0 trust board agenda (public) 22 january 2020...

GROUP TRUST BOARD MEETING IN PUBLIC1

The next meeting of the group trust board will take place on Wednesday 22 January 2020 at 1.00 pm in the 2nd floor boardroom, executive office, Royal Free Hospital.

Dominic Dodd Group chair

A G E N D A

ITEM LEAD PAPERQUALITY IMPROVEMENT/CPG ITEM

2019/20-175 Clinical practice group (CPG) presentationAmbulatory and Emergency Care (AEC) - Tara Sood , CPG Chair

Chief medical officer

Verbal

ADMINISTRATIVE ITEMS

2019/20-176 Apologies for absenceTo note apologies for absence – none

Group chair

2019/20-177 Declaration of interests To note the interests declared. If any member of the board has an interest in any item on the agenda, they must declare it at the meeting, and if necessary withdraw from the meeting

Group chair 1.

2019/20-178 Minutes of meeting held on 18 December 2019To approve the minutes of the last meeting

Group chair 2.

2019/20-179 Matters arising report To note updates on actions arising from previous meetings

Group chair 3.

2019/20-180 Record of items discussed at the confidentialboard meeting on 18 December 2019 To note the report

Group chair 4.

2019/20-181 Chair’s and group chief executive’s report To note the report

Group chair/group chief executive

5.

PATIENT AND STAFF EXPERIENCE

2019/20-182 Performance report – workforceTo note the report

Chief people officer 6.

2019/20-183 Patients’ voicesTo note the patients’ voices

M Basterfield, non-executive director

Verbal

2019/20-184 Go see visitsTo provide feedback on visits and note the report

Chief communications officer

7.

2019/20-185 Annual workforce equality reportTo discuss the report

Chief people officer 8.

2019/20-186 People committee report – 4 December 2019To receive the report from the committee

Committee chair 9.

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).

ITEM LEAD PAPEROUTCOMES AND SAFETY

2019/20-187 Development of the quality account 2019/20To discuss the report


10.

2019/20-188 Director of infection prevention and control quarterly report To discuss the report

Chief nurse 11.

2019/20-189 Clinical standards and innovation committee report –8 January 2020 To receive the report from the committee

Committee chair 12.

FINANCE AND COMPLIANCE

2019/20-190 Performance report - finance and compliance To consider the report

Chief finance and compliance officer

13.

2019/20-191 Operational performanceTo consider the report

Hospital chief executives

14.

2019/20-192 Finance and compliance committee report –17 December 2019 and 21 January 2020 To receive the report from the committee

Committee chair 15.

2019/20-193 Group services and investment committee report – 12 December 2019 and 9 January 2020 (verbal) To receive the report from the committee

Committee chair 16.

ANY OTHER BUSINESS

2019/20-194 Questions from the public Group chair

2019/20-195 Any other business Group chair

2019/20-196 Date of next meeting – 26 February 2020 Group chair

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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 register has been updated with the interests declared by Ravi Baghirathan, chief

transformation officer.

Action required/recommendationBoard 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.

Meetings where this report has been discussed previously Not applicable

Board/GEC/LEC/committee goals

GOALS BAF

risks

1. Not applicable

CQC standards impacted Well led

Financial/business implications Not applicable

Equality analysis Not applicable

Compliance impact Compliance with NHS Improvement

(Monitor) code of governance and trust

constitution

Report from Dominic Dodd, chair Author Alison Macdonald, board secretary

Report to Date of meeting Attachment number

Trust Board 22 January 2020 Paper 1

Paper 1

Version 43 Updated 10/01/20

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

This image cannot currently be displayed.

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

Director of UCLPartners

1

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

Non-executive director Skin Analytics

Chair of Royal National Orthopaedic Hospital NHS Trust

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

Nil Nil

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.

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Non-executive directors









Mary Basterfield Non-executive director 8/3/18

Flatberg Ltd (property management)

Group finance director, Just Eat Plc

Trustee, National Cancer Research Institute and UCL Union.

Wanda GoldwagNon-executive director

• Chair of the Office of Legal Complaints (OLC)

• Lay Member QC Appointments Panel

• Advisor SmedvigVenture Capital

• Interim chair, LEASE (Leasehold Advisory Service)

• Chair of independent Financial Services Consumer Panel (wef 1/3/19)

• Chair, independent uniform network code modification panel chair (a gas industry regulatory body) (wef 1/1/20)

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

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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

Chris Ham Non-executive director

• Non-clinical chair, NHS Assembly

Visiting fellow, King’s Fund Advisor to Carnall Farrar Chair of the Coventry and Warwickshire Health and Care Partnership

Doris Olulode Non-executive director

Non-Executive Director, Chartered Institute of Legal Executives (CILEx)Non-Executive Director, Diocese of Chelmsford Multi Academy Trust Lay member, employment tribunal Non executive director, Cambridge University Hospitals (CUH), NHS Foundation Trust.

HR consultancy with South London and the Maudsley NHS Foundation Trust

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Akta Raja Non-executive director

• Director RFL Property Services Company Ltd

• Enhabit Ltd • Geneff Ltd

Nil Nil Trustee, The Royal Free Charity

Nil Nil Nil

Professor Anthony Schapira Non-executive director

Upper Hampstead Walk Residents’ Association. AHV Schapira Ltd

Non-executive director of Oxford University Hospitals NHS Foundation Trust from May 2020.

Nil Nil Parkinson’s Disease Society Research Strategy Group

Member of the NHS Reconfiguration Panel

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

Nil

Paper 1











James TugendhatNon-executive director

Director and managing director, UK, Europe and International Companies: BHFS ONE LIMITED and all its registered subsidiaries BHFS TWO LIMITED

Nil Nil Nil Nil Nil Nil

Executive directors

Caroline Clarke Group chief executive

Director RFL Property Services Company

Nil Nil Nil Trustee, Overcoming MS

Trustee, Healthcare Finance Managers Association

Nil Nil

Peter Ridley

Chief finance and

compliance

officer

Director RFL

Property Services

Company and

Royal Free

Dispensing Ltd

Nil Nil Nil Nil Nil Nil

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Deborah Sanders Chief nurse

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

Nil Nil Nil Chair of NHS Elect Advisory Committee

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

Nil Nil

Chris Streather

Chief medical

officer

Director, RFC

Developments Ltd

Director HSL Ltd

Nil Nil Trustee of Healthcare Management Trust (HMT) a not for profit organisation which provides care home facilities and healthcare in Lincolnshire and Swansea.

Personal friend is

an investor with

Vitruvian, the

fund which owns

Healthcare at

Home, who are a

significant

supplier of

services to the

trust.

Nil Nil

Non-voting directors

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David Grantham

Chief people

officer

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

Chief

communications

officer

Nil Nil Nil Nil Nil Nil Nil

Ravi Baghirathan

Chief

transformation

officer

Nil Nil Nil Nil Nil Nil Nil

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MINUTES OF THE TRUST BOARD

HELD ON 18 DECEMBER 2019

Present

Mr D Dodd Ms M Basterfield Ms C Clarke Ms W Goldwag Prof Sir Chris Ham Ms A Raja Mr P Ridley Ms D Sanders Prof A Schapira Ms K Slemeck Dr C Streather

Group chair Non-executive director Group chief executive Non-executive director Non-executive director Non-executive director Chief finance and compliance officer Chief nurse and interim chief executive, Barnet Hospital Non-executive director Chief executive, Royal Free Hospital Chief medical officer

Invited to attend

Mr R Baghirathan Ms Natalie Forrest Mr D Grantham Ms E Kearney Mrs J Dewinter Miss A Macdonald

Chief transformation officer Chief executive and director of nursing, Chase Farm Hospital Chief people officer Chief communications officer Lead governor Board secretary (minutes)

Others in attendance

Ms A Bryan Ms I Brito

Physiotherapist, Marie Curie Hospice (for item 2019/20-155) Occupational therapist, Marie Curie Hospice (for item 2019/20-155)

2019/20-155 APOLOGIES FOR ABSENCE AND WELCOME

Apologies for absence were received from:

Ms D Olulode Non-executive director Mr J Tugendhat Non-executive director

The group chair welcomed the chief transformation officer to his first board meeting, along with those others present.

2019/20-156 DECLARATION OF INTERESTS

The group chair reminded board members to always have in mind whether they had any actual or potential conflict of interest, particularly if they had a change in circumstances. Ms Goldwag, non-executive director, declared an interest as independent uniform network code modification panel chair (a gas industry regulatory body) with effect from 1 January 2020 and the report on the register of interests was noted.

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2019/20-157 QUALITY IMPROVEMENT PROJECT PRESENTATION – WHAT MATTERS TO YOU AND LIVING LIBRARY AT THE MARIE CURIE HOSPICE

Ms A Bryan and Ms I Brito were in attendance for this item. The presentation provided information about the quality improvement projects taking place at the hospice. The first of these was looking at ‘always events’ which were things identified by patients as being important to their care and experience. Patients were generally very positive about their experience and they sometimes found it difficult to identify anything that they would want to improve. However by asking the question “what do you think an always event should be?” some themes had been identified such as communications, feedback and information. The living library project was to recognise that although staff might have expert knowledge about conditions and treatments, patients are experts on living with and managing the condition and that this expertise can be used to help other patients. Six patients with experience of breathlessness and fatigue had given the hospice team their expertise and the Marie Curie information booklets had been changed as a result. Another project had been around “I can” emphasising what patients are able to do with some extra help. The final project shared with the board was ‘smart clinics’ which was designed to streamline clinics so that patients could see all the clinicians they needed to but in fewer visits to the hospital. The next steps were to extend the ‘What matters to you’ project and work with patients to ensure all the work so far resonated with them.

Mrs Dewinter, lead governor, asked how the expert patients were identified and supported. The response was that these were self-selected patients who were articulate and open to sharing their stories.

The Royal Free chief executive congratulated the team on their tenacity and on demonstrating how powerful co-creation with patients could be in redesigning and personalising care.

The group chief executive noted that this approach was fundamental to everything the trust was trying to do and asked what the key to success was. Ms Bryan responded that this was to ask the question, hear the answer and either do something about it or explain why this was not possible.

The group chair asked how best to mainstream this approach and the chief medical officer responded that the key was a consistent template, an environment that encouraged improvement and nurturing those The group chair thanked Ms Bryan and Brito for attending.

2019/20-158 MINUTES OF MEETING HELD ON 27 NOVEMBER 2019

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

• Date of meeting to be corrected • Typographical errors in list of attendees to be corrected • Item 2019/20-143 Nursing and midwifery staffing - addition of new

paragraph as follows:

The chief nurse and interim chief executive of Barnet Hospital then commented

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that the safecare live module provided rich data on patient acuity and dependency and this data was reviewed twice daily and as part of the establishment review process, along with a range of other patient safety data.

2019/20-159 MATTERS ARISING REPORT

The following update was provided:

Non emergency patient transport The chief nurse and interim chief executive at Barnet Hospital advised that she had checked the position and having obtained other transport in the past (eg from family or a friend) would not prevent them being assessed for eligibility to receive hospital transport in the future. 94% of patients requesting transport received it; those who were refused were given a unique reference number and advised how to appeal.

Ms Goldwag, non-executive director, commented that she had heard a member of staff at another hospital tell a patient that they would not get transport next time if they accepted a lift. The chief nurse said that she would ensure that all hospitals using the service were informed of the correct procedure and that staff were informed of this.

The group chief executive then reported that the chief executives of all client trusts had met last month and been assured of the recovery plan in place. Performance had improved against most indicators, although further improvement was needed. A review of demand and capacity was being undertaken so that capacity and demand could be better aligned; in the meantime more resource had been put in.

The chief communications officer confirmed that a new patient information leaflet had been designed and was being reviewed by patients.

The report was noted.

2019/20-160 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 27NOVEMBER 2019

The report was noted.

2019/20-161 CHAIR’S AND CHIEF EXECUTIVE’S REPORT

The group chief executive noted how busy the NHS was nationally and locally, which reinforced the importance of flu vaccination. The take up rate was better than in previous years but was still not good enough. The staff survey response rate was also better than last year but, again, not as good as had been hoped.

Prof Sir Chris Ham, non-executive director, asked about flow week and how this was different to the MADE (multi-agency discharge event) events. The Royal Free chief executive explained that the flow week was about getting more staff out to the front line, cancelling non-essential meetings and reducing email traffic. The group chair said that the board would be interested to hear about how it went and the lessons learned and this would be included in the next chair and chief executive’s report.

Board secretary

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The board noted the report.

2019/20-162 PERFORMANCE REPORT - WORKFORCE

The chief people officer noted that this was headline data which continued to show an improving picture including a lower vacancy rate and turnover demonstrating that the staff was recruiting and retaining staff. The greatest growth was in the clinical staff group. Appraisal had dipped slightly, but mandatory and statutory training (MaST) was slowly improving. Bank and agency was relatively well controlled.


