target for M1 was £1.3m and the actual delivery was £1.1m for April. The Trust has currently identified £39.3m of plan and imminent schemes to deliver the £45.4m FIP target for the year.

Cash position –

£41.9m at end of

April

4 The cash balance on the 30th April was £41.9m This continues to be high due to the Parcel B land sale receipts being ring fenced for Chase Farm capital redevelopment. The Trust anticipates that it will need to access working capital loans from September onwards. Focus continues on reducing debt with CCGs and NHSE who account for the majority of the aged debt in order to minimize loan drawdown and therefore interest charges. The Trust is continuing to manage its cash position in the best interests of both patients and creditors.

2

M01 (April) Performance FY19 Paper 6

M01 Overview M01 (April) Performance FY19 Paper 6

Page 1 of 1

Operational performance report


The board is asked to review the current performance of RFL against the key cancer, A&E

and RTT operational performance standards




number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

X

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

X



4. Excellent compliance with our external duties – to meet our

external obligations effectively and efficiently

X

5. A strong organisation for the future – to strengthen the

organisation for the future


Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 12 Safe care and treatment

Regulation 17 Good governance

Regulation 18 Staffing

Regulation 20A⃰ Requirement as to display of performance assessments


Failure to achieve and maintain compliance against Monitor risk assessment framework

standards and targets.

Equality analysis

• No identified negative impact on equality and diversity

Report from Peter Ridley

Director of planning

Authors Sally Dootson, chief executive (Barnet), Sarah Dobbing, chief executive

(RFH) Amy Caldwell-Nichols, head of group performance

Date 17 May 2018


Part 1 Trust board meeting 23 May 2018 Paper 7

Paper 7

Royal Free London –operational performance

May 2018

Paper 7

2

Operational performance summary report

Where we are Predictions Key Risks

Cancer – Feb 2018

• Performance in March was reported at 83.3%, bringing performance for the quarter to 84.3%

• The majority of breaches were in the breast, lower GI, gynae and prostate pathways

• Un-validated April performance is 77.6%

• The backlog has increased since Easter - now 130-135 compared to 70-75 in March leading to high risk of non-compliance in April and May

• We have seen high referrals in:• Breast• Bladder• Prostate

• These have driven the trust PTL above target and are now having an impact on backlog

• We have also seen a rise in the lower GI backlog since the beginning of March that has persisted

RTT –Feb 2018

• Performance in March 2018 was 83.1%, similar to January and February

• 35 over 52 week waiters, compared to 32 in February

• Expect persistence of >52 week waiters due to ‘pop-ons’ until Patient Tracking List construction problems are fully resolved

• The quality and availability of our data in this area is a priority for improvement

A&E –Mar 2018

• Overall performance in Marchwas 87.6%

• Barnet – performance is stable and consistently better than the same time last year

• RFH – performance recovered to 86.7%, though below this time last year

• Expected improvement in performance in line with summer reduction in admissions

• Further improvements at RFH via opening of new AAU in mid-May 2018

• Development of AAU proposal at BH

• Performance problems at other trusts, leading to redirections of ambulance and walk-in activity

• Volatility in attendances and admissions

Paper 7

3

62 Day Cancer – Performance Summary

Current Period March: stable, ahead of last year, below trajectory and standard at Trust level

Relative position Mar 2018: 3rd quartile in London

% cancer patients waiting < 62 days from GP referral to first treatment

Source: NHS England, May 2018

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

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

Standard Trajectory 2017/18 2016/17

Trust name Mar-18

Croydon Health 93.1%

Kingston 92.4%

Epsom & St Helier 90.8%

Whittington 90.7%

Kings College 88.5%

St George's 88.1%

Hillingdon 87.8%

Barts Health 87.0%

Barnet & Chase Farm 86.6%

Chelsea & Westminster 86.3%

BHR 85.9%

Imperial 85.3%

London North West 85.2%

North Middlesex 83.6%

Royal Free London 83.3%

Homerton 80.5%

Lewisham 80.0%

Royal Free Hospital 79.8%

UCLH 76.2%

Guys & St Thomas' 75.1%

Peer Average 85.5%

Paper 7

4

-3

-2

-1

0

1

2

3In March, 4 out of 15 tumour/hospital site combinations accounted for 49% of the trust’s total breaches:

● Lower GI-BCF 3 breaches (performance 50%)

● Gynae-BCF 2.5 breaches (performance 50%)

● Lung-RFH 2 breaches (performance 50%)

● Urology-RFH Prostate and renal 3 breaches (performance 79.3%)

62 Day Cancer – Sources of Current Performance

February Performance by Tumour/Hospital Combination Observations

Number of excess patient breaches*

* Actual breaches minus breaches that would have been incurred if the tumour site were exactly at 85% standard

49% of total RFL breaches

8 tumour –hospital sites meeting 85%

standard

12 tumour-hospital sites not meeting

85% standard

Paper 7

5

62 Day Cancer – Diagnosis and Actions

What is our diagnosis of what is driving current performance and future risks?

What are our action priorities and what is our status on them?

1. Increases in referrals to breast pathway which may be a result of the current Public Health England breast cancer awareness campaign

2. Increase in backlog for Lower GI at Barnet Hospital

3. Increase in referrals to prostate and bladder pathways, potentially as a result of high profile cases. Public Health England haematuria campaign running over July-August.

4. Late referrals to the plastics service at RFH

1. Re-plan breast capacity based on recent levels of demand, put in place temporary capacity at Finchley Memorial Hospital

2. Full review of straight to test pathway and identification of bottlenecks and pathway flaws. Follow-up deep dive on 08/06/2018.

3. Re-plan prostate and bladder capacity based on current levels of demand with uplift in capacity for July/August.

4. Contact referring trusts with planned pathway

Paper 7

6

RTT – Performance Summary

Current Period March 2018: stable and below standard and trajectory

Relative position Mar 2018: 3rd quartile in London

% patients waiting < 18 weeks from referral to treatment


Trust name March 2018

Homerton 95.4%

Kingston 93.2%



Whittington 92.3%


UCLH 91.0%

Hillingdon 88.8%


Lewisham 88.1%

BHR 87.1%



Imperial 83.3%



Kings College 80.5%

Barnet Hospital 80.3%

Barts Health N/A

St George's N/A

Peer Average 88.4%

70%

75%

80%

85%

90%

95%

100%



Paper 7

7

0

10

20

30

40

50

60

70



RTT – Sources of Current PerformanceCurrent Period Performance by Specialty/Hospital Combination

* Actual breaches minus breaches if achieving 85% standard

Barnet Hospital Royal Free Hospital

Current Period > 52 week waiters

Introduction of new patient

tracking list

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%


80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%


Mar-18 = 35

Paper 7

8

RTT – Diagnosis and Actions

What is our diagnosis of what is driving current performance?


1. The Patient Tracking List (the waiting list) continues to suffer from unexpected ‘pop-on’ long-waiting patients.

2. The full suite of waiting list and performance reports is not yet available to operational and clinical teams to enable them to monitor their performance and act on early warnings.

3. Need for productivity improvements in outpatients and theatres.

4. Need for close oversight of new >52 week waiters.

1. Revise the construction of the Patient Tracking List with support from the Intensive Support Team

2. These reports will rely on construction of accurate waiting lists so this work is being prioritised. Once released we will develop Qlikview performance dashboards similar to that already developed for Cancer

3. The outpatients productivity programme work has started and we are refreshing our theatres productivity programme. This will include a re-designed theatres productivity dashboard.

4. Weekly PTL reviews of >40 week waiters and regular escalation meetings for specialties of concern.

Paper 7

9

A&E – Barnet Sources of Current Performance

Current Period Performance

Performance against 4 hour standard

DTOC and MOs

Stable and similar to last year, though still below standard

Current actions• Running ED ‘super-week’ in w/c

14/05/2018

Total DTOC and MO bed days DTOC by borough – April 2018

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


1,795

1,386

1,607

2,129

1,8031,688

1,7651,617

1,292

1,7351,565

1,728 1,659

0

500

1,000

1,500

2,000

2,500MOs

DTOCs

Herts Barnet Enfield Others

Social Care 14 16 5 8

NHS 156 127 81 11

Total 170 143 86 19

020406080

100120140160180

Paper 7

10

A&E – Barnet Diagnosis and Actions



1. Attendances continue to be high but are reducing. Flow has improved but is not consistent.

2. Some infection control challenges have limited bed capacity We are reducing our winter bed capacity.

3. We currently have increased DTOC reducing flow through our bed base.

4. ED workforce vacancies cause inconsistent staffing levels & skill mix

1. Focus on early discharge, planning for the next day & keeping ED and the front door flowing.

2. Developing AAU proposal

3. Daily multiagency review meetings continue

4. Workforce plan in place & reviewed weekly but the divisional team

Paper 7

11

A&E – Performance Summary

Current Period April 2018: stable and similar to last year, on trajectory but below standard

Relative position Apr 2018: 2nd quartile in London

% patients waiting < 4 hours in A&E


50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Trust name April 2018


Homerton 94.3%


Kingston 88.9%

St George's 88.4%




Lewisham 87.6%



Whittington 86.3%

Barts Health 86.2%

Imperial 84.6%

Barnet Hospital 84.5%

UCLH 83.5%


Hillingdon 80.3%

BHR 79.0%

Kings College 78.8%

Peer Average 86.6%

Paper 7

12

A&E – Royal Free Sources of Current Performance

Current Period Performance

Performance against 4 hour standard

DTOC and MOs

Similar to performance last year; below standard

Current actions• Improved flow through the hospital

(high number of discharges), has reduced delays for beds

• Improved streaming and ambulance handover times

• AAU opening 17th May

Total DTOC and MO bed days DTOC by borough – April 2018

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


1,434 1,4111,473

1,334

909

1,262

1,1281,229 1,221 1,265

862

1,221 1,198

0

200

400

600

800

1,000

1,200

1,400

1,600MOs

DTOCs

Camden Barnet Brent Enfield Haringey Other

Social Care 38 8 25 0 21 0

NHS 125 109 7 24 0 53

Total 163 117 32 24 21 53

0

20

40

60

80

100

120

140

160

180

Paper 7

13

A&E – Royal Free Diagnosis and Actions



1. ED process delays. Breach reports suggest that 40%-50% of current breaches are attributed to ED processes.

2. ED workforce capacity. We need to complete our middle grade and consultant establishments.

3. In-hospital flow. Current average length of stay for patients who stay at least 1 day is 7.3 days.

4. Out of hospital capacity. DTOCs have increased as we have improved our process for capturing information. The % of stranded patients has declined as we have focused on MDT reviews of these patients.

1. CPG work now focusing on improvement in: Streaming, the SitRep process and AAU. Streaming is improving with 73% of patients last week seen within 15 minutes.

2. Revised ED workforce plan has been developed, with support from ECIP.

3. The new Adult Assessment Unit (AAU) will open in May, and focus is on delivering a new models of care for this

4. Improved focus on DTOCs and additional resource within the discharge team has led us to identify more patients who are delayed, and therefore an increase in DTOCs. Each division has a weekly stranded patient review.

Paper 7

Paper 8

1 X:\ Chair and CEO report 23 May 2018

CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

Executive summary

This is a combined chairman’s and chief executive’s report containing items of interest/relevance to the board.

Action required


Report From D Dodd, chairman and D Sloman, chief executive Author(s) Alison Macdonald, board secretary Date 14 May 2018



Paper 8


CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

A TRUST DEVELOPMENTS

CHASE FARM HOSPITAL REDEVELOPMENT UPDATE

The redevelopment of Chase Farm Hospital remains on budget and the handover of the new hospital is scheduled for 12 July 2018.

It is planned that the first patients will be seen in the new hospital on 30 July 2018, in outpatients. A detailed timetable of sequential moves has been agreed, whereby all other services will move during July, August and September. The communications team will be implementing a plan over the coming weeks to communicate key dates to stakeholder groups. Letters are being sent to patients whose next appointment will be in the new hospital. Works to roads and landscaping will be completed in 2019, after which an official opening ceremony will take place.

The trust project team continues to support staff in preparing to mo ve into the new hospital. Designated move managers have been identified in each department, and teams have been provided with move checklists and plans setting out when they will receive training for new information management and technology (IM&T) systems. Significant clinical engagement is underway to sign off the design of the new IM&T systems and oversee the transition to a digital paperless hospital at Chase Farm. This work will realise efficiencies, making a major contribution to the trust’s financial strategy. Staff consultations are underway to agree shift patterns in the new hospital, and effect the changes required to move into the new hospital.

ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT REDEVELOPMENT UPDATE

The Royal Free Emergency Department redevelopment is being undertaken under two contracts. The first has been completed, which provided a new dedicated paediatric emergency department and waiting area, new staff facilities and office accommodation and a new ambulatory care unit.

Contract 2 started on 26 September 2016 and comprises three main phases. The first phase of the construction works has delivered Part 1 of majors, a new reception desk, and the rapid assessment and treatment area including new London Ambulance Service handover facilities. Phase 2 which provides a new imaging facility (including two x-ray rooms and one CT suite) and a six bedded resuscitation unit was completed in November 2017. Work is now progressing on the final phase which completes the majors’ facility and delivers a new 30 bedded clinical decision unit (CDU) transferred on 17 May 2018. The remaining works allow for some minor changes to allow temporary rooms to convert into their final usage. The project is making good progress and the clinical and project teams are working closely to maintain clinical operations at all times

Paper 8


THE PEARS BUILDING

Construction work on the Pears Building which will house the UCL Institute of Immunity and Transplantation is running to schedule.

The construction working group has met with a new chair: Rob Leak, a trustee of the Royal Free Charity and former chief executive of Enfield Council. The terms of reference are being broadened to allow any local individual or group to attend and to allow community input into the meeting agendas.

A governance structure to oversee the development is being discussed in the confidential board meeting and a summary will be provided in the next chairman’s and chief executive’s report.

B REGULATION

INFORMATON COMMISSIONER’S OFFICE (ICO) UNDERTAKINGS

The trust continues to work through the undertakings agreed with the Information Commissioner. Regarding the commissioning of a third party audit of the current processing arrangements between the data controller and DeepMind, the ICO approved the trust’s suggestion of Linklaters LLP and the scope of the audit. The report of the audit was submitted to the ICO by the end of March 2018; the ICO has been in touch with the trust to clarify some points following which the report can be finalised and published.