2019/20-163 PATIENTS’ VOICES

Ms Raja, non-executive director, read out a complaint from a patient’s daughter relating to the rheumatology department. When the patient saw her doctor in clinic in November 2019 he said that he wanted to see her again in January 2020 as she would be reducing her medication. An appointment was received for 15 January 2020 but it was then cancelled and moved to 15 June 2020. The daughter was concerned at her mother’s appointment being put off for so many months. The appointments office said that the medical secretary had made the change. Three messages were left for her but no return call was received. This caused the patient a lot of stress and anxiety. The response was that the January appointment was cancelled because the doctor was assigned to be on call that day. Unfortunately, the medical secretary was off sick at the time of the phone calls and the secretarial manager had been reminded to check the voicemails of staff when they are off sick. The doctor was contacted and he agreed to add an extra appointment to the clinic on 27 January 2020. This was relayed to the patient, along with apologies for the poor communication, and she was very grateful.

The compliment was from a patient who got in touch to express her gratitude to the rheumatology team. She commented that her appointments were always informative and the staff were always helpful and good to talk to. She stated that she would be extremely likely to recommend the service to her friends and family.

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

Mary Basterfield

2019/20-164 GO SEE VISITS

The chief communications officer noted that as well as those visits listed in the report, many other informal visits took place, especially by the hospital chief executives. Regarding the question that had been raised at the last meeting that visits had more involvement from nursing and managerial staff with very little medical input, she noted that nursing staff were in the wards and department all the time, whereas medical staff tended to be there intermittently. The chief medical officer said that it might be helpful for divisional directors to be more engaged with these visits and he would pursue this.

Ms Raja, non-executive director, then reported on her visit to Barnet Hospital


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on a Saturday afternoon. She had spent some time in the operations centre, where the clinical site team was based, and then visited most of the other areas in the hospital which were open on a Saturday afternoon including the emergency department (ED). She noted that the ED had been very busy with up to 30 ambulances arriving in an hour. During her visit she had met a patient who had been coming to the hospital for 15 years who was very complimentary about the service and Ms Raja had been struck by the engagement and commitment of staff despite the challenges they faced.


2019/20-165 CARE QUALITY COMMISSION ACTION PLAN

The chief nurse noted that the report had been discussed at the hospital clinical performance and patients safety committees and the finance and compliance committee. The trust was on track with the action plans. Some of the ‘should do’ actions were very wide in scope and needed to be discussed with the CQC so that they were clear about the scope, current progress and how realistic it was to expect these actions to be achieved. Progress had been made in mandatory and statutory training compliance but there was an issue of pace. The group executive committee had agreed a new policy that nurses and midwives who only worked through the bank (ie were not substantive staff) would not be able to work after 31 January 2020 if they were not MaST compliant. Consideration was also being given to the approach which needed to be taken for junior doctors.

The board noted that report.

2019/20-166 BARNET INTEGRATED CARE PARTNERSHIP

The chief nurse and interim chief executive of Barnet Hospital advised that the memorandum of understanding had been discussed at the population health committee. Because Barnet had a slightly less complex set of stakeholders: one hospital, one community trust, developed primary care networks and one borough it provided a great opportunity to do practical things to improve things from the patient’s perspective and the integrated care partnership provided the vehicle to do this.

The chief medical officer echoed this point and said that it would be important to take the work forward by focusing on particular priorities; complex elderly patients and the emergency pathway sprang to mind.

Prof Sir Chris Ham, non-executive director, welcomed the memorandum of understanding as a first step and noted that the current parties were the NHS providers, commissioners and the local authority. It would be important to bring in the community and voluntary sectors, and service users. Ms Raja, non-executive director, commented that the other parties needed to have the same degree of commitment as the trust.

Summarising the discussion the group chair said that there was strong board support for the statement of intent but in order to deliver the benefits there needed to be clarity about the expected measures of success and sufficient resource needed to be directed to the project. He reminded the board that the board had previously agreed some principles for partnerships and he

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suggested it would be helpful to refer to these for the purposes of this project.

The board

• Noted progress to date with developing the Barnet ICP • Agreed the memorandum of understanding

2019/20-167 FINANCIAL PERFORMANCE REPORT

The chief finance and compliance officer noted that there had been a detailed discussion of the financial position at the finance and compliance committee meeting. He noted that the in month position was broadly on plan and that the forecast was to meet the agreed 2019/20 plan. Within that overall position, the private patients unit was performing less well and it had been agreed to undertake a deep dive of this at the next finance and compliance committee meeting.

The financial improvement programme (FIP) position had improved slightly and the most likely year end position would be a shortfall of £3m. However £25m of the savings were non –recurrent mitigations which equated to a shortfall of £15m on the recurrent target and £8m adverse on the underlying position. The cash position remained strong and the expected maximum loan requirement for this year would be £20m, and this would not need to be drawn down until March.

He then added that there would also be a deep dive on the capital programme at the next finance and compliance committee meeting.

The financial highlights for the year were much reduced usage of bank and agency administrative and clerical staff, better relationships with commissioners with the best ever debt position and well aligned year end forecasts. The trust had also been very successful in securing additional funding, for example £5m capital for the emergency department and medical admissions unit at Barnet Hospital, £3.7m for diagnostic equipment and winter revenue funding.

Prof Sir Chris Ham, non-executive director, congratulated the chief finance and compliance officer on a positive financial report. He then asked about loans and whether they had to be repaid.

The chief finance and compliance officer responded that the loans were on the trust’s balance sheet, interest was paid on them and they would need to be repaid in due course.

Ms Basterfield, non-executive director, asked when the trust would be shifting the focus from FIPs to benefit and sustainability. The chief finance and compliance officer responded that this process had already started; a much earlier start had been made on the planning and budget setting process and next year financial performance would not be expressed in terms of FIP delivery but rather whole service resource use in the context of a three year plan. He would be bringing a brief update on planning to the January board meeting.

The board noted the current financial position of the trust.

Chief finance and compliance officer

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2019/20-168 OPERATIONAL PERFORMANCE REPORT

The Royal Free Hospital chief executive noted that the trust was making progress against the cancer targets and improving patient pathways. For example the prostate pathway had been changed so that patients had their scans earlier. The breast service was much improved with new leadership in place. More resource was being put into managing cancer services as there was insufficient senior resource at present. Overall the service was moving in the right direction but this needed to be sustained.

The emergency departments continued to be under great pressure. The previous Monday there had been more than 1000 attendances across the trust.At the Royal Free Hospital more patients were attending in the evenings, with high attendances continuing into the night. Inpatient bed occupancy was 99% with some very long lengths of stay. However there was a good recruitment pipeline. The chief nurse and interim chief executive at Barnet Hospital noted that the past fortnight had seen improved performance with a positive bed balance and better flow. However this week the pressure had increased again and on Monday morning there had been 32 patients waiting for beds with another 40 in the department waiting to be assessed. The team were working very hard to improve length of stay. She then commented that although winter funding had been approved for beds at Kings Oak Private Hospital (on the Chase Farm Hospital site), no patient had yet been identified who was suitable for transfer there. Similarly although it had been agreed to fund additional nursing home places there was a lack of nursing home capacity in the area, so suitable places had not been found. There was a real need for additional capacity, both inpatient beds and nursing homes and this was being actively pursued. In the meantime it was important to support the staff who were facing the challenges. The group chair asked how this could be done in practical terms. The chief nurse and interim chief executive at Barnet Hospital said that one example was to challenge unacceptable behaviour in terms of violence or aggression from members of the public or patients and the chief executive of the Royal Free Hospital was leading some work on this, learning from and working with Transport for London who had done a lot of work on his area.

The chief executive of Chase Farm Hospital and group clinical services then reported on DMO1 (diagnostic waits) and noted that the trust was close to achieving compliance with the targets. She also reported that the endoscopy unit at Chase Farm Hospital had achieved JAG accreditation (Joint Advisory Group - the Royal College of Physicians’ national accreditation scheme for endoscopy services) which was a great achievement by the team.

The board noted the current operational performance of the trust.

2019/20-169 FINANCE AND COMPLIANCE COMMITTEE REPORT

The chief finance and compliance officer reported on the most recent committee meeting. He noted that the committee had received a detailed report on the RTT recovery plan which was on track. In year financial performance meant that the trust was on track to achieve the plan for the year and there had been some discussion about whether it would be possible to over-achieve the plan in order to assist the wider STP (sustainability and

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transformation partnership). The committee had also heard about the proposed new approach to budgeting.

The board noted the report from the committee.

2019/20-170 AUDIT COMMITTEE REPORT

The board noted the report from the committee.

2019/20-171 GROUP SERVICES AND INVESTMENT COMMITEE REPORT

The board would receive the formal committee report at its next meeting.

2019/20-172 QUESTIONS FROM THE PUBLIC

A member of the public expressed the view that the pressures being faced by the emergency departments reflected the difficulty being experienced in obtaining a GP appointment. There was also a public perception that patients would avoid having to queue if they arrived at the emergency department by ambulance. He asked if the trust reviewed information about the main conditions that patients attending the emergency departments had.

The group chair responded that the trust was aware that primary care issues were affecting emergency department attendance and was keen to work with the wider system. The integrated care partnership in Barnet discussed earlier in the meeting was a good example of this. Patients were attending the emergency departments with infections such as Norovirus and flu. The chief nurse and interim chief executive of Barnet Hospital advised that the trust worked closely with Public Health England who maintained intelligence on infectious diseases prevalence and outbreaks.

2019/20-173 ANY OTHER BUSINESS

There was no other business.

2019/20-174 DATE OF NEXT MEETING

The next trust board meeting would be on 22 January 2020 at 1300 in the boardroom, 2nd floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 22 January 2019……………………………. Dominic Dodd, group chair

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TRUST BOARD – PUBLIC

ACTION TRACKER AS AT 22 JANUARY 2020

Ref Open actions – as at 22 January 2020

(Completed actions will remain on the open actions log in a shaded box for reporting at the next meeting and will then be moved to the

closed actions log)

Action Date Target Owner Status and update

2019/20-142 Go see visits

Mr Tugendhat, non-executive director, said that in his visits he had

mostly met nursing and managerial staff and there had been very

little medical input. The chief communications officer said that she

would give this some thought and discuss with medical

colleagues.

December update – Chief medical officer would explore greater

engagement from divisional directors.

23/10/19

18/12/19

18/12/19

22/1/20

Chief comms

officer

Chief medical

officer

Update to be provided

at meeting

2019/20-167 Financial performance report

The CFCO would be bringing a brief update on planning to the

January board meeting.

18/12/19 22/1/20 Chief finance

and

compliance

officer

On agenda

2019/20-143 Nursing and midwifery staffing

Prof Sir Chris Ham added that the GMC produce a report on the

lived experience of junior medical staff and that junior medical staff

would provide interesting insight from their frequent rotations

between specialties and hospitals. The chief people officer

responded that there was not currently a report but undertook to

provide one for the people committee.

23/10/19 26/2/20 Chief people

officer

Next people

committee 19/2/20

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2019/20-124 Performance report - workforce

• People committee to recommend data to be presented to the

board on a regular basis.

• People committee to review any specific areas where retention

is an issue and whether there was any evidence that people

suffered detriment as a result of raising the issue of bullying

and harassment.

•

23/10/19 18/12/19 Chief people

officer

See workforce

performance report on

agenda

People committee

report on agenda

2019/20-74 Workforce race equality standard (WRES)

Ms Goldwag, non-executive director, suggested that employment

offers should only be permitted to be made if this process had

been followed. Mr Tugendhat undertook to revisit this at the

people committee.

24/7/19 18/12/19 Chief people

officer

People committee

report on agenda

2019/20-74 Workforce disability equality standards (WDES)

The chief communications officer reminded the board that the

unconscious bias training the board had done some time ago had

indicated that there were issues around disability. The chair

suggested pursuing this at the people committee.

24/7/19 18/12/19 Chief people

officer

People committee

report on agenda

2019/20-53 Learning from deaths report – Q3 2018/19

The chairman asked whether it would be worthwhile to look at

trusts which had lower mortality rates and the chief medical officer

agreed to do this.

26/6/19 26/2/20 Chief medical

officer

Work has commenced

on this (letter written

to other trusts) and it

will be included in the

next report

([programmed for

February 2020).

Completed actions – as at 22 January 2020

(Completed actions will remain on the open actions log in a shaded box for reporting at the next meeting and will then be moved to the

closed actions log)

2019/20-126

2019/20-131

Non emergency patient transport update

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The chief nurse undertook to check whether a patient who

obtained a lift from a friend or relative on one occasion was then

unable to get hospital transport on future occasions.

Chief nurse to seek assurance from RFLPS that patients receive

clear information about how to appeal if refused transport.

Chief communications officer to arrange for patients’ panel to

review the evaluation criteria document

23/10/19 27/11/19 Chief Nurse

Chief nurse

Chief comms

officer

Closed – update

provided at meeting

and CCO confirmed

patient information

materials being

developed with patient

involvement.

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ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 18 December

2019

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 previous confidential meeting are outlined below.