C BOARD AND COUNCIL MATTERS

No items this month.

D LOCAL NEWS AND DEVELOPMENTS

GROUP GOALS AND GOVERNANCE

At its April meeting, the board discussed a suite of papers which described the group goals and how these translated into the governance structure.

The board approved primary objectives for 2018/19 in the context of group goals and hospital strategies.

The primary objectives are:

1. All sites rated CQC outstanding for leadership (well-led) 2. Develop our partnership with North Middlesex University Hospital 3. Chase Farm open in 2018 4. Achieve our financial improvement target 5. Eliminating never events 6. Improve A&E performance 7. Meet the cancer access target

Paper 8


8. Eliminating 52-week waits 9. Make progress on inclusion and the WRES 10. Implement the GDE 11. 20 Clinical Pathways embedded 12. Building relationships for an integrated care system

ESTATES OPERATING MODEL

As part of the development of the RFL group, the trust continues to review and consider the way its estates service functions across an enlarged organisation. Initially, the focus remains on the option of forming a company, wholly owned by the trust, the purpose of which would be to deliver the property services required for the new Chase Farm Hospital that will open later this year.

NEW TRUSTEES APPOINTED AT ROYAL FREE CHARITY

The Royal Free Charity re-appointed one trustee and appointed four new trustees to its board in April. Judy Dewinter, Michael Luck, Robert Leak and Steve Shaw are the new trustees and Christine Fogg, who has been a trustee of the charity since 2008, is the new chair. Caroline Clarke, group chief finance officer, was already a trustee of the Charity.

Judy Dewinter had a successful career with a leading stockbroking firm, running their European equity business until 2003, when she started treatment for multiple myeloma. While recovering she decided to focus her efforts on improving the treatment and care of myeloma patients in the UK, joining the board of Myeloma UK, where she has been chairman since 2006. Judy is also lead governor at the Royal Free London NHS Foundation Trust.

Michael Luck is director of business development for Sainsbury’s.

Robert Leak spent the first part of his career in senior management positions in the retail sector, before moving into local government. He was chief executive of Enfield Council for 14 years, retiring in May 2017.

Dr Steve Shaw took up the role of chief executive officer at BH in July 2017. Steve is qualified in both medicine and dentistry and has been a consultant in intensive care for more than 20 years. Steve was clinical director for intensive care at RFH for many years and more recently divisional director for urgent care.

Christine Fogg joined the Royal Free Charity’s board of trustees in July 2008 and works independently as a management consultant and executive coach. She was chief executive of Breast Cancer Care from September 2000 until early 2008. Prior to this she was the chief executive of two HIV/AIDS charities and also worked in NHS management within the HIV/AIDS and sexual health field.

NEW ADULT ASSESSMENT UNIT OPENING AT THE ROYAL FREE HOSPITAL

A new adult assessment unit (AAU) opened at the RFH on 17 May under the management of medicine and urgent care.

Paper 8


The unit provides rapid assessment and turnaround for patients to be discharged within 24 hours or transferred to an in-patient bed. The unit is located on the lower ground floor next to the emergency department (ED), where building work has been ongoing for some months.

The current ED clinical decision unit (CDU) has moved into the AAU, creating nine beds, which was followed by the opening of a further nine beds on 17 May when ward 6E closed. Although the new AAU initially has 18 beds, capacity is expected to be expanded to 30 beds during winter 2018.

NURSING AND MIDWIFERY WEEK 2018 AT THE ROYAL FREE LONDON (RFL)

The RFL celebrated nursing and midwifery week 2018 between 5-12 May. This is an annual event incorporating international nurses day on 12 May and international day of the midwife, which takes place on 5 May.

A series of events and activities across all of the trust’s hospitals were held during this week, bringing together and celebrating all staff working in these professions. Celebrations included the nursing and midwifery assistants’ awards ceremony, the Cordwainers scholarship awards and clinical practice stall events on all three sites.

FRIENDS AND FAMILY TEST (FFT) UPDATE

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feed back on their care and treatment to enable hospitals and other providers to improve services.

It asks patients whether they would recommend hospital wards, A&E departments, maternity services and out-patient clinics to their friends and family if they needed similar care or treatment. The April results are below.

Royal Free London combined data

% likely/extremely likely to recommend April 2018

(range: 0 – 100%)

Number of patient responses

In-patient 89% 1252

A&E 85% 5100

Barnet Hospital % likely/extremely likely to recommend April 2018

(range: 0 – 100%)


In-patient 87% 366

A&E 82% 2438

Antenatal care 100% 3

Paper 8


Labour and birth 98% 51

Postnatal hospital ward 95% 64

Postnatal community care 100% 90

Out-patients 90% 256

Chase Farm Hospital % likely/extremely likely to recommend April 2018

(range: 0 – 100%)


In-patient 97% 153


Royal Free Hospital % likely/extremely likely to recommend – April 2018

(range: 0 – 100%)


In-patient 88% 733

A&E 88% 2662

Antenatal care 100% 2

Labour and birth 95% 41

Postnatal hospital ward 90% 41

Postnatal community care 100% 90


COMMUNICATIONS BOARD REPORT: APRIL 2018

Media coverage

The trust was mentioned in 259 stories. Main positive stories:

• We were listed as one of the 10 trial trusts with cancer ‘one stop shops’ to diagnose cancer faster.

• An editor’s opinion piece in the Ham & High urging readers to see the bigger picture regarding the construction of the Pears Building and to get behind the project.

• Widespread positive coverage, for our reintroduction of china cups and saucers instead of plastic cups.

The table below shows the sentiment of press mentions in April:

Paper 8


April Royal Free London Barnet Hospital Chase Farm Hospital

Total

Positive 89 1 1 92Neutral 101 4 5 110Negative 58 0 0 58Total 248 5 6 259

The negative mentions were mainly criticism of setting up subsidiary companies following national coverage of a Unison report. There were seven negative items related to the Royal Free London’s connection to the construction of the Institute of Immunity and Transplantation (the Pears Building).

Digital Communications Total number of Facebook followers: 5549 (+ 68) Number of Posts: 30, reaching 59k peopleTotal number of Twitter followers: 15,371 (+ 158) Number of Tweets: 56, reaching 120.2k people Our top tweet was a response to positive feedback posted on Twitter by Michelle Collins, a well-known TV and stage actress.

Internal communications

Clinically-led digital transformation: we’ve developed a fully integrated communications and engagement plan to support our journey to see us becoming the most digitally advanced trust in the UK. Together with developing a new brand identity, the plan uses targeted messaging to engage with staff via existing channels and new ones, including special events, film and toolkits.

Theatre strategy programme: we continue to publicise the theatre strategy programme, with prominence on the home page of Freenet and our website. We’ve also produced new letter templates to support the pain management elective procedure changes and further resources are being developed for this.

endPJparalysis national campaign: we pledged our support towards the national #endPJparalysis 70-day challenge on 17 April. The #endPJparalysis campaign aims to encourage patients to get up, get dressed and get moving. Several teams across the trust, as well as all four directors of nursing, made pledges in support of the campaign, which were our top posts of the week on Facebook and Instagram between 14-20 April.

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E NATIONAL NEWS AND DEVELOPMENTS

NEW CARE QUALITY COMMISSION (CQC) CHIEF EXECUTIVE APPOINTED

Ian Trenholm has been appointed as CQC’s new chief executive and will take over the role from Sir David Behan when he leaves in July.

Mr Trenholm has been chief executive of NHS Blood and Transplant since 2014. Having started his career in the police service, his previous roles include chief operating officer at the Department of Environment Food and Rural Affairs (Defra) and chief executive of the Royal Borough of Windsor and Maidenhead.

CARE QUALITY COMMISSION (CQC) BOARD MEETING – 18 APRIL 2018

The main items discussed are summarised below.

Chief executive’s report • Care Quality Commission’s (CQC’s) response to the Health Education

England (HEE) draft workforce strategy consultation highlights that:

• the findings from CQC’s local system reviews have identified capacity and capability of the workforce as one of the most significant challenges faced by systems in the delivery of joined-up care for older people, and a shortage of social care staff in domiciliary care, nursing homes and care homes is a major contributing factor.

• the workforce strategy needs to consider the right model of care for the future and then consider how to secure the staff needed accordingly.

• training a wider range of staff, particularly in social care, to support the multidisciplinary teams that the system will need and around new care models, is important.

• system-wide solutions such as supporting flexible working across the health and social care interface should be considered, including initiatives such as ‘passports’ that allow staff to move across health and social care.

• while some local systems are working proactively to develop career pathways within the care sector, competition from other sectors means the care sector is facing difficulty in attracting and retaining staff.

• works needs to be considered to move to the ‘health and social care system’ (and not just the NHS) being the employer of choice.

• CQC published its 2018/19 fees scheme in March 2018 following consultation. The new scheme changes the fees structure for NHS trusts with larger providers generally paying more and smaller providers less.

• CQC has written to all 10 existing Integrated Care Systems (ICSs) to discuss its relationship and engagement arrangements.

• CQC and NHS Improvement’s (NHSI’s) joint thematic review of ‘Never Events’ is due to be published in October 2018 with an interim progress update to the Secretary of State this summer. It will look at how NHS safety guidance is

Paper 8


performing and how effective the implementation of guidance is within NHS trusts.

• Following the announcement that NHS England and NHSI will work together more closely, they have committed to working with CQC and other partners over the coming months to design these joint ways of working.

Paper 9

Page 1 of 4

FINAL chair approved

Report from the quality improvement and leadership committee (QILC) meetings held

26 March and 27 April 2018

Executive summary

To follow is a report outlining the key items discussed and actions taken at the QILC meetings on 26 March and 27 April 2018 are outlined below.

Action required

The trust board is asked to note the report.

Trust strategic priorities and business planning objectives supported by this paper

2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and

staff experience

4. Excellent compliance with our external duties – to meet our external obligations

effectively and efficiently


Regulation 9 Person-centred care Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 16 Receiving and acting on complaints Regulation 18 Staffing


Any risks would be outlined in the report.

Equality analysis

No identified negative impact on equality and diversity

Report from Jenny Owen, non-executive director and chair of the QILC

Author(s) Veronica Jackson, committee secretary

Date 9 May 2018



Paper 9

Page 2 of 4


26 March 2018

• Group goals and group board assurance framework – QI&LC aligned goals A recommendation was made to transfer the committee’s goal in respect of the ‘Top 10% for workforce efficiency’ to the group executive committee (GEC). Although staff engagement was definitely a focus for the QILC, it considered that staffing more widely should be the responsibility of GEC particularly as staffing levels were aligned to the Financial Improvement Plans which were reviewed by GEC. A goal change request would be presented to the trust board in May for consideration.

• Quality improvement Presentation The committee received a presentation on the QI project within theatres, Chase Farm Hospital to improve the turnaround times between surgical procedures in the urology theatre from 20 minutes (average) to 10 minutes (average) by April 2018. It heard of the QI methodology that had been applied, noting that the team considered having the support of a dedicated QI coach to help define the project helpful. A discussion was had on the main learning from the project; it was noted that the availability of robust data had helped influence decision making and gain support for change ideas, and the need to involve other members outside of the team such as consultants and admin had been challenging initially but was improving.

General update The committee noted that there was good momentum on a number of areas of QI work and, overall, QI was being successfully integrated across the trust. However, work was needed to ensure the impetus was not lost and that the Improvement Science In Action work was aligned with the site’s daily priorities, whilst ensuring staff had access to support and the tools to progress QI work.

• Cancer and dementia patient experience The committee received its regular updates on work being undertaken in respect of improving the cancer patient and dementia patient experience. The chair noted the vast amount of work being undertaken on both fronts, and was pleased to see the trust’s cancer lead was moving forward in recruiting additional staff resource, and the dementia team’s progress on the action being taken to help improve the trust’s performance in the next round of the national dementia audit.

• Quality account priorities 2018-19 The committee requested a minor amendment to the wording around ‘improving our involvement with stakeholders’ so that is referred to ‘patients and carers’ specifically, and in terms of ‘improve infection prevention and control’, E-coli would replace MRSA.

• National staff survey results The committee was pleased to note that response rates had improved but there was disparity across sites / groups in terms of the numbers responding. Given the challenging national context, it was pleasing to see that the trust had maintained a good position in terms of patent and staff engagement. Plus, the roll out of the work on clinical practice groups (CPGs) and QI later in the year appeared to also have had a positive impact in that respect. From the QILC’s perspective, the chair considered it was important to ensure that non-clinical staff were included within and felt engaged in the QI and CPG work and it would be helpful to identify staff groups across the organisation that were not benefiting from the trust’s leadership programmes.

Paper 9

Page 3 of 4


• Equality Workforce Race Equality Standards (WRES) The committee received a progress update against a number of the WRES based trust board actions, and noted that the trust was making progress in respect of the WRES data. It was recognised that there was more to do in ensuring the trust’s messages to staff and patients around WRES were more compelling in order to ensure everyone was on board.

Workforce disability equality standards (WDES) The committee noted that there was an issue around staff disclosing that they had a disability, and there was disparity in the figures with more staff having reported themselves as having a disability in the 2016 staff survey compared to the number on ESR. Despite this, there had been a slight shift in the numbers confirming a disability when comparing the 2016 and 2017 data. As with WRES, it was noted that managers etc. would be required to undertake disability unconscious bias training. The committee would continue to receive progress reports against the WDES.

Gender pay gap The committee noted that the report was fulfilling a statutory duty under Equality Act 2010 regulations which required all public sector organisations with 250 or more employees to calculate and publish details of their gender pay gap (GPG). Overall, the trust’s position was better than that seen in the private sector but there were areas that required improvement. It was noted that more sophisticated and targeted analysis of the data was required alongside the need for a clear and focussed action plan and communications.

• Leadership and talent The committee noted that the trust board had approved the proposal to amend the two group goals relating to leadership, merging them into one goal and the proposed alternative measure. The revised goal now read, ‘Top 10 for leadership’ and the leading indicator was ‘recognition and value of staff by managers and the organisation’. The committee also noted the outcomes from the Leading without Formal Authority training needs analysis report and noted the delivery planned for 2018/19. The committee considered that the picture was positive overall.