• Referral to treatment time (RTT) update – the board noted that a detailed discussion had taken place at the finance and compliance committee which was the board committee with oversight of this issue.

• Queen Mary’s Hospital update – the board discussed Queen Mary’s House which remains confidential due to commercial sensitivity.

• Royal Free London – sustainable development update – a summary is in the chair

and chief executive’s report.

• Closer working with University College Hospital – the chief medical officer gave a

further update on clinical and other collaboration between the two organisations to

their mutual benefit.

• Joint Royal Free and RFL board workshop – the Charity and board had a useful

workshop focusing on the forthcoming major Charity fundraising campaign.

Action requiredFor the board to note.

Meetings where this report has been discussed previously Not applicableMeeting Date Decision


GOALS BAF risks

1. RTT 18 weeks target: 92% G-036

2. Be a digital exemplar(HIMSS level 7) G-040

3. Deliver regulatory undertakings G-021

4. Demonstrable organisation health group governance) G- 42



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Page 2 of 2


Financial/business implications Financial/business implications are articulated where

relevant in reports under consideration by the board.

Equality analysis Equality and diversity implications are articulated

where relevant in reports under consideration by the

board.

Compliance impact Any compliance impacts are articulated where

relevant in reports under consideration by the board.

Report from D Dodd, chair Author A Macdonald, board secretary Date 8 January 2020

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1 X:\ Chair and CEO report 22 January 2020

CHAIR’S AND CHIEF EXECUTIVE’S REPORT

Executive summary

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

Action required

The board is asked to note the report.

Meetings where this report has been discussed previouslyMeeting Date Decision Not applicable


GOALS

Not applicable

BAF risks




Compliance impact Not applicable

Report from D Dodd, group chair and C Clarke, group chief executive Author Alison Macdonald, board secretary



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CHAIR’S AND CHIEF EXECUTIVE’S REPORT

A PATIENT AND STAFF EXPERIENCE

FLU VACCINATION CAMPAIGN 2019

With an increase in the number of patients with flu in our hospitals, staff are being reminded of how important it is for them to get their flu jab.

Mid-way through the flu season, there has been a spike in flu cases in London and across the whole of the NHS. As at Monday 6 January there were 26 cases at the Royal Free and eight at Barnet Hospital, including two patients admitted to the ICUs on each site.

Vaccinations for all RFL staff have been available since 30 September 2019; all staff having a vaccination receive a free reusable cup which entitles them to a discount on hot drinks across the trust.

The chief nurse and chief medical officer have written to all clinical staff emphasising the importance of having the vaccination.

As at 10 January 2020 5152 (57.54%) of front line patient facing staff had had their vaccinations. This is against the target of 80%. At the same time last year we were at 47.5%

FLOW WEEK AT BARNET HOSPITAL AND THE ROYAL FREE HOSPITAL 6-10 JANUARY 2020

Both of our hospitals with emergency departments have had ‘flow weeks’ between 6-10 January, the first full working week after the Christmas and New Year holiday.

The focus for the week was to ensure we had the right patients in the right place at the right time with the right plan, improving discharges and ensuring efficient and effective flow.

At Barnet Hospital the week included:

• A frailty consultant in the emergency department • Additional nurses in TREAT to support frailty flow • An additional flow coordinator in medical short stay unit to prepare patients for

prompt discharge • Ward liaison officers in each clinical area to support board rounds/ multidisciplinary

teams (MDTs ) and escalate issues • Speciality doctors to support the teams admitting patients, bringing specialty care to

the front door • A review of the use of the ‘patient choice policy’ including assessment for discharge

as part of the admission process • Executive team support to MDTs • Emergency care intensive support team colleagues visit during the week to support

MDTs.

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• MADE – the multi-agency discharge event – was held on 7 January, and played a large part in involving colleagues across the system to ensure safe and effective discharge.

Thanks to everybody’s hard work, and the support of specially recruited ward liaison officers, the hospital achieved more discharges, creating extra capacity to cope with high demand.

There was very positive feedback from external partners, including NHS England’s Emergency Care Improvement Support Team, for the positive examples of teamwork they saw.

Useful learning from the week means there will be opportunities to review and improve: the process for ordering patients’ drugs to take away (TTAs); predicted discharges to help get patients safely home for lunch; and how colleagues work with imaging regarding demand and capacity and who is making requests.

At the Royal Free Hospital there was a different focus each day, following the SAFER steps:

S – Senior review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions

A – All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recovery and assuming no unnecessary waiting.

F – Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am.

E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday.

R – Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days – ‘stranded patients’) with a clear ‘home first’ mindset.

Ward liaison officers (WLO) were identified to assist wards with discharges and to avoid delays. There was a discharge marketplace responsible for escalating and solving delays, communicating this instantly to the ward liaison officers; also booking transport and helping with pharmacy requirements. Ward managers aimed to have at least one empty bed for the morning bed meeting and the nurse in charge of each ward was required to maximise confirmed discharges to the discharge lounge by 10am.

A raft of awards were handed out to the best performing wards at the end of Free Flow Week – after staff discharged 50 additional patients at the RFH compared to the previous week. 21 per cent of the patients were discharged before lunch compared with the usual eight per cent. There were 43 ward liaison officers (WLO) who volunteered 300 hours of their time to help improve patient flow and speed up discharges

UPDATE ON NON-EMERGENCY PATIENT TRANSPORT SERVICES (NEPTS)

Clinical commissioning groups across North Central London are responsible for commissioning non-emergency patient transport services (NEPTS) and two NEPTS contracts were awarded to DHL which commenced on 1 September 2019.

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These contracts covered:

1) The eligibility and assessment service 2) The patient transport service

Royal Free London Property Services Ltd has been commissioned by Barnet CCG to manage the eligibility and assessment service on behalf of the RFL, North Middlesex University Hospital NHS Trust, Moorfields Eye Hospital NHS Foundation Trust and Whittington Health NHS Trust. However, each trust has operational control and is responsible for its own transport service.

During the early days of the contract some patients were waiting longer than we would like for a trained agent to answer their call when trying to book their transport over the phone and we recognise this was not acceptable. More staff have now been employed and the average waiting time for calls to be answered is 1.61 minutes against a key performance indicator (KPI) of three minutes and in the week ending 10 January 2019 93% of calls were answered within three minutes. This is an improvement on the position reported at the December board meeting.

For Lot 2 (transport), performance has improved since the last board meeting for both the renal transport service and the general transport service, and the focus remains on an effective local working relationship and ensuring clinically appropriate prioritisation of patients.

There is a weekly call between the trusts and DHL, contract review at a monthly chief executives’ meeting and a clinical oversight group has been set up.

NEW BUS SERVICE AT CHASE FARM HOSPITAL

From 18 January, the W8 and W9 buses will be stopping along the new road outside Chase Farm Hospital

The new routes will mean that patients can get on and off the bus much closer to the hospital. As a result of the bus extension, the patient shuttle service will no longer be required – the service will cease at 5pm on Friday 17 January.

ROYAL FREE HOSPITAL CHILDREN’S SCHOOL ACHIEVES OUTSTANDING OFSTED RATING

The Royal Free Hospital Children’s School (RFHCS) has received a faultless inspection from Ofsted - taking it from a ‘good’ to ‘outstanding’ rating.

Inspectors praised the school, saying it provided an “exceptional quality of education” and said pupils were “settled, safe and happy”. Inspectors not only met with teachers, a paediatric consultant and other senior leaders, they also met with pupils, parents and members of the governing body.

Their report said: “Leaders reassure pupils who are admitted to the ward that they can continue learning and keep up with school work. Teachers help pupils learn at their bedside or in the classroom.”

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Ofsted were also impressed to discover that pupils complete an ‘all about me’ booklet so that all adults at the school understand the pupil’s personality, interests and goals for the future.

The inspectors noted that pupils’ behaviour is “excellent”. They also said: “They (pupils) are kind and supportive of each other because adults show them how. Pupils are confident that there is no bullying, or, if there were, that adults would deal with it.”

Teachers were praised for ensuring work was suitable for individual pupils and for their help and support. Inspectors also gave teachers credit for making sure pupils challenged themselves and they observed the hospital’s teachers were creative and diligent, coming up with lesson plans that took account of children’s interests.

FAMILY AND FRIENDS TEST (FFT)

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 December results are below.

Patient friends and family test

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feed back on their care and treatment and 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 December results are below.

Royal Free London combined data

% likely/extremely likely to recommend December 2019

(range: 0 – 100%)

Number of patient responses

In-patient 85% 1,283

A&E 82% 5,468

Barnet Hospital % likely/extremely likely to recommend December 2019

(range: 0 – 100%)


In-patient 84% 482

A&E 80% 2,595

Antenatal care 50% 10

Labour and birth 100% 106

Postnatal hospital ward 96% 106

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Postnatal community care* 100% 19

Out-patients 76% 341

Chase Farm Hospital % likely/extremely likely to recommend December 2019

(range: 0 – 100%)


In-patient 92% 118


Royal Free Hospital % likely/extremely likely to recommend – December 2019

(range: 0 – 100%)


In-patient 85% 683

A&E 83% 2,873

Antenatal care 0% 1

Labour and birth 100% 33

Postnatal hospital ward 97% 33

Postnatal community care* 100% 19


*The postnatal community care question is only reported as a whole trust figure and not split by site.

The best performing ward on each site where 20 or more responses were received: BH: CDU (with 87% likely or extremely likely to recommend) RFH: 10 West (with 96% likely or extremely likely to recommend)

Please make sure the findings, particularly the comments from patients, are shared with staff in your areas. They are a rich source of data and can be used to improve services.

PEARS BUILDING

The building remains on target to be practically complete as planned in September 2020, with the external façade rapidly nearing completion. This includes the feature brickwork and concrete banding as well as high thermally efficient windows.

The concrete and steel frame is now substantially complete, with fit-out of the institute areas well underway. The fit-out of the patient accommodation is now the main focus of attention alongside completion of the atrium roof.

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Mock-ups of a typical laboratory work station and a typical patient bedroom/bathroom are helping to show what they will look like and how the different aspects of the design will interact with each other. On completion of the floors, installation of the furniture in the laboratories will start. Work is continuing on the design of the café and tendering for facilities management is well underway.

From an engineering perspective, installation of the IT infrastructure is progressing together with installation of the main electrical switchgear, as well as the main mechanical plant (including boilers, air handling plant and attenuation tanks). In addition Willmott Dixon has taken delivery of the passenger and goods lifts, which are expected to be installed shortly.

Off-site production of specialist items such as the bespoke reception desk and some laboratory equipment is progressing with installation expected to start in the spring of 2020.

The fundraising and communications sub group will, next month, consider the branding of the building. It has already been agreed to adopt UCL’s signage system throughout the building, the design of which allows for the differentiation of the various organisations.

B OUTCOMES AND SAFETY

STREAMS GO LIVE AT BARNET HOSPITAL

Streams, a ground-breaking app which provides a rapid alert when patients are at risk of acute kidney injury (AKI) will be available to clinicians at Barnet Hospital this month (January 2020). Like breaking news alerts on a mobile phone, the technology notifies nurses and doctors immediately when test results show a patient is at risk of becoming seriously ill with AKI, and provides information they need to take action.

The app has cut the time taken to diagnose AKI at the Royal Free Hospital from hours to minutes and was developed by technology experts at Google Health in collaboration with clinicians at the Royal Free London NHS Foundation Trust (RFL) and launched in November 2016.

According to an evaluation by UCL which was published in July in Nature Digital Medicine and the Journal of Medical Internet Research, the app improved the quality of care for patients by speeding up detection and preventing missed cases. Thanks to Streams, clinicians were able to respond to urgent AKI cases in 14 minutes or less - a process which, using existing systems, might otherwise have taken many hours. It also concluded that the app reduced the cost of care to the NHS – from £11,772 to £9,761 per hospital admission for a patient with AKI.

According to the evaluation, the app has improved the experience of clinicians responsible for treating AKI, saving them time which would previously have been spent trawling through paper, pager alerts and multiple desktop systems.

The RFL retains control of patient information at all times. Personal data can only be used for providing the Streams app and for no other purpose.

The Information Commissioner’s Office said in July 2019 that it was satisfied with the use of Streams and the data sharing agreement the RFL has with Google Health UK.

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ADULT ELECTIVE ORTHOPAEDIC SERVICES CONSULTATION

On 13 January a twelve week public consultation was launched on the future arrangements for adult elective orthopaedic services in north central London; it will run between 13 January 2020 and 6 April 2020. The proposals were approved for public consultation by the Joint Commissioning Committee of the five north central London CCGs on 9 January 2020.

Working through North London Partners in health and care, the consultation aims to understand the views of past, current and prospective patients and carers of adult elective orthopaedic services, staff and stakeholders. We are supporting the consultation process in a number of ways including promoting the consultation through our social media and internal communication channels, running information stalls at each of our main hospital sites and inviting the North London Partners consultation team to attend our staff and patient experience committees at each site and share details on the proposals.