In terms of talent development, the committee noted that GEC had provided a clear steer on identifying business critical roles; this meant that there was now a larger pool of staff than originally suggested and so the challenge was greater and would take longer to action. Work was underway to review the data on the number of staff within those groups, including those that had been appointed within the last 12 months, and to identify clear selection criteria.

• Move to monthly QILC meetings The committee’s one-hour meeting would focus on key two to three issues to help progress the committee’s goals. The first of the one-hour meetings would take place on 27 April 2018 and focus on patient participation and engagement, and reports from the local patient and staff experience and workforce committees (PSE&WCs) on progress made since their establishment. It was noted that given the lighter agendas at the one-hour meetings, there would be no need for all attendees to join the meeting if they felt the discussion items were not relevant to their work area. However, all members would be expected to attend.

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27 April 2018

• Patient participation and engagementThe committee held a detailed discussion on how to find and recruit patients to participate in key trust projects and areas of work, such as CPGs, board committees and other formal structures, and QI projects, and how staff could be supported with that undertaking. It was noted that there were a number of the trust’s existing groups that could offer a useful pool of patients to liaise with, e.g. patient governors, membership and volunteer base, which provided a sense that patient involvement at a trust level could be achievable. There were also tools, such as the Point of Care Foundation guidance and training, available to assist the trust in taking this work forward. Further consideration was needed, however, on how to ensure there was good quality patient representatives that could deliver on what each area / project required; how to ensure that there was a diverse group of patient representatives that reflected the trust’s user base; how best to reach out to relevant patient cohorts etc.; and ensuring the patient co-design process was not heavy handed or over complicated. The Royal Free Charity was keen to be help where necessary and it was agreed that a paper on this, including the financial ask, would go to the RFC board in June.

• Reports from the PSE&WCs The committee received detailed reports from each of the site’s PSE&WCs on action taken, decisions made etc. since their inception under the new group governance structure. It was clear that there was a huge amount of work going on at a local level, and the committee was pleased to see that efforts had been made in improving patient and staff experience across all three hospital sites. It noted that the staff experience element of the meetings were well attended and were being well received by staff. The committee was also pleased to see that Barnet Hospital’s committee had a patient representative at the meeting which was adding a new, real dimension to the discussions. It was hoped that clarity around the trust’s patient participation and engagement processes would assist the Royal Free Hospital and Chase Farm Hospital PSE&WCs in recruiting patient representatives to sit on their meetings.

End

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Page 1 of 3 Final approved

Report from the clinical standards and innovation committee (CSIC) held 9 April 2018

Executive summary

The CSIC met on 9 April 2018. The key issues discussed and actions agreed are outlined below.

Serious incidents The committee received the serious incident (SI) performance update, noting the number of new SIs reported in March and confirmed Never Events (NEs) during the year. There appeared to be an upward trend in the number of overdue SIs by site and the committee noted the challenges associated with this, including staff resourcing issues. The committee was assured that this trend was being kept on the patient safety and risk team’s radar and had also been raised with the serious incidents review panel. It was suggested that the resourcing issue would be a good topic for the local clinical performance and patient safety committees (CPPSCs) to monitor and report progress back to the CSIC.

The committee noted that oversight of the closure of the actions arising from SI investigations was taking place at both the CSIC held every other month, plus the local CPPSCs on a quarterly basis. The frequency of reporting to the latter would be reviewed once the new clinical governance staff were in post across each of the sites. The committee noted that this was an example of an assurance process that had been reallocated within the new group governance structure. It was suggested that it would be helpful to assure the trust board of the SI work being undertaken behind the scenes, not just the numbers, and consideration would be given to how that could best be achieved.

Seven day service national audit The committee noted that Barnet Hospital had been working on addressing the documentation gaps identified in the last (fourth) round of audit, e.g. capturing all consultant reviews, to ensure it was in a better position going forward to the next round of data submission in May 2018. It was agreed that the CSIC would receive an indicative view of whether the site’s performance had improved or not at the May meeting. The full results from the fifth round of the national audit would be analysed at the Barnet Hospital CPPSC and reviewed at CSIC thereafter.

Never event action plan implementation update The report had been submitted to assure the committee that action plans arising from NEs were being monitored accordingly and that sufficient evidence was being presented to enable actions to be closed off. It was agreed that the report would come back to the CSIC on a monthly basis until all actions were completed (green).

C. difficile deep dive The committee received a presentation on the trust’s C. difficile infection rates. The discussion focussed on the number of infections, including ‘lapses in care’ cases, the risk



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factors including the main modifiable risk factors, i.e. the acquisition of C. difficile and antimicrobial exposure, and control measures, for example hand hygiene processes and deep cleaning programmes.

The committee noted that an action plan was in place to reduce the number of C. difficile cases. It focussed on greater feedback around cleaning scores; a request to the group executive committee for additional antimicrobial stewardship; ensuring the necessary clinical input into RCAs (root cause analyses), particularly on busy wards; electronic patient tracking on beds; and a suggestion from previous external audit to make infection prevention and control and antimicrobial stewardship part of the consultant appraisal.

Action required





number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

x

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

x



4. Excellent compliance with our external duties – to meet our

external obligations effectively and efficiently

x

5. A strong organisation for the future – to strengthen the

organisation for the future

x


Regulation 4 Requirements where the service provider is an individual or partnership

Regulation 5 ⃰ Fit and proper persons: directors

Regulation 6 Requirement where the service provider is a body other than a partnership

Regulation 7 Requirements relating to registered managers


Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 15 Premises and equipment

Regulation 16 Receiving and acting on complaints


Regulation 18 Staffing

Regulation 19 Fit and proper persons employed

Regulation 20⃰ Duty of candour

Regulation 20A⃰ Requirement as to display of performance assessments

Care Quality Commission (Registration) Regulations 2009 (Part 4)

Regulation 12 Statement of purpose

Regulation 13 Financial position

Regulation 14 Notice of absence

Regulation 15 Notice of changes

Regulation 16 Notification of death of a service user

Regulation 17 Notification of death or unauthorised absence of a service user who is

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detained or liable to be detained under the Mental Health Act 1983

Regulation 18 Notification of other incidents

Regulation 19 Fees

Regulation 20⃰ Requirements relating to termination of pregnancies

Regulation 22A⃰ Form of notifications to the Commission


N/A

Equality analysis

• No identified negative impact on equality and diversity

Report from Prof Anthony Schapira, non-executive director and chair of CSIC

Author(s) Veronica Jackson, committee secretary

Date 14 May 2018

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Page 1 of 2

Final

Report from group services and investment committee (GSIC) meeting held 10 May

2018

Executive summary

The group services and investment committee (GSIC) held on 10 May 2018. The key items discussed and decisions taken are outlined below.

Property Services Company GSIC reviewed and provided comments on a further draft of the business case proposing the implementation of a new operating model and the establishment of a wholly owned subsidiary company for the delivery of capital project, property, estates and facilities management services. It noted that a final decision on this proposal would be required from the board in May.

Queen Mary’s House (QMH) The committee received an update on the QMH marketing process. The report set out the work planned over the next month, in advance of a paper which would be taken to the GSIC and trust board in June seeking a decision as to whether to select a preferred bidder and commence detailed sales negotiations, or whether to pursue a different sales strategy.