The consultation asks for views on a new way to organise these services, which, if approved would create two partnerships for planned orthopaedic care – with University College London Hospitals and Whittington Health working together, and The Royal Free London Group working with North Middlesex University Hospital. These partnerships would offer two NHS hospitals with dedicated operating theatres and beds, for patients who need to stay overnight after their operation – Chase Farm Hospital and University College London Hospital, a choice of NHS hospitals for those needing day surgery and a choice of NHS hospitals for outpatient appointments. Patients would have appointments with a named surgeon and their surgical team, who would stay with them throughout their care, regardless of where it takes place.

Under the proposals: patients at The Royal Free Hospital, Chase Farm and Barnet Hospital would continue to have outpatient appointments at the hospital of their choice, with day surgery and surgery requiring an overnight stay taking place at Chase Farm Hospital; and patients at the North Middlesex would still have outpatient appointments and day surgery at the North Middlesex and surgery requiring an overnight stay taking place at Chase Farm Hospital.

The supporting documents including the pre-consultation business case and a full set of consultation documentation is available at: www.northlondonpartners.org.uk/orth_consultation

The consultation outcome will influence a Decision-Making Business Case that will be presented to the North Central London CCG for approval in the summer of 2020 (the exact timing will be subject to the volume and content of the responses).

C SYSTEM PERFORMANCE AND POPULATION HEALTH

SUSTAINABLE DEVELOPMENT UPDATE

The trust is required to have a sustainable development plan, including carbon reduction in line with the Climate Change Act 2018. A report was discussed at the confidential board meeting in December which contained information about what had been achieved to date, with a 10% decrease in direct emissions since the baseline year of 2014/15 towards the

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2023/24 target reduction of 25%. The current rate of reduction did not meet the trajectory to achieve the 25% target, however the Chase Farm development and other improvements which were detailed in the report were expected to result in further improvements being seen when the 2029/20 data was available.

Although initially the focus for this issue has been in estates and facilities, the trust’s approach needs to be wider than estates. For example action needs to be taken in supplies and with patient services to reduce carbon emissions. There are already examples of changes in service delivery which have reduced the carbon impact of trust services by reducing the number of patient journeys/contacts, for example the virtual fracture clinic and teledermatology In order to support further progress it will be necessary to appoint a sustainability manager and in the meantime some consultancy support had been engaged.

The trust is committed to making sustainability fundamental to the way we work, focusing on eliminating waste and promoting sustainability. The board will need to agree an ambitious but achievable target needs for when the trust will become carbon neutral. The population health committee will be the board committee with oversight of this work. A further paper will be submitted to the board describing in detail how each of the proposed next steps will be progressed, and how staff and the wider population would be engaged with.

D FINANCE AND COMPLIANCE

NHS IMPROVEMENT (NHSI) OVERSIGHT

The group executive leadership team continue to meet monthly with a team from NHSI, NHS England and the North London Partners in Health and Care (formerly NCL STP) leadership team to discuss operational and financial performance. Quarterly meetings are held with NHSI and North London Partners in Health and Care which are attended by the group chairman and Akta Raja, chair of the finance and compliance committee, with other group directors.

E STAKEHOLDERS

COUNCIL OF GOVERNORS AND MEMBERS

Medicine for members events.

Barnet Hospital held an event on 8 January 2020 called Becoming frail: living and dying well. This was attended by 75 trust members and received excellent feedback. The event was particularly commended by attendees for giving practical advice. The next medicine for members event will be at the Royal Free Hospital on 4 February 2020 called The Thai boys trapped in the cave. What we can learn about creating resilient societies. Chase Farm Hospital membership chose the work of the urgent care centre. A date for this event is yet to be confirmed but is likely to be in April 2020.

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NORTH CENTRAL LONDON CLINICAL COMMISSIONING GROUPS (CCG) NEW ACCOUNTABLE OFFICER

The five North Central London Clinical Commissioning Groups (NCL CCGs) have announced the appointment of Frances O’Callaghan as their accountable officer.

Ms O’Callaghan joins in February 2020 and will lead the formation of one North Central London CCG in April 2020, bringing together Barnet, Camden, Enfield, Haringey and Islington CCGs. She takes over the role from Helen Pettersen, who departs at the end of February 2020, having steered the five CCGs through a period of complex change and financial challenge.

Ms O’Callaghan has worked in the NHS for over 20 years leading clinical services and in strategy roles, most recently as director of strategic implementation and partnerships at Homerton University Hospital NHS Foundation Trust. She has been responsible for estates, communications and other corporate services at board level, in addition to three years as a director within the corporate finance team at PricewaterhouseCoopers.

F OTHER UPDATES

COMMUNICATIONS BOARD REPORT: DECEMBER 2019

Media coverage

Positive stories: The Ham & High, Camden New Journal and other local news sites featured the story of married emergency medicine registrars, working in ED on Christmas Eve and Day. News website The Sun Best featured a story on a now healthy baby girl who was cared for at Barnet Hospital after being born prematurely last year.

Main negative story: The Ham & High featured the story of a former Royal Free Hospital haemophilia patient, Nicola Jones, who is trying to get financial support for her lifelong health problems. The table below shows the sentiment of press mentions in December.

December Royal Free Hospital

Barnet Hospital Chase Farm Hospital

Total

Positive 36 6 1 43Neutral 459 9 5 473Negative 19 0 0 19Total 514 15 6 535

Digital Communications

Total number of Facebook followers: 8,237 (+83) Number of Posts: 43, reaching 90,730 people.

Total number of Twitter followers: 19,300 (+200) Number of Tweets: 81, reaching 307,900 people.

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Our top Twitter post for December was about Arsenal FC mascot ‘Gunnersauras’ who visited the Barnet Hospital paediatrics ward. It received 22,238 impressions and 297 total engagements.

The second most popular digital content was about Spurs Ladies visiting our children’s ward. The Twitter post received 9,441 impressions and 80 total engagements.

Internal communications

The focus of our internal communications was on encouraging our staff to have their flu vaccination – helping the trust to achieve a performance of nearly 60% for frontline staff. We promoted our long service awards and supported efforts at the RFH and BH to improve flow through our hospitals.

Freenet (intranet) engagement

We launched our new intranet on 30 October. Here are some of the key headlines for December:

• Total number of staff who have used the site: 9,541

• Total pages viewed = 567,712

• Total Sessions = 214,352

Top news stories: 1) Double liver transplant success at RFH (645 views); 2) ‘Twas the nightshift before Christmas (608 views); 3) Christmas and New Year pay arrangements (557 views)

Workforce Performance report – December 2019

Executive summary

This report outlines the key workforce performance metrics converted to as SPC charts. This format of presentation

- Takes account of feedback from the board previously - Helps the reader to identify trends - Helps to align with performance team reporting

In addition more detailed information is provided for WRES and Turnover given these relate to the strategic priorities for the group.

.

Action required/recommendation (for decision, for discussion, for information)

The board is requested to provide feedback on this style of reporting, in particular:

1. Is this style an improvement? 2. Are the key metrics included? 3. For ER activity – we plan to provide a more comprehensive set of slides to show lapsed time for ER case work. Would this be helpful for the board to see? 4. For the bank and agency metrics – would a breakdown by staff group be helpful? (given the cost variation for different roles)

The board is requested to note:

• We are still working to identify an immediate measure for staff satisfaction as our Staff FFT take up is very low and therefore not an accurate measure. In the meantime turnover as a measure will be used, although this is not pre-emptive which is what we want to do with reporting key metrics.

Meetings where this report has been discussed previously •

Meeting Date Decision


GOALS BAF



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risks

Quality

All sites self-assessed as CQC outstanding G-023

Value

Top 10% for workforce efficiency (55% of clinical income)

Deliver additional 2% year on year FIP G-047

Review service delivery portfolio to deliver £15m benefit G-032

Release capacity in planned care to achieve £5m benefit G-033

Compliance

RTT 18 week target: 92% G-036

Cancer access 62 days: 85% G-037

100% compliance with statutory / regulatory requirements G-034

Alternative appointments for cancelled operations (28 days) G-038

99% diagnostics target across 15 procedures G-039

ED: access target 95% G-010

Deliver regulatory undertakings (NHSI / ICO)

Resilient organisation

Increase revenue support from Charity G-035

Demonstrable organisation health (group governance) G042/044

CQC standards impacted Safe / effective / caring / responsive / well led

Financial/business implications

Equality analysis • Positive evidence that proposal has considered equality and diversity

Compliance impact NHS Equality Delivery System

Report from David Grantham – Chief People Officer Author Bill Tibbutt – Workforce Systems & Information Analyst & Ragini Patel,

Deputy director of people Date 14th January 2020

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Workforce Performance Report

December 2019

1

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Headlines

2

Temporary staffing: Mast & Appraisal compliance

• With WRES Indicators 1, 2 we are making inroads and good progress (as demonstrated in the annual workforce equality report).

• We need to re-focus efforts for WRES indicator 3. The trustwidepicture (Slide 5) shows a bias overall towards more BAME staff being subjected to formal action. However by HBU there is marked variation as illustrated on Slide 6.

• ER activity tracking shows there has been a general increase in no of ER cases up to November (supported by Speaking Up and B&H initiatives and plans), fallen more recently.

• 2019 National staff survey response rate – 42%, full results awaited.

• Overall temporary staffing usage has stabilised with seasonal fluctuations - usage would have decreased in December due to Bank holidays and some areas being closed (hence reduced requirement).

• Since July agency usage started to fall again with the exception of November 2019.

• Clinical agency requests have increased slightly month on month.

• Mast & Appraisal compliance improving as consistently tracking upwards

• All HBU’s have plans in place to improve compliance against Mast & appraisals

WRES & ER: Other key updates:

Turnover:• All time record lower then target at 12.96%. The on-going

retention initiatives appear to be impacting positively with steady progress in reducing turnover

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Workforce performance – key metrics

Vacancy – Dec 19 – 11.56% (Target 12%) Stability Index

Turnover – Dec 19 – 12.96% (Target 13%) Monthly Starters

Cumulative Sickness – Dec 19 3.31% (Target 3.5%) Monthly Leavers

3

10.0%

10.5%

11.0%

11.5%

12.0%

12.5%

13.0%

13.5%

14.0%

14.5%

Ap

r 1

7

May

17

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Ap

r 1

8

May

18

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Mar

19

Ap

r 1

9

May

19

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

Nov

19

Dec

19

Vac

ancy

Rat

e %

Vacancy Rate % Upper/Lower Limits Mean Value

Trend Shift Outlier

Trajectory Goal Target

12.0%

12.5%

13.0%

13.5%

14.0%

14.5%

15.0%

15.5%

16.0%

16.5%

17.0%

Apr

17

May

17

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

Dec

17

Jan

18

Feb

18

Ma

r 1

8

Apr

18

May

18

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

No

v 1

8

Dec

18

Jan

19

Feb

19

Ma

r 1

9

Apr

19

May

19

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

No

v 1

9

Dec

19

Turn

ove

r R

ate

%

Turnover Rate % Upper/Lower Limits Mean Value

Trend Shift Outlier


3.0%

3.1%

3.2%

3.3%

3.4%

3.5%

3.6%

Apr

17

May

17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Ma

r 1

8

Apr

18

May

18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Ma

r 1

9

Apr

19

May

19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

Nov

19

Dec

19

Cu

mu

lati

ve S

ickn

ess

Rat

e %

Cumulative Sickness Rate % Upper/Lower Limits Mean Value

Trend Shift Outlier


80.0%

81.0%

82.0%

83.0%

84.0%

85.0%

86.0%

87.0%

Ap

r 1

7

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

Nov

17

De

c 1

7

Jan

18

Feb

18

Ma

r 1

8

Ap

r 1

8

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

Nov

18

De

c 1

8

Jan

19

Feb

19

Ma

r 1

9

Ap

r 1

9

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

Nov

19

De

c 1

9

Stab

ility

In

de

x %

Stability Index % Upper/Lower Limits Mean Value

Trend Shift Outlier


0

50

100

150

200

250

Ap

r 17

May

17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Ap

r 18

May

18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Mar

19

Ap

r 19

May

19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

Nov

19

Dec

19

Mo

nth

ly S

tart

ers

WTE

Monthly Starters WTE Upper/Lower Limits Mean Value

Trend Shift Outlier


0

50

100

150

200

250

300

350

Apr

17

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

Nov

17

De

c 1

7

Jan

18

Feb

18

Ma

r 1

8

Apr

18

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

Nov

18

De

c 1

8

Jan

19

Feb

19

Ma

r 1

9

Apr

19

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

Nov

19

De

c 1

9

Mo

nth

ly L

eav

ers

WTE

Monthly Leavers WTE Upper/Lower Limits Mean Value

Trend Shift Outlier


paper 6


Appraisals – Dec 19 – 70.88% (Target 90%) Total Temporary Staffing Usage (wte)

MaST – Dec 19 – 78.73% (Target 90%) Bank Staffing Usage (wte)

4

Employee Relations Cases Opened/Closed per month (excl Sickness) Agency Staffing Usage (wte)

0

50

100

150

200

250

0

10

20

30

40

50

60

70

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

2018 2019

Act

ive

Cas

es

Case

s O

pe

ne

d &

Clo

sed

Employee Relations Cases Opened/Closed per month (excl Sickness)

Cases Closed

Cases Opened

Formal Active Cases

Informal Active Cases

Total Active Cases

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

Ap

r 17

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

Nov

17

De

c 17

Jan

18

Feb

18

Mar

18

Ap

r 18

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

Nov

18

De

c 18

Jan

19

Feb

19

Mar

19

Ap

r 19

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

Nov

19

De

c 19

Ap

pra

isal

Rat

e %

Appraisal Rate % Upper/Lower Limits Mean Value

Trend Shift Outlier


60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

Ap

r 17

May

17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

Nov

17

De

c 1

7

Jan

18

Feb

18

Mar

18

Ap

r 18

May

18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

Nov

18

De

c 1

8

Jan

19

Feb

19

Mar

19

Ap

r 19

May

19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

Nov

19

De

c 1

9

MaS

T R

ate

%

MaST Rate % Upper/Lower Limits Mean Value

Trend Shift Outlier


1,000

1,100

1,200

1,300

1,400

1,500

1,600

1,700

Ap

r 1

7

May

17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

No

v 1

7

Dec

17

Jan

18

Feb

18

Mar

18

Ap

r 1

8

May

18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

No

v 1

8

Dec

18

Jan

19

Feb

19

Mar

19

Ap

r 1

9

May

19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

No

v 1

9

Dec

19

Tem

po

rary

Sta

ffin

g U

sage

W

TE

Temporary Staffing Usage WTE Upper/Lower Limits Mean Value

Trend Shift Outlier


800

900

1,000

1,100

1,200

1,300

1,400

Ap

r 1

7

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 17

Sep

17

Oct

17

Nov

17

De

c 1

7

Jan

18

Feb

18

Mar

18

Ap

r 1

8

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 18

Sep

18

Oct

18

Nov

18

De

c 1

8

Jan

19

Feb

19

Mar

19

Ap

r 1

9

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 19

Sep

19

Oct

19

Nov

19

De

c 1

9

Ban

k S

taff

ing

Usa

ge

WTE

Bank Staffing Usage WTE Upper/Lower Limits Mean Value

Trend Shift Outlier


100

150

200

250

300

350

Apr

17

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

De

c 1

7

Jan

18

Feb

18

Ma

r 1

8

Apr

18

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

No

v 1

8

De

c 1

8

Jan

19

Feb

19

Ma

r 1

9

Apr

19

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

No

v 1

9

De

c 1

9

Age

ncy

St

affi

ng

Usa

ge

WTE

Agency Staffing Usage WTE Upper/Lower Limits Mean Value

Trend Shift Outlier


Paper 6


WRES Indicator 1 - % BAME Staff in Senior Team vs Overall workforce

5

0%

10%

20%

30%

40%

50%

60%

Trustwide - % of BAME staff in senior team vs overall workforce

All Staff

Senior team

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

20

17

20

182

019

White>BAME BAME>White

2017 2018 2019

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

1.83 1.81 1.82 1.83 1.85 1.83 1.85 1.84 1.81 1.38 1.32 1.51 1.46 1.73 1.57 1.50 1.72 1.70 1.67 1.55 1.83 1.73 1.80 1.71 1.69

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

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Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

BA

ME>

Wh

ite

Re

lati

ve L

ike

lih

oo

d

WRES Indicator 3 – Relative Likelihood of Entering Formal Disciplinary Process

Paper 6

Workforce performance – WRES Indicator 3 by Business Unit

6

WRES Indicator 3 – Relative Likelihood of Entering Formal Disciplinary Process

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

2 0 1 72

018

20

19

Barnet Hospital Business UnitWhite>BAME BAME>White

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

2 0 1 72

018

20

19

Chase Farm Hospital Business Unit White>BAME BAME>White

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

2 0 1 72

018

20

19

Corporate Business Unit White>BAME BAME>White

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

20

17

20

182

019

Group Clinical Services Business Unit White>BAME BAME>White

Dec

Feb

Apr

Jun

Aug

Oct

Dec

Feb

Apr

Jun

Aug

Oct

Dec

2 0 1 72

018

20

19

Royal Free Hospital Business Unit White>BAME BAME>White

Paper 6

Workforce performance – Turnover by Business Unit

Barnet Hospital Business Unit Chase Farm Hospital Business Unit

Corporate Business Unit Group Clinical Services Business Unit

Royal Free Hospital Business Unit

7

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Ap

r 17

May

17

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

De

c 17

Jan

18

Feb

18

Ma

r 18

Ap

r 18

May

18

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

No

v 1

8

De

c 18

Jan

19

Feb

19

Ma

r 19

Ap

r 19

May

19

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

No

v 1

9

De

c 19

Turn

ove

r R

ate

%


Trend Shift Outlier


10.0%

11.0%

12.0%

13.0%

14.0%

15.0%

16.0%

Apr

17

Ma

y 1

7

Jun

17

Jul 1

7

Au

g 1

7

Sep

17

Oct

17

No

v 1

7

Dec

17

Jan

18

Feb

18

Ma

r 1

8

Apr

18

Ma

y 1

8

Jun

18

Jul 1

8

Au

g 1

8

Sep

18

Oct

18

No

v 1

8

Dec

18

Jan

19

Feb

19

Ma

r 1

9

Apr

19

Ma

y 1

9

Jun

19

Jul 1

9

Au

g 1

9

Sep

19

Oct

19

No

v 1

9

Dec

19

Turn

ove

r R

ate

%


Trend Shift Outlier


12.0%

12.5%

13.0%

13.5%

14.0%

14.5%

15.0%

15.5%

16.0%

16.5%

Apr

17

Ma

y 17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Ma

r 18

Apr

18

Ma

y 18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

Nov

18

Dec

18

Jan

19

Feb

19

Ma

r 19

Apr

19

Ma

y 19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

Nov

19

Dec

19

Turn

ove

r R

ate

%


Trend Shift Outlier


10.0%

11.0%

12.0%

13.0%

14.0%

15.0%

16.0%

Ap

r 17

Ma

y 17

Jun

17

Jul 1

7

Au

g 17

Sep

17

Oct

17

Nov

17

De

c 17

Jan

18

Feb

18

Mar

18

Ap

r 18

Ma

y 18

Jun

18

Jul 1

8

Au

g 18

Sep

18

Oct

18

Nov

18

De

c 18

Jan

19

Feb

19

Mar

19

Ap

r 19

Ma

y 19

Jun

19

Jul 1

9

Au

g 19

Sep

19

Oct

19

Nov

19

De

c 19

Turn

ove

r R

ate

%


Trend Shift Outlier


10.0%

11.0%

12.0%

13.0%

14.0%

15.0%

16.0%

17.0%

18.0%

19.0%

Apr

17

Ma

y 17

Jun

17

Jul 1

7

Aug

17

Sep

17

Oct

17

No

v 17

Dec

17

Jan

18

Feb

18

Ma

r 18

Apr

18

Ma

y 18

Jun

18

Jul 1

8

Aug

18

Sep

18

Oct

18

No

v 18

Dec

18

Jan

19

Feb

19

Ma

r 19

Apr

19

Ma

y 19

Jun

19

Jul 1

9

Aug

19

Sep

19

Oct

19

No

v 19

Dec

19

Turn

ove

r R

ate

%


Trend Shift Outlier


Paper 6

Paper 7

Page 1 of 5

GO SEE VISITS

Executive summary

This report provides an update on the go see visits programme, which was established in

December 2017. Go See visits continue to be advertised internally and areas which have

been nominated by staff have been incorporated in the programme.

The attached report provides updates on:

• Visits which have taken place since the last Board meeting

• Forthcoming visits which have been confirmed

• Forthcoming visits awaiting confirmation

Action required/recommendation The board is asked to note the report.

Meetings where this report has been discussed previously Meeting Date Decision Not applicable

Board goals

GOALS BAF risks

1. Quality Improvement (QI) embedded as our method of transformation

G-031




Compliance impact Not applicable

Report from Emma Kearney, chief communications officer

Author Sue Little, executive support manager



Paper 7

Page 2 of 5

1. Introduction

The board has an established programme of go see visits, which are open to all group

directors, along with site chief executives, non-executive directors and governors. Prior to the

visits, a fact sheet is provided giving some key information about the areas. This includes

information on staffing and where appropriate, patient or client feedback. Visits are not

designed to be inspections, but opportunities to listen to staff and, where appropriate, meet

patients. Non-executives are paired with governors: once the date for a visit is confirmed

governors are invited to attend and the aim is that the same governor accompanies the non-

executive director for the second visit. Feedback is provided both to the area visited and to

the board at each board meeting. Visits are also reported at council of governors meetings.

It is clear that staff really value this opportunity to meet with non-executive directors,

governors and executive directors and it is important that the visits touch as many areas of

the trust as possible. The aim will be that all main areas will have been visited within the

next year.

Approximately 70 new areas to visit have been identified – including support service areas

such as porters, domestics and catering and group shared services. Areas where there are

new quality improvement (QI) projects have also been incorporated. At the same time, the

go see visit programme was promoted on Freenet, the trust’s intranet site, and staff were

asked to put their departments forward if they wanted to have a visit. The hospital chief

executives were also asked to suggest areas where they would particularly welcome a visit.

In addition to these go see visits, the chief executives’ also carry out visits across all the sites

where the trust has services.

As part of the chief transformation officer’s induction programme, he has/will be visiting all

main trust sites.

Feedback forms

Following visits carried out by non-executive directors and governors, non-executive

directors should complete a brief template (provided in advance of the visit) with their

observations on what is working, what is not working and what needs to change. Feedback

from staff should also be included. The non-executive director should ask the governor who

accompanied them to also provide their input. A summary of these feedback reports will be

presented to the board to help identify key themes. The template is shown at the end of this

report although for this month it is blank as no formal go sees took place in the period 19 Dec

– 21 Jan.

Out of Hours Go Sees

At the September 2019 Board meeting, the chief communications officer made the

suggestion of having additional go see visits out of hours (OOH), i.e. over the weekends

including early Friday evenings. The suggestion was supported by board members.

Hospital Flow weeks

Both Barnet and the Royal Free Hospitals had a ‘hospital flow week’ between 6-10 January

which was the first full week following the Christmas and New Year holiday and a very busy

time for hospitals. Non patient-related and non-essential meetings were cancelled and the

Paper 7

Page 3 of 5

senior leadership team across the group spent time supporting the emergency departments

and ward teams to maintain flow through the hospitals. Group executive directors

participated in these events and spent time ‘on the shop floor’.

2. Visits in December 2019 / January 2020

Below are the visits which executive directors and non-executive directors have participated

in since the last board meeting on 18 December 2019 and up to 21 January 2020. These

opportunities are very popular with governors, who were invited to accompany non-executive

directors; these are shown below, indicated by (G)

Date Area Visited by

19 Dec 2019 –

21 Jan 2020

Informal general walk about, Royal

Free and Barnet Hospital sites

Caroline Clarke (group chief

executive)

3. Forthcoming confirmed visits

Below are the non-executive/governor and executive director upcoming confirmed visits.

Where responses have been received from governors at the time of writing, these are shown

below, indicated by (G).


22 Jan – 31

Jan 2020

Care of the Elderly, Royal Free

Larch ward (care of the elderly), Barnet

Patients Subject Access Team, Barnet

Volunteer Service, Royal Free

Back to the Floor – Security, Royal Free

Phlebotomy, Barnet

Chris Ham (non-exec director) and

Ian Bretman (G)

Chris Ham and Peter Zinkin (G)

Chris Ham

Mary Basterfield (non-exec

director)

Caroline Clarke

James Tugendhat (non-exec

director) and Esther Samuels (G)

February Private Patients Unit, Royal Free

Patient Advice & Liaison Service (PALS),

Royal Free

Mary Basterfield and Judy

Dewinter (G)

James Tugendhat

Paper 7

Page 4 of 5

March Chaplaincy services, Royal Free Mary Basterfield and Ian Bretman

(G)

4. Forthcoming unconfirmed visits


February Eating disorder team (Child & Adolescent

Mental Health Services), Royal Free

Orthopaedic services, Royal Free

Imaging, Chase Farm

Surgical ward, Chase Farm

Chris Ham

Chris Ham

Emma Kearney (chief

communications officer)

Emma Kearney

March Outpatients, Chase Farm

Pharmacy, Chase Farm

To be allocated

To be allocated

Visits for executive directors are currently being organised.

An update will be provided at the next Board meeting.

Paper 7

Page 5 of 5

Feedback from Go See visits

Date of

visit

Area / Site Feedback provided by What is

working

What is not

working

What needs to change /

improve

Other comments

Draft Annual Workforce Equality Report 2019-2020

Executive summary

This report summarises key equality data on the workforce for 2019-2020 and importantly the actions and initiatives to further improve equality where gaps are identified. It is produced in compliance with the trust’s Public Sector Equality Duty (PSED).