Endoscopy The committee received dialogue 2 of the endoscopy phase 3 business case, including responses to a number of queries that the group executive committee asked be addressed prior to presentation of dialogue 3.

Health Services Laboratory The committee received a general commercial update from an investor perspective.

Financial strategy update as it is relevant to GSIC The committee received an update on the financial strategy and how it was being refreshed. It included the proposed governance of the strategy, with an outstanding question on the role of GSIC within that.

GSIC goals and Board Assurance Framework risks The committee undertook regular review of its group goals;

• efficiency leader on corporate services

• CFH deficit eliminated

• double contribution of private patients

• being a digital exemplar

• proceeds from QMH (>£75m)

The committee also reviewed its forward planner.



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Page 2 of 2

Final

Action requiredThe board is asked to note the report.

Trust strategic priorities and business planning objectives supported by this paper

Board assurance risk number(s)

1. Excellent outcomes – to be in the top 10% of our peers on outcomes

x

2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience

x

3. Excellent financial performance – to be in the top 10% of relevant peers on financial performance

x

4. Excellent compliance with our external duties – to meet our external obligations effectively and efficiently

x

5. A strong organisation for the future – to strengthen the organisation for the future

x

CQC Regulations supported by this paperRegulation 4 Requirements where the service provider is an individual or partnership Regulation 5 ⃰ Fit and proper persons: directors Regulation 6 Requirement where the service provider is a body other than a partnership Regulation 7 Requirements relating to registered managers Regulation 8 ⃰ General Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 15 Premises and equipment Regulation 16 Receiving and acting on complaints Regulation 17 Good governance Regulation 18 Staffing Regulation 19 Fit and proper persons employed Regulation 20⃰ Duty of candour Regulation 20A⃰ Requirement as to display of performance assessments Care Quality Commission (Registration) Regulations 2009 (Part 4)Regulation 12 Statement of purpose Regulation 13 Financial position Regulation 14 Notice of absence Regulation 15 Notice of changes Regulation 16 Notification of death of a service user Regulation 17 Notification of death or unauthorised absence of a service user who is

detained or liable to be detained under the Mental Health Act 1983 Regulation 18 Notification of other incidents Regulation 19 Fees Regulation 20⃰ Requirements relating to termination of pregnancies Regulation 22A⃰ Form of notifications to the Commission

Risks attached to this project/initiative and how these will be managed (assurance)N/A

Equality analysis• No identified negative impact on equality and diversity

Report from Wanda Goldwag, non-executive directorAuthor(s) Duncan Gordon-Smith, trust secretaryDate 15 May 2018

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Page 1 of 2 Final

Report from population health and pathways committee (PHPC) held 24 April 2018 Executive summary The PHPC met on 24 April 2018. The key items discussed and decisions taken are outlined below. Group goals and Board Assurance Framework risks The following was noted:

• Removed £5m from system contracting costs - the committee noted this goal had been considered for an area of de-prioritisation in 2018/19. There was recognition that this was an important goal but it had been suggested that this would benefit from greater focus in 2019/20 instead.

• Urgent and emergency care transformation programme delivered – the committee sought clarity on the committee’s role in respect of this goal. It wished to ensure that it was not duplicating the focus and work undertaken currently by the group executive committee (GEC) on improving the A&E operational performance. Similarly, clarification was needed on how the committee’s role in respect of the trust’s partnership with North Middlesex University Hospital (NMUH) differed from that of the trust / NMUH standing committees already in existence.

• Develop partnerships with non-hospital providers – there was currently no exactness in terms of the goal’s measurement. This would be addressed, and the priority reframed accordingly, for discussion at the next meeting.

The committee noted that individual committee work plans for 2018/19 were being developed and a first iteration of the PHPC’s planner would be taken to the next meeting for discussion. Sustainability and Transformation Partnership (STP) and integrated care in North Central London (NCL) The committee received an overview of the STP. It noted the partnership’s mutually agreed impact and interdependencies for 2018/19, and discussed its role and what its contribution could be in respect of the STP, including defining the trust’s own unique agenda in terms of its vision for population health across NCL. NMUH and trust partnership update The committee received a progress report from the first two meetings of the NMUH / trust joint steering group where a governance structure between both parties was already in place. Specific focus was given to developing a ‘case for change’ and the PHPC’s role in this work versus the role of the joint steering committee and the trust board.

Report to

Date of meeting Attachment number


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Page 2 of 2 Final

It was agreed that a progress update on all the trust’s partnership developments would form a standing item on the committee’s agenda going forward. MSK, urology and gynaecology programme update The committee discussed the integrated MSK, integrated urology and integrated gynaecology services across Barnet and Enfield, for which the trust was currently the lead provider, noting that conversations had been had with the provider programme board on how best to take this work forward in the context of driving integration and financial risk. It was agreed that the regular tender report presented to GEC would also be taken to PHPC as an information item. The committee would need to agree how it would want to oversee community tenders and other integrated care tenders going forward. Action required

The board is asked to note the report. Trust strategic priorities and business planning objectives supported by this paper

Board assurance risk number(s)

1. Excellent outcomes – to be in the top 10% of our peers on outcomes

x

2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience

x

3. Excellent financial performance – to be in the top 10% of relevant peers on financial performance

x

4. Excellent compliance with our external duties – to meet our external obligations effectively and efficiently

x

5. A strong organisation for the future – to strengthen the organisation for the future

x




Any risks will be outlined in the report. Equality analysis

• No identified negative impact on equality and diversity Report from James Tugendhat, non-executive director and chair of the PHPC Author(s) Veronica Jackson, committee administrator Date 9 May 2018

Page 1 of 2

Trust board code of conduct

Executive summary

The NHS Improvement (Monitor) code of governance contains the following requirement:

A.1.9. The board of directors should operate a code of conduct that builds on the values of the NHS foundation trust and reflect high standards of probity and responsibility. The board of directors should follow a policy of openness and transparency in its proceedings and decision-making unless this is in conflict with a need to protect the wider interests of the public or the NHS foundation trust (including commercial-in-confidence matters) and make clear how potential conflicts of interest are dealt with.

Compliance with the code of governance is on a comply or explain basis, which should be covered in the trust’s annual report.

The board approved the attached code of conduct at its meeting on 24 May 2017 and the code requires annual review.

There have been no statutory or governance developments in the intervening period that suggest that any change is required to the code of conduct, other than to add a reference to the General Data Protection Regulation (GDPR). Reference has been added to hospital leadership teams and wholly owned subsidiaries.


The board is asked to approve the enclosed code of conduct and board members are asked

to confirm their continued commitment to compliance with it.

Trust strategic priorities and business

planning objectives supported by this paper Delete those that do not apply

Board assurance risk number(s) if you do

not know risk number, please leave blank , or mark

relevant cell with an X

4. Excellent compliance with our external

duties – to meet our external obligations

effectively and efficiently

5. A strong organisation for the future – to

strengthen the organisation for the future

CQC Regulations supported by this paper Please delete those that do not apply

Regulation 5 ⃰ Fit and proper persons: directors


Trust board 23 May 2018 Paper 13

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Page 2 of 2



The trust is required to either comply with the requirement to have a code of conduct or to

explain why one is not in place.