The board is requested this approve this report for publication externally via the trust website

Meetings where this report has been discussed previously • People Committee – 4th December 2019



GOALS BAF

risks

Quality

All sites self-assessed as CQC outstanding G-023

Value

Top 10% for workforce efficiency (55% of clinical income)


Review service delivery portfolio to deliver £15m benefit G-032

Release capacity in planned care to achieve £5m benefit G-033

Compliance

RTT 18 week target: 92% G-036

Cancer access 62 days: 85% G-037

100% compliance with statutory / regulatory requirements G-034

Alternative appointments for cancelled operations (28 days) G-038

99% diagnostics target across 15 procedures G-039

ED: access target 95% G-010



Increase revenue support from Charity G-035


Trust Board 22nd January 2020 Paper 8

Paper 8



Financial/business implications

Equality analysis • Positive evidence that proposal has considered equality and diversity

Compliance impact NHS Equality Delivery System

Report from David Grantham – Chief People Officer Author Yemisi Osibote, Head of workforce staff experience and Ragini Patel,

Deputy director of people Date 14th January 2020

Paper 8

1

Draft

Annual Workforce

Equality Report

2019 – 2020

Paper 8

2

Contents page

Section Title Page

Executive summary 3

1.0 Workforce equality – setting the scene 6

2.0 Workforce Equality Objectives 6

3.0 Workforce Equality Profile 7

4.0 Workforce Equality Disability Standards (WDES) 9

5.0 Workforce Equality Race Standards (WRES) 12

6.0 Workforce Sexual Orientation 21

7.0 Workforce Gender & Gender Pay Gap 23

8.0 Improving People Practices 29

9.0 Engagement with Trade Unions 29

10.0 Public Sector Duty 30

11.0 Workforce equality data analysis – 2019 summary 30

12.0 Future actions and priorities for 2020 31

13.0 Conclusions 31

Appendices Appendix 1 –Workforce profile as at 31st October 2019 32

Appendix 2 – section 1 – Workforce recruitment equality data 36 Appendix 2 – section 2 - Workforce employee relations equality data

41

Appendix 2 – section 3 - Workforce training equality data 48

Appendix 2 – section 4 - Workforce appraisal equality data 53

Appendix 2 – section 5 - Workforce MaST equality data 58

Appendix 1 – section 6 - Workforce promotion equality data 64

Appendix 1 – section 7 - Workforce leavers equality data 69

Appendix 2 – Staff Experience and Retention Plan (SERP) drivers diagram

77

Paper 8

3

Workforce equality report

Executive summary

The Royal Free London NHS Foundation Trust (RFL) is committed to making progress in the area of equality, diversity and inclusion. In line with the NHS long term plan and NHS people plan we aim to be a model employer where staff are able to fulfil their potential and flourish at work.

This report summarises key equality data on the workforce for 2019-2020 and importantly the actions and initiatives to further improve equality where gaps are identified. It is produced in compliance with the trust’s Public Sector Equality Duty (PSED).

Key highlights and successes achieved in the last 12 months are:

• The board has become more diverse and representative by recruiting 3 BAME (Black, Asian and minority ethnic) directors (2 non-executive and 1 executive) to reflect the community it serves. There are now 85% White and 15% BAME voting directors.

• The trust’s workforce remains broadly representative of the local population it serves, although the overall representation of BAME staff at senior levels is below that which would be expected.

• In line with the NHS Improvement (NHSI) 10 year Workforce Race Equality Standards (WRES) projection, within the last 12 months there has been an acceleration in the recruitment of senior BAME staff numbers in Bands 8a, 8b and 8c, The current average rate of recruitment is 2.75 (headcount), previously this was at 1.6 (headcount). This has been achieved via the board’s support to ensuring recruiting managers are held accountable through:

- being trained in recruitment and selection - institutionalising diverse interview panels - Provision of qualitative feedback to all candidates - Provision of rationale for any non-appointment of BAME candidates to Bands 8a+ posts to the Group chief executive officer (CEO) (see section 5.0, pages 12-14).

• If this rate of change is maintained, it will take the RFL 5 years rather than 8 years as indicated in the 10 year NHSI projection to achieve parity with proportionate representation of BAME staff at senior levels to the overall trust workforce. Please see section 5.0, pages 12-14).

• The overall ratio of BAME staff going forward into formal disciplinary hearings has decreased from 2.21 in 2015 to 1.58 in 2019. This is in line with the trust’s ambition to reduce the likelihood of staff entering the disciplinary process for both white and BAME staff. The trust is working with the Pan London WRES Indicator 3 project and continues to review all allegations via a disciplinary checklist authorised at director level to ensure consistency and fairness is applied and that a formal hearing is utilised as the last option.

Paper 8

4

• Implementing the newly introduced Workforce Disability Equality Standards (WDES). This was introduced as of 1st April 2019 by NHS England as a new requirement. It has ten metrics to measure the experiences of disabled staff across the NHS for the first time in its history. The main objective is to close the gaps identified in the ten WDES indicators. A key part of trust’s action in this area is to help staff to increase disability disclosure in order for support to be provided to them through reasonable adjustments, gaining views and also for monitoring purposes. So far an additional 38 staff have disclosed their disability status in the last 12 months. Please see link to trust WDES report, see section 4, page 10

• The trust held a disability awareness session in collaboration with Barts Health and NHS Employers to mark the NHS Equality, Diversity and Human Rights week in May 2019. The session was well attended and featured dialogue between a disabled member of staff and their line manager that considered how they provided support.

• A group of Bands 8a and above managers voluntarily held application and interview support sessions across the trust earlier this year to help staff with their career development. These sessions were well received.

• The trust has in place four key staff networks, Ability @ The Free, BAME, LGBT+ and its Women’s network. All have held various engaging events in the last 12 months. In addition the BAME staff network published its debut newsletter in order to reach out to a wider audience. The LGBT+ staff network also developed and published its first newsletter in 2019.

• Education and other departments are working through implementing equal opportunities monitoring of trust’s training in areas such as Quality Improvement (QI).

• The trust’s LGBT+ staff network forum held the first Royal Free London LGBT+ Workplace Conference in January 2019 featuring Stonewall’s Chief Executive, transgender speakers, NHS England Patient Choice leads and many more. The event was well attended by staff and external organisations.

• The trust’s gender pay gap report (section 7, page 23-29) for 2019 showed a gender pay gap of women earning on average 17.68% less than men (hourly rate of pay), the median is 10.51%. This is similar to national figures across the NHS and public services. The gender pay gap is driven by a number of factors including the predominance of female staffing in the nursing and support staff professional groups; the consultant workforce (through the impact of seniority and bonus payments) and the under-representation of women in very senior roles. The trust revised its CEA scheme as a result.

• The trust continues to implement initiatives to help improve its people practices to address bullying and harassment.

• The speaking up champions network has increased to 60+ staff trained to support and raise issues on behalf of staff.

• The trust’s Equality, Diversity and Inclusion policy is under review to enhance staff knowledge in areas such as transgender and transitioning.

• The trust has recently gone live with a brand new intranet with dedicated pages to all staff networks as well as WRES and WDES.

Paper 8

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Equality is everyone’s duty, demonstrated through compassionate leadership displayed by

the Group, Hospital/ service and Directorate management to enable progress in these areas.

This report sets out actions taken by the trust in the past 12 months, outcomes, as well as areas of priorities in the coming months to continue to demonstrate our equality agenda.

David Grantham Chief People Officer

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1.0 Workforce equality – setting the scene

The Royal Free London NHS Foundation trust (RFL) is committed to providing a workplace that is free from discrimination and inclusive of all staff. Over the last 12 months we have continued to focus on embedding equality, diversity and inclusion in everything we do to support our goal of full equality within the workforce. We publish our workforce equality data analysis annually, together with details of the actions taken to address the gaps in equality that we identify. This is one of our responsibilities under the Equality Act 2010 and supports the delivery of the general Public Sector Equality Duty (PSED). This report includes:

• An outline of the RFL’s equality objectives • Overview of key achievements in 2019 - 2020 • Future plans for 2020 – 2021 • A detailed profile of the workforce at 31 October 2019 (Appendix 1) • Further data analysis against protected characteristics (Appendix 2)

2.0 Workforce equality objectives

The RFL’s equality goal is to promote equality and diversity and to do this through two key workforce equality objectives (derived from the NHS’s own Equality Delivery System (EDS2) objectives). They are:

• a representative and supported workforce • inclusive leadership representative of the communities we serve

To support delivery of these two workforce equality objectives, the trust has developed a staff experience and retention plan (SERP) using quality improvement methodology, (Appendix 3, page 77), which includes areas of focus for equality, diversity and inclusion.

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We are working to deliver each equality objective through these key activities:

A representative and supported workforce

• Applying fair recruitment and selection processes; • Ensuring equal pay for work of equal value through robust job evaluation of roles in

the trust; • Providing training and development opportunities for all staff and monitoring take up

and reviewing staff evaluation of the training; • Making sure that staff are free from abuse, harassment, bullying and violence from

any source while at work; • Making adjustments to support people with disabilities; • Providing flexible working options for all staff consistent with the needs of services; • Raising awareness of ‘unconscious bias’ amongst managers and staff; • Enabling staff to report positive experiences of their membership of the workforce • Monitoring equality and taking steps to address the inequalities we identify.

Inclusive leadership representative of the communities we serve

• Increasing the diversity of our Board; • Appointing Board champions for diversity (for disability, women, LGBT+ and BAME

groups) • Changing recruitment practice for senior roles to encourage greater BAME

representation at this level; • Responding to staff feedback to improve their experience; • Boards and senior leaders routinely demonstrating their commitment to promoting

equality within and beyond the organisation; • Identification of equality related impacts within papers that come to Board and other

major committees including risks and its management • Middle managers and other line managers supporting their staff to work in culturally

competent ways within a work environment free from discrimination.

3.0 Trust workforce equality profile

The info-graphic provides an overview of the RFL’s workforce by the protected characteristics identified in the Equality Act 2010 (for more detail see Appendix 1, page 32).

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4.0 Workforce Disability Equality Standards (WDES)

NHS England introduced WDES on 1st April 2019 and as a result the trust has commenced monitoring in line with the ten metrics highlighted below.

Table 4a – WDES ten metrics

NHS England workforce disability equality indicators for NHS trusts

Metric 1. WDES metric 1 requires the trust to measure the percentage of staff in Agenda for Change (AfC) pay bands or medical and dental pay bands and very senior managers (including Executive Board members) compared with the percentage of staff in overall workforce, i.e. disabled and non-disabled in 7 clusters.

• Cluster 1: AfC Pay Band 1, 2, 3 and 4

• Cluster 2 – Pay bands 5, 6, and 7

• Cluster 3 – Pay bands 8a and 8b

• Cluster 4 – Pay bands 8c, 8d, 9 and very senior managers including executive board members

• Cluster 5 – Medical and Dental staff, consultants

• Cluster 6 – Medical and Dental staff, Non – consultant career grade

• Cluster 7 – Medical and Dental staff, Medical and dental trainee grades

Metric 2. WDES metric 2 measures the relative likelihood of disabled applicants compared to non-disabled applicants being appointed from shortlisting across all posts.

Metric 3. WDES metric 3 measures the relative likelihood of Disabled applicant compared to non-disabled staff entering the formal capability process, as measured by entry into the formal capability procedure.

Metric 4. WDES metric 4 compares staff survey responses in the NHS 2018 survey broken down by Disability as a protected characteristic against that of non-Disabled staff.

(4a) (i) Patients/service users, their relatives or other members of the public (4a) (ii) Managers (4a) (iii) Other colleagues (4b) Reporting harassment, bullying or abuse at work

National NHS Staff Survey findings

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For each of these four staff survey indicators, the Standard compares the metrics for each survey question response for Disabled staff and non-disabled staff.

Metric 5. WDES metric 5 measures the percentage of Disabled staff compared to non-disabled staff believing that the trust provides equal opportunities for career progression or promotion.

Metric 6. WDES metric 6 measures the percentage of Disabled staff compared to non-disabled staff saying that they have felt pressure from their line manager to come to work, despite not feeling well enough to perform their duties.

Metric 7. WDES metric 7 measures the percentage of Disabled staff compared to non-disabled staff saying that they are satisfied with the extent to which their organisation values their work.

Metric 8. WDES metric 8 measures the percentage of Disabled staff saying that their employer has made adequate adjustment(s) to enable them to carry out their work.

Metric 9. WDES metric 9a - Measures staff engagement score for Disabled staff, compared to non-disabled staff and the overall engagement score for the organisation.

WDES metric 9b - Has your trust taken action to facilitate the voices

of Disabled staff in your organisation to be heard? Yes or No

Metric 10. WDES metric 10 measures Board representation, it asks trust to compare the difference between the Disabled and non-Disabled Board members, i.e. by voting membership of the Board and the executive membership of the Board.

The trust has published its first WDES report based on 2018/19 financial year with actions to address findings, please see link for full details

http://s3-eu-west-1.amazonaws.com/files.royalfree.nhs.uk/Reporting/Annual_Workforce_Disability_Equality_Standards_(WDES)_report_-_29th_July_2019.pdf

4.1 Key areas of disability disclosure work are as follows:

• The trust has developed a step-by-step guide for staff to use to update their disability status on self-service ESR.

• Existing staff with disabilities are sharing their stories of how disclosure helped provide them with adequate support and/or adjustments at work to encourage other staff to disclose and get the help they need.

• Workforce surgery was set up earlier in the year inviting staff to attend to get help with updating their ESR status.

• Recruiting disability allies amongst line managers to champion and support disability initiatives that will help improve disabled staff experience in the trust is an area currently in development

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• The medical and dental staff group is the 2nd highest group with “unknown” status with regards to disability. Where clinical leaders disclose their disability, it will help promote an open working culture where the clinical staff is able to disclose and not see disability as a barrier to their professional career development.

• The medical, dental and trainee grades have the lowest “unknown” disability status. The medical training in further education now expects full disclosure in order to provide support.

• The staff disability network has been set up across 4 sites and the name has been changed to “Ability@ The Free” to highlight a positive message that focuses on the ability of those who have disabilities and to reduce/remove stigma attached to disability.

• The trust introduced Mental Health First Aiders hub to support staff across the trust.

4.2 WDES Leadership and Governance

The trust Board is committed and accountable for the delivery of WDES.

The People Committee reports to the trust Board and receives the WDES report for discussion, scrutiny and implementation.

The trust has the Equality Steering Group reports to the People Committee and oversees the work of the Disabled staff network.

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The Ability @ The Free staff network is part of the trust’s staff network collaborative working with the LGBT+, BAME and Women’s network to share good practice and support each other with trade unions and the Chaplaincy on board.

4.3 Disability confident employer

There are 17.5% of people of working age in the UK who are disabled or have a health condition, but only 11.5% of people in work are disabled or have a health condition.

The RFL signed up to the government’s ‘disability confident’ scheme in 2016 to help its hospitals and services lead the way in their local communities in supporting people with disabilities into work and using their talents in the workplace. It continues to work on its disability employment practices to create a more inclusive work environment.

The disability confident scheme: • aims to provide employers with the confidence, skills, and tools they need to help

them recruit and retain disabled staff as they progress in their careers; • supports challenging misconceptions towards disability and employment; • increases understanding and awareness of disabilities, both mental and physical; • supports employers to make the most of talents and insights disabled people can

bring to the workforce.

The trust is currently a Level 2 disability confident employer status.

4.4 Ability @ The Free staff network

The trust has a disability staff network in place to support staff with disabilities.

The aim and objectives of the disability staff network is to: • Provide a safe, supportive and confidential environment for staff with disabilities to

discuss issues relating to their disabilities; • Provide a forum to discuss all aspects of working with a disability; • Provide networking support; • Share best practice; • Contribute to staff development and awareness in relation to disability issues; • Consult on health and wellbeing policies and initiatives

5.0 Workforce Race Equality Standards (WRES)

The trust has been monitoring the overall workforce data for WRES since 1st April 2015.

There are nine indicators within WRES measuring the gaps between the experience of white and BAME staff groups across the NHS and within its organisations. The expectation is to reduce the gap and have a better balanced and more equal experience for both staff groups.

5.1 WRES indicator 1

Indicator 1 measures the percentage of white and BAME managers in bands 8a and above in proportion to their overall representation within the workforce. Currently the trust has 49% White and 50% BAME staff in post and 1% unknown.

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To support NHS trusts with the in the implementation of WRES indicators 1 & 2, NHS Improvement (NHSi) and NHS England (NHSE) published a document titled ‘ A model Employer: Increasing black and minority ethnic representation at senior levels across Royal Free London NHS Foundation Trust’ to help implement the NHS WRES leadership strategy.

The excerpt below is from the document for the trust outlining the 10 year WRES trajectory:

The graph below represents the trusts actual position against this trajectory for each band.

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To achieve a proportionate balance whereby the RFL’s leadership team similarly representative of both the population it serves and the workforce, there is a need to recruit approximately 166 more BAME managers into its leadership roles. This would ensure a diverse leadership and ensure that the RFL and its patients are not missing out on the talent, perspectives and fresh ideas a diverse leadership brings.

Key points:

• By October 2019, the trust achieved equity of representation in Bands 8a, 8b and 8c,

demonstrating good progress at the lower senior bands that will provide the pool of

recruits for the higher roles (8d and VSM) in the future

• The areas with gaps remain Bands 8d, 9 and VSM as at October 2018.

RFL launched a scheme for ‘diverse interview panels’ on 1st June 2018 and re-launched the initiative a year later on 1st June 2019 with the Chairman and Group Chief Executive sending out clear expectations that all recruiting managers will take the following 3 actions in a letter to all recruiting managers in the trust:

1) All recruiting managers, at all levels, must have completed interview training, including unconscious bias training, in order to sit on interview panels.

2) All interviews for positions at Band 8a and above will be conducted by diverse panels which include a trained BAME recruiting manager.

3) Whenever a shortlisted BAME candidate is not appointed to a Band 8a role or above the recruitment panel will write to the Group CEO, to explain:a. Why the successful candidate was more suitable in terms of experience, skills or

aptitudeb. What the unsuccessful BAME candidate(s) could do to develop their experience,

skills or aptitude in order to be more likely to be appointed for a similar role in the future.

The benefits of the new approach are expected to be: • an improvement in the interview experience of BAME staff; and greater assurance

that reasons for non-appointment are clearly documented and fed back as they should be for all candidates;

• assurance that trust recruitment policies and processes are followed because managers have received the right training;

• achieving the NHSI 10 year ambition to reach an equitable position for bands 8a to VSM in the trust.

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The BAME management in the trust was 22.2% in 2014/15 against 45.3% BAME workforce

overall. By 2019 BAME management has risen to 31.1%% against 50.4% workforce overall.

See details in graph 1 below.

Graph 5a – WRES indicator 1 – 2015 – 2019

5.2 WRES indicator 2

Indicator 2 measures the relative likelihood of BAME staff being appointed from shortlisting compared to white staff. The trust has been making continued progress in the area, the lower the figure the better the likelihood; this was 1.69 in 2015 and currently at 1.35 as at 31st December 2019. Please see details in graph 2 below.

Graph 5b –WRES indicator 2 – 2015 – 2019

5.3 WRES Indicator 3

Indicator 3 measures the relative likelihood of BAME staff entering the formal disciplinary process compared to white staff.

The trust has been making continued progress in this area through various wide ranging interventions; from developing an investigation and disciplinary checklist for all managers to complete and sign off by the Director of the occupational staff group before progressing all cases at the informal stage. This ensures a consistent and fair approach is applied to all cases.

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The employee relations team train managers regularly in investigation process and also holds surgeries in the divisions to support managers in managing informal cases to resolutions where appropriate. The trust participated in the NHS England quality improvement pilot project on WRES indicator 3 and lessons learnt have been shared across the divisions and other NHS hospitals.

The trust has been making continued progress in the area, the lower the figure the better the likelihood; this was 2.21 in 2015 and currently at 1.69 as at 31st December 2019. Please see details in graph 3 below.

Graph 5c –WRES indicator 3 – 2015 – 2019

Nationally the NHS has now set expectations that this indicator will be improved with expectations as below:

The trust is close to the 2020 target but will need to maintain focus in this area.

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Indicator 4 measures the relative likelihood of BAME staff accessing non-mandatory and career progression development CPD.

The trust has improved its data collation in this area, though more work is still required in order to ensure all non-mandatory training is collated into the trust’s OLM system to enable more accurate data reporting. The lower the figure the better the likelihood; this was 1.16 in 2014/15 and currently at 1.02 as at 31st December 2019. BAME staff are more likely to access non-mandatory training than their white counterparts. Please see details in graph 3 below.

Graph –WRES indicator 4 – 2015 – 2019

The trust Board continues to mentor BAME staff to support their career progression and the OD team attends the BAME staff network meetings regularly to help cascade more information about leadership development.

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5.5 WRES indicators 5 - 9

The remaining WRES indicators (5-9) are measured annually in the NHS staff survey. A summary is provided below. 2018 staff survey comparative data is provided for information while 2019 staff survey data is currently awaited.

Table 1 – WRES indicators 5 – 9 - 2015 – 2019

Table 2 – WRES indicator 5-8 WRES indicators 5 – 8

RF National staff survey

White staff 2017

BAME staff 2017

White staff 2018

BAME staff 2018

London Average

Indicator 5 - % of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months.

Favourable result for BAME staff (lowest - best) 20%)

34% 31% 33% 30% 30%

Indicator 6- % of staff experiencing harassment, bullying or abuse from staff in the last 12 months.

Unfavourable result for BAME staff (Highest - worst 20%)

21% 28% 23% 26% 30%

Indicator 7 % of staff believing that the organisation provides equal opportunities for career progression or promotion.

Unfavourableresult for BAME staff (Highest worst 20%)

84% 65% 83% 66% 68%

Indicator 8 % of staff having personal experience of discrimination from manager/team leader or colleagues

Unfavourable result for BAME staff (highest – worst 20%)

8% 18% 8% 16% 16%

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The trust has in place a wide range of interventions to address bullying and harassment

driven by a working group who led on the development and implementation of 9 videos to

explore the impact of different behaviours on staff, helping to cultivate insight to help

manage behaviours in the workplace.

To date over 1000 staff have seen these videos to enable staff to call out incidents of this

nature. The pathways are promoted and enable staff to access facilitated conversations as

well as mediation informally.

The trust has over 60 speaking up champions in place to act as independent support

advising staff to raise concerns. The trade unions are working in collaboration with trust

management to lead the speaking up champions initiative trust wide.


Indicator 9 measures the percentage difference between the organisations board voting membership and its overall workforce.

In 2015, the trust Board was 100% white, it has since made progress and recruited 3 BAME directors (2 non-executive and 1 executive)in its journey to reflect the community it serves.

The trust Board including all directors is 17 in total, 13 of which are non- executive directors who have voting rights.

The breakdown of the voting directors is 85% white and 15% BME.

5.7 WRES Leadership and Governance

The trust Board is committed and accountable for the delivery of WRES and works with the wider system to drive improvements. The Board’s focus is on achieving a proportionate number of BAME managers in the trust. This requires a cultural transformation which the enforcement of the trust’s recruitment and selection policy and procedure underpins.

The People Committee reports to the trust Board and receives the WRES report for discussion, scrutiny and implementation and in turn provides the Board with the assurance required that WRES is regularly monitored, delivered and sustained.

Management at directorate levels regularly review the WRES data as part of their workforce performance scorecards to monitor improvements and agree actions to address gaps in their areas.

The trust has the Equality Steering Group, which reports to the People Committee and oversees the work of the BAME staff network.

Members of the trust Board mentor BAME staff across the trust as part of trust’s initiative to support BAME career progression. In addition work has begun to establish a pool of BAME mentors available to mentor BAME staff.

The BAME staff network is part of the trust’s staff network collaborative working with the LGBT, Disabled and Women’s network to share good practice and support each other with trade unions and the Chaplaincy on board.

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5.8 2019 Black history month

During the month of October 2019, the trust celebrated black history, culture and heritage across Royal Free, Barnet, Chase Farm, and Enfield Civic Centre sites. The event was sponsored by the Royal Free Charity and the trust’s senior executive team.

The theme was “Know the past, shape the future” with presentations from Patrick Philip Vernon OBE, British social commentator and Roger Walker, historian, discussing the vital contributions of BAMEs in the UK and the NHS. Kate Anolue, Mayor of London Borough of Enfield, gave presentation on inclusion of BAMEs in social care and fostering good relations between people who share the same protected characteristics and those who don’t. Dame Elizabeth Anionwu and Dr David Sellu encouraged staff to be part of shaping the future. Jeff Hinds, magistrate and boxing referee played the steel pan and discussed the Windrush generations contributions. Overall the events across the sites were well attended by staff and food from different nationalities was served.

5.9 Black, Asian and Minority Ethnic staff network

The trust has a Black, Asian and Minority Ethnic (BAME) staff network in place.

The aim and objectives of the BAME staff network is to: • Provide a safe, supportive and confidential environment for BAME staff to network

and discuss issues of specific interest that have an effect on the protected group; • Provide a professional support and information about how individual issues may be

raised in the trust; • Act as a voice for BAME staff offering a source of consultation and a means of

communicating with the trust about BAME issues in relation to trust’s policies and practices;

• Assist with policy development on BAME issues by providing advice and feedback to the Equality, Diversity and Inclusion Staff Group and any other relevant sub-groups or committees;

• Contribute to staff development and awareness raising in relation to equality and diversity.

The network leads on coordinating black history months and has been advising on the actions the trust leadership can take to tackle discrimination.