Equality analysis

• Positive evidence that proposal has considered equality and diversity

Report from Emma Kearney, director of corporate affairs and communications

Author(s) Alison Macdonald, board secretary; Duncan Gordon-Smith, trust secretary

Date 10 May 2018

References Monitor (NHS Improvement) code of governance, Department of Health codes

of conduct and accountability

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Code of conduct for trust board members

1. Introduction

1.1 High standards of corporate and personal conduct are an essential component of public service. The purpose of this code is to provide clear guidance of the standards of conduct and behaviour expected of all directors.

1.2 This code of conduct applies to all voting members of the trust board, namely the chairman, non-executive and group executive directors and other directors who participate in Board meetings. These are all referred to as directors. These standards also apply to the local hospital leadership teams and will apply to the directors of any wholly owned subsidiary of the Royal Free London group.

1.3 This code, together with the NHS constitution, forms part of the framework designed to promote the highest possible standards of conduct and behaviour within the trust. The code is designed to operate in conjunction with the NHS Improvement code of governance, the trust’s constitution and standing orders and other relevant codes of practice.

1.4 This code is complementary to the trust’s world class care values: consistently welcoming, respectful, communicating, reassuring.

1.5 Directors are responsible for complying with the provisions of this code whenever they conduct business of the trust or act as its representative.

2. Principles of public life and public service values

2.1 In 1995, the Committee on Standards in Public Life (the Nolan Committee) identified three public service values and seven principles of conduct underpinning public life “for the benefit of those who serve the public in any way”. These are as follows:

2.2 There are three crucial public service values that underpin the work of the trust.

• Accountability – everything done by the trust must be able to stand the test of external scrutiny, public judgements on propriety and professional codes of conduct.

• Probity – there should be an absolute standard of honesty in dealing with the assets of the trust; integrity should be the hallmark of all personal conduct in decisions affecting patients, staff and others, and in the use of information acquired in the course of NHS duties.

• Openness- there should be sufficient transparency about the activities of the trust to promote confidence in the organisation, by its key stakeholders and the public.

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2.3 These three public service values are underpinned by seven principles of public life applied to members of the trust board, as holders of public office: • Selflessness Directors should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

• Integrity The trust board and its individual directors should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of official duties.

• Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards or benefits, the trust board should make choices on merit.

• Accountability The trust board is accountable for its decisions and actions to the public and must submit itself to whatever scrutiny is appropriate.

• Openness The trust board should be as open as possible about all the decisions and actions that it takes. The board should give reasons for its decisions and only restrict information when the wider public interest clearly demands.

• Honesty Directors have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

• Leadership Directors should promote and support these principles by leadership and example.

3. General principles

3.1 Public sector values matter in the trust and directors have a duty to conduct trust business with probity. They have a responsibility to respond to staff, patients and their families, and other stakeholders impartially, to achieve value for money from the public funds with which they are entrusted and to demonstrate high ethical standards of personal conduct.

3.2 The success of this code depends on a vigorous and visible example from the trust board and the consequential behaviour of all those who work within the organisation. The trust board therefore undertakes to set an example in the conduct of its business and to promote the highest corporate standards of conduct. The trust board will lead in ensuring that the provisions of the NHS constitution, the standing orders, financial standing instructions and accompanying scheme of delegation, conform to best practice and serve to enhance standards of conduct. The trust board expects that this code will inform and govern the decisions and conduct of all directors.

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3.3 The board has confirmed its commitment to compliance with the Bribery Act and to ensure that all staff are aware of their responsibilities in relation to the prevention of bribery and corruption and that the risk of trust exposure to acts of bribery is mitigated. Directors must ensure that they are aware of the implications of the Bribery Act 2010, and of its underpinning principles, and will support related initiatives.

4. Public service values in management

4.1 The trust board will ensure that public service values guide the organisation in achieving its results. The trust board has a duty to ensure that public funds are properly safeguarded and that at all times the board conducts its business as efficiently and effectively as possible. Proper stewardship of public monies requires value for money to be high on the agenda for the trust board.

4.2 Accounting, tendering and employment practices will reflect the highest professional standards. Public statements and reports by the trust board will be clear, comprehensive, understandable and balanced, and fully represent the facts. Annual and other key reports will be issued in good time to all stakeholders in the community who have a legitimate interest in health issues to allow full consideration by those wishing to attend public meetings on local health issues.

4.3 The trust board will maintain a sound system of internal control and establish formal and transparent arrangements for considering how they should apply the financial reporting and internal control principles and for maintaining an appropriate relationship with all its stakeholders.

5. Declaration of interest and conflicts of interest

5.1 Directors will act impartially and will not be influenced by social, family or business relationships. They will not use their public position to further their private interest.

5.2 Directors have a statutory duty to avoid a situation in which they have (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the trust. Directors have a further statutory duty not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity. Directors must make a declaration of interests in accordance with the trust’s conflicts of interests policy on appointment, as changes arise and annually. These will be formally recorded in the minutes of the trust board and entered into a register, which is published on the trust’s website. Failure to register a relevant interest in a timely manner may constitute a breach of this code.

5.3 If directors acquire any relevant interest subsequent to their appointment, they must declare this at the next board meeting so that it is formally recorded in the minutes, and entered into the register.

5.4 Declaration of interests is a standing item at the beginning of every meeting of the trust board or its committees, to ensure that any change in interests is declared and that board or committee members declare any interest they have that is relevant to a matter on the agenda. Their subsequent participation at the meeting will be at the chair’s discretion.

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6. Hospitality and other expenditure

6.1 Directors will set an example to the trust in the use of public funds and the need for good value in incurring public expenditure. All expenditure on these items should be capable of justification as reasonable in the light of general practice in the public sector.

6.2 The trust board is conscious of the fact that expenditure on hospitality or entertainment is the responsibility of management and is open to be challenged by the internal and external auditors and that ill-considered actions can damage respect for the organisation in the eyes of the immediate community and its wider stakeholders.

6.3 The trust has adopted a conflict of interests policy, which covers gifts and hospitality, and which will be followed at all times by directors and all employees. Directors must not accept gifts or hospitality other than in compliance with this policy and must make disclosures in accordance it. Advice on the acceptance of gifts and hospitality should be sought from the Director of corporate affairs and communications trust secretary

6.4 The board should also take cognisance of the trust’s Fraud, Corruption and Bribery Policy and is legally bound by the Bribery Act 2010, under which it is an offence for employees to pay or receive bribes.

7. Relations with suppliers

7.1 The conflict of interests policy includes provisions relating to the declaration of hospitality and sponsorship offered by, for example, suppliers. Their authorisation must be carefully considered and the decision recorded. The trust board should be aware of the risks of incurring obligations to suppliers at any stage of a contracting relationship. Suppliers will be selected on the basis of quality, suitability, reliability and value for money.

8. Fit and proper person

8.1 All directors are required to comply with Care Quality Commission Regulation 5: fit and proper persons: directors. Directors must certify on appointment, and each year within the appraisal process, that they are/remain a fit and proper person. If circumstances change so that a director can no longer be regarded as a fit and proper person or if it comes to light that a director is not a fit and proper person, they are suspended from being a director with immediate effect pending confirmation and any appeal. Where it is confirmed that a director is no longer a fit and proper person, their board membership is terminated.

9. Personal conduct

9.1 Directors must conduct themselves in a manner which maintains the integrity of the organisation and its standing in the NHS and the wider community.

Specifically directors must:

• act in the best interests of the trust and adhere to its values and this code of conduct;

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• respect others and treat them with dignity and fairness; • seek to ensure that no one is unlawfully discriminated against and

promote equal opportunities and social inclusion; • be honest and act with integrity and probity; • contribute to the workings of the board in order for it to fulfil its role and

functions; • recognise that the board is collectively responsible for the exercise of its

powers and the performance of the trust; • raise concerns and provide appropriate challenge regarding the running of

the trust or a proposed action where appropriate; • recognise the differing roles of the chair, senior independent director, chief

executive, executive directors and non-executive directors; • make every effort to attend meetings where practicable; • adhere to good practice in respect of the conduct of meetings and respect

the views of others; • take and consider advice on issues where appropriate; • acknowledge the responsibility of the council of governors to hold the non-

executive directors individually and collectively to account for the performance of the board;

• represent the interests of the trust’s members, public and partner organisations in the governance and performance of the trust; and to have regard to the views of the council of governors;

• not use their position for personal advantage or seek to gain preferential treatment; nor seek improperly to confer an advantage or disadvantage on any other person; and

• accept responsibility for their performance, learning and development.

10. Openness and public responsibilities

10.1 The trust board will make its decisions in public unless there is a justifiable and properly documented reason for not doing so.

10.2 The needs of the population that the trust serves and the resulting provision of services are subject to constant change. The trust board will be open with the public, patients and staff as the need for change emerges. Major changes will be consulted upon before decisions are reached in accordance with statute, guidelines and best practice. Clear and understandable information supporting those decisions will be made available and positive responses will be given to reasonable requests for information.

10.3 The trust will act in a socially responsible and inclusive manner. The trust board will forge an open relationship with the communities it serves. The trust board will actively involve staff, the council of governors and other key stakeholders and partners in setting out a vision for the organisation, which demonstrates concern for the wider health of the population and best use of public resources allocated to the trust. The trust will work in partnership and co-operate with local and national bodies to support the delivery of safe, high quality care.

11. Confidentiality and access to information

11.1 Directors must comply with the trust’s confidentiality policies and procedures. Directors must not disclose any confidential information, except in specified lawful circumstances.

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11.2 Information on decisions made by the trust board and information supporting those decisions should be made available in a way that is understandable. Positive responses should be given to reasonable requests for information and in accordance with the Freedom of Information Act 2000 and other applicable legislation, and directors must not seek to prevent a person from gaining access to information to which they are legally entitled.

11.3 The trust has adopted policies and procedures to protect confidentiality of personal information and to ensure compliance with the Data Protection Act (now replaced by the General Data Protection Regulation - GDPR), the Freedom of Information Act and other relevant legislation which will be followed at all times by the trust board.

11.4 Nothing said in this code precludes directors from making a protected disclosure within the meaning of the Public Disclosure Act 1998.

12. Raising matters of concern – “speaking up” or “whistle-blowing”

12.1 The trust board acknowledges that directors and staff must have a proper and widely publicised procedure for voicing complaints or concerns about maladministration, malpractice, breaches of this code and other concerns of an ethical nature. The trust board has adopted a policy (speaking up policy and procedure ((incorporating whistleblowing/raising concerns policy and procedure)) which should be followed at all times by directors and all staff.

12.2 Where a director believes that a board colleague is non-compliant with all or part of this code, they should raise the matter with the chairman of the board. Where the chairman is the person who is alleged to have contravened the code, the concerns should be raised with the senior independent director.

12.3 The trust board will seek to ensure that NHS resources are protected from fraud, corruption and bribery and that any incident of this kind is reported to the Local Counter Fraud Specialist in line with the counter fraud policy.

13. External communications

13.1 The trust has a guideline for communicating with the media. Directors will be familiar with, and abide by, this policy. All press enquiries must be referred to the communications team.

13.2 When speaking as a director of the board, whether in a public forum or in a private or informal discussion, directors should ensure that they reflect the current policies or view of the trust. They should do so only with the prior knowledge and approval of the director of corporate affairs and communications, and in accordance with the trust’s policy. Where this is not practicable, they should report their action to the director of corporate affairs and communications or their nominated deputies as soon as possible.

13.3 Directors must ensure that their comments are well considered, sensible, well informed, made in good faith, in the public interest and without malice and that they enhance the reputation and status of the trust.

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14. Compliance

14.1 Directors must satisfy themselves that the actions of the board and its members in conducting business fully reflect the values in this code and, as far as is reasonably practicable, that concerns expressed by staff and others are fully investigated and acted upon. All directors are required, on appointment, to subscribe to the code of conduct.

14.2 The chairman and non-executive directors of the board are responsible for taking firm, prompt and fair disciplinary action against any executive or other director in breach of the code of conduct.

14.3 The corporate nature of the organisation will mean that, in most cases, if a decision is open to criticism individual directors will not be legally liable due to the specific statutory protections where they are acting in good faith. However directors who commit a criminal offence will carry personal responsibility for any liability.

14.4 Directors will be cognisant of their responsibilities and appropriate conduct relating to equality and human rights and the related legislation. Non-executive directors have a key role in applying proper scrutiny to equality and human rights in NHS organisations.

14.5 All directors, on appointment, will be required to give an undertaking to abide by the provisions of this Code (appendix A). In addition, directors are required to sign up, on an annual basis, to the Professional Standards Authority 'Standards for members of NHS boards and Clinical Commissioning Group governing bodies in England' (Appendix B – declaration; appendix C – standards). http://www.professionalstandards.org.uk/docs/default-source/publications/standards/standards-for-members-of-nhs-boards-and-ccgs-2013.pdf?sfvrsn=2

15. Review

The code of conduct will be reviewed in April 2019.

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Appendix A

CODE OF CONDUCT TRUST BOARD MEMBERS

DECLARATION

I (full name)……………………………………………………………………..have read, understood and agree to comply with the Royal Free London NHS Foundation Trust’s code of conduct for trust board members.

Signature …………………………………………………….

Date …………………………………………………….

Please return this completed, signed form to:

Duncan Gordon-Smith Trust secretary Royal Free London NHS Foundation Trust

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Appendix B

STANDARDS FOR MEMBERS OF NHS BOARDS AND CCG GOVERNING BODIES IN ENGLAND

To justify the trust placed in me by patients, service users, and the public, I will abide by these standards at all times when at the service of the NHS.

I understand that care, compassion and respect for others are central to quality in healthcare; and that the purpose of the NHS is to improve the health and well-being of patients and service users, supporting them to keep mentally and physically well, to get better when they are ill and, when they cannot fully recover, to stay as well as they can to the end of their lives.

I understand that I must act in the interests of patients, service users and the community I serve, and that I must uphold the law and be fair and honest in all my dealings.

Signature …………………………………………………….

Date …………………………………………………….

Please return this completed, signed form to:

Duncan Gordon-Smith Trust secretary Royal Free London NHS Foundation Trust

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Appendix C

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Documents

GROUP TRUST BOARD MEETING IN PUBLIC A G E N D As3-eu-west-1.amazonaws.com/files.royalfree.nhs.uk/Trust... · 2018-05-21 · GROUP TRUST BOARD MEETING IN PUBLIC1 The next meeting of