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6.0 Workforce Sexual Orientation (Lesbian, Gay, Bisexuals, Transgender, plus, LGBT+)

The LGBT+ staff network held a wide range of successful events over the last 12 months such as the following:

The network celebrated the trust’s first Transgender Day of Remembrance in November 2018 in collaboration with RFL Chaplaincy while a second event is taking place in November 2019. The network participated across the year in the trust’s staff health and wellbeing events held in May and October 2019, marked the International Day against Homophobia, Biphobia and Transphobia in May 2019, Transgender Day of Visibility in March 2019, and Black History month events in October.

It launched a Trans & Non-Binary Working Group and an LGBT+ Patient Working Group to develop policies and processes that improve equality and access for both staff and patients.

The LGBT+ network collaborated with the Royal Free London Rounds in September 2019 to feature “LGBT at the Free, is it relevant? The session enabled panellist and staff stories to share stories about how non-LGBT+ clinicians and care givers want to care effectively for the LGBT+ population, concerns around not confusing a same sex partner with a friend of the patient, using the right words and terminology to address patients, being sensitive to the needs of the patients and their families and not getting it wrong. The outcome of the session has led to further on-going work in the trust around Transgender, and the needs of transgender patients as well as staff.

The aim and objectives of the trust’s LGBT network is to:

• Provide a source of advice and guidance to the Royal Free London NHS Foundation trust in their policy making and the general wellbeing of the employees within the trust.

• Provides an informal discussion environment for staff on various issues raised by staff and the trust to improve the working environment.

• To foster and to promote a safe and inclusive environment for LGBT+ staff, patients and visitors, linking in with the world class care objectives, positively welcoming, visibly reassuring, and actively respectful and clearly communicating.

• To ensure through trust Executive Directors, managers and senior clinical staff that LGBT+ issues are mainstreamed into policies, practices and functions of the organisation.

• To work with service providers to ensure participation in the LGBT+ Forum and also in the sexual orientation diversity programmes or assessments.

• To receive assurances to ensure through trust executive directors, managers and senior clinical staff that the trust is well organised and ready as a model employer.

• Carrying out fair and equitable employment practices, whilst acknowledging and valuing staff differences, regardless of their sexual orientation.

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6.1 London Pride 2019

The trust’s LGBT+ staff network participated in London 2019 Pride event with a float of 75 staff inclusive of the Executive Directors and Chief Executives of the trust. This event was supported by the Royal Free Charity.

All participants had an enjoyable experience celebrating achievements of the LGBT+ community accomplished throughout the years and trust’s float show cased our inclusive workforce.

6.2 Stonewall Equality Index Assessment 2019

The trust participated in the yearly Stonewall Equality index assessment in 2019. This is the UK’s LGBT benchmark for organisations to assess their inclusive working practices against a wide range of criteria. The process helps the trust to self-assess and provide evidence to demonstrate its progress and identify priorities for the coming year. The trust’s result is awaited in early 2020.

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7.0 Workforce Gender

7.1 Gender Pay Gap Reporting

The trust has complied with the Gender Pay Reporting requirements and reported its gender pay gap on the government online reporting service in March 2018 and March 2019. The Gender Pay report contains all full and part time staff, those on fixed term contracts, hosted organisations, and bank and agency workers. Staff on maternity leave and long term sickness are excluded from the calculations.

The mean pay gap is the difference between the pay of all male and female employees when added up separately and divided respectively by the total number of males, and the total number of females in the workforce.

The median pay gap is the difference between the pay of the middle male and middle female, when all male employees and all female employees are listed from the highest to the lowest paid.

In 2018 the trust used the ESR business Intelligence Gender Pay Gap reports, built by ESR, these reports did not allow the trust to include some local elements of ordinary and bonus pay, though these were in small numbers. The trust could also not include payments to contractors paid via 24/7. Due to other operational matters, the ESR Business Intelligence Gender Pay reports have not been resolved. Hence the trust has had to produce its own Gender Pay Gap report using “Financial Cost Analysis” reports using detailed payroll reports which outline all payments. This has been developed in line with the national guidance on Gender Pay Reporting thereby resulting in a more complete data set.

7.2.1 Gender Pay Gap Information 2018

There has been an increase in male staff and reduction in female staff over the past months.

Though the trust has a higher proportion of female employees in line with most NHS trusts

as indicated below:

Chart 7a - Gender Pay Gap reporting – 2019

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7.2.2 Hourly rate Gender Pay Gap

The current trust’s gender pay data shows female employees earn an hourly average pay of 15.74% less than men, see table 7 below including trends over the last 3 years. This data is inclusive of all staff groups, including medical and dental. Please see table 7a below.

Table 7a: The overall pay gap based on the basic hourly rate for all employees is as follows:

All Staff

Mean Median Gender Pay Gap %

Female Male Female Male Mean Median

2017 £ 19.44

£ 23.61

£ 17.60

£ 20.31 17.68% 13.32%

2018 £ 20.14

£ 23.97

£ 18.31

£ 20.64 15.98% 11.28%

2019 £ 20.65

£ 24.51

£ 18.90

£ 21.31 15.74% 10.51%

The gender pay gap is driven by a number of factors including the predominance of female staffing in the nursing and support staff professional group, the consultant workforce (through the impact of seniority and bonus payments) and the under-representation of women in very senior roles.

In addition to the pay gap the trust is required to split its male and female pay into quartiles to demonstrate the proportion of male and female employees within each of the quartiles.

The graph below demonstrates we have higher proportion of males in the upper and lower quartiles of pay. Please see table 7b below.

Table 7b – Gender Pay Gap by quartiles

2017 2018 2019 2017 2018 2019 Male Female Male Female

Upper quartile

37.62% 37.15% 37.34% 62.38% 62.85% 62.66% 1168 1976 1202 2017

2017 Upper Middle Quartile

22.85% 22.42% 22.46% 77.15% 77.58% 55.54% 673 2329 696 2403

Lower Middle Quartile

20.55% 22.06% 21.57% 79.45% 77.94% 78.43% 678 2395 669 2433

Lower Quartile

27.03% 25.99% 26.53% 72.97% 74.01% 73.47% 798 2273 833 2307

The table below shows a year on year comparison and indicates a shift in the lower quartile

with the volume of females increasing and in the lower middle quartile with the volume of

males increasing. This change, although minor could indicate progress in the wrong

direction, however detailed analysis of staff that fall within the lower quartile would need to

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be conducted to establish if this increase has occurred as a result of women being recruited

in to lower banded roles.

Chart 7b - Gender Pay Gap by quartiles

Bonus/additional payment GPG

There is a 19.753% mean pay gap overall for bonus payment in the trust.

Graph 7c below shows the overall bonus payments for all staff in the trust.

Clinical excellence awards (CEAs) and distinction awards/discretionary points are the only bonus payments made, and paid only to medical staff. CEA awards are determined locally in the trust while national awards are determined nationally. Table 7d and 7e shows the bonus payments for consultants.

Graph 7c: The overall bonus payments for all employees are as follows:

Mean bonus pay gap – 19.75% Median bonus pay gap – 40.74%

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Table 7d below show the proportions for employees paid a bonus – in the trust (only

Medical and Dental Consultants are paid a bonus).

GenderEmployees Paid Bonus

Total employees within a 12 month period

Percentage of all employee receiving a bonus

Female 98 9218 1.06%

Male 182 3400 5.35%

Total 280 12618 2.22%

Table 7e – Bonus GPG for Consultants

GenderEmployees Paid Bonus

Total Consultants within a 12 month period

Percentage of Consultants receiving a bonus

Female 98 301 32.56%

Male 182 404 45.05%

Total 280 705 39.72%

Table 7f below shows a year on year comparison of the bonuses paid and the bonus pay

gap.

• More Consultants have been in receipt of a bonus in the year to 31st March 2018 than those in 2017, however the actual bonus amounts have reduced. It must be considered that we have included bonuses paid under locally agreed elements that were not included last year which has increased the numbers reported.

• The increase in the number reported and the amount of bonuses paid will have impacted the mean and median amounts.

Table 7f – Bonus Gender Pay Gap for Consultants

Year

No. in receipt of Bonus

Mean bonus amount Median bonus amount

Female Male Female Male % Gap Female Male % Gap

2017 94 178 £10,783.63 £13,834.46 22.13% £5,976.20 £11,934.30 50.00%

2018 101 193 £9,262.13 £11,541.05 19.75% £4,821.57 £8,136.45 40.74%

2019 98 182 £9,393.63 £12,168.62 22.81% £5,020.36 £ 9,047.99 44.51%

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Table 7g below demonstrates the pay gap for each grade within the Medical and Dental workforce for all staff.

Band Headcount % Avg. Hourly Rate

Pay Gap %

Female Male Female Male

FY1 76 47.37% 52.63% £17.75 £17.50 -1.40%

FY2 95 60.00% 40.00% £21.48 £20.98 -2.40%

StR 1637 62.98% 37.02% £26.93 £29.13 7.54% Hospital Practitioner 2 50.00% 50.00% £31.81 £26.62 -19.50% Specialty Doctor 97 48.45% 51.55% £32.32 £37.17 13.05%

Consultant 705 42.70% 57.30% £47.18 £50.53 6.61% Medical Ad Hoc 12 58.33% 41.67% £18.77 £23.19 19.07%

Grand Total 2624 56.40% 43.60% £30.75 £36.33 15.35%

Table 7g – Gender Pay Gap by Occupational Staff Group

Staff Group Headcount% Avg. Hourly Rate Mean

Pay Gap % Female Male Female Male

Add Prof Scientific and Technic 334 70.06% 29.94% £22.88 £22.33 -2.47% Additional Clinical Services 1,294 77.05% 22.95% £12.66 £12.85 1.48% Administrative and Clerical 1,999 71.94% 28.06% £16.88 £19.32 12.64% Allied Health Professionals 588 82.65% 17.35% £21.75 £20.75 -4.83%

Estates and Ancillary 314 47.13% 52.87% £12.47 £13.84 9.88%

Healthcare Scientists 178 55.62% 44.38% £22.09 £24.26 8.94%

Medical and Dental 2,487 56.65% 43.35% £30.38 £35.99 15.58% Nursing and Midwifery Registered 2,874 86.74% 13.26% £20.55 £20.93 1.79%

Students 23 100.00% 0.00% £13.79 N/A

Grand Total 10,091 72.61% 27.39% £20.64 £25.32 18.49%

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Chart 7h – Gender Pay Gap by length of service and chart 7i – Gender Pay Gap by age

below demonstrate that the trust’s medical and dental workforce have a higher impact

on gender pay gaps.

The gender pay gap in the trust can be attributed to the Medical and Dental and the Administrative and Clerical occupational staff groups. These are the areas of work where men are in larger proportion and in more senior higher paid positions. The review of the trust’s Clinical Excellence Awards will take time to impact on the trust figures due to staff length of service.

Within the Administrative and Clerical areas, the trust is aware of the BAME representation at senior levels. These are been addressed within WRES action plan.

7.2 Women’s staff network

The overall objective of the trust’s women’s network is to create a platform that continues to empower women in employment, encourage and motivate them through a range of initiatives.

A “coffee - connect” initiative was set up in the last 12 months to help staff make connections and build networks. This initiative is open to all staff whereby the network pairs staff with another staff within the organisation to have coffee together. The expectation is to set up a coffee connect” to know a new member of staff and give staff a break from their daily routine and it has been well received by staff.

-5.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

< 1 year 1 - 3 years 3 - 5 years 5 - 10 years > 10 years

Gender Pay Gap by LOS - 2019

All Staff Groups

Excl M&D

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Under 20 21-30 31-40 41-50 51-60 61-70 71+

Gender Pay Gap by Age - 2019

All Staf Groups

Excl M&D

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The network held an inclusive event in October 2019 with Yvonne Coghill, WRES National Director as the guest speaker. She has been voted as one of the top 50 most inspirational women, nurse leaders and BAME pioneer, two years in a row and has been awarded an OBE for services to healthcare. Male staff who are allies also attended the event where she shared her personal experiences as a female leader and encouraged both female and male staff to work together to create a working environment and culture where everyone thrives.

A “Let’s talk Menopause” women’s staff network event was also set up in October 2019, led by Sheila Radhakrishnan, Consultant Gynaecologist and Giovanna Leeks, Head of Employee Relations with the aim to explore the topic of menopause through interactive discussion. Facilitated breakout sessions were held in small groups to give staff an opportunity to talk about this often seen as a taboo subject. As a result of the session, a follow up event will be scheduled in the near future as staff welcome the idea of having such small and big conversations.

To further increase collaboration in the local health economy, the network has set up an arrangement with UCLH women’s network to share access and ensure all events involving inspirational speakers are accessible to both organisations via video conferencing. This will enable all staff across both organisations to watch and participate in such events whenever they take place in the trust

8.0 Improving People Practices

The bullying and harassment working group continues to implement the trust’s bullying and harassment action plan, inviting staff to discuss their experiences and share good practice. Our disciplinary and suspension checklist have been reviewed in light of the ‘just culture’ concept as have the tone of trust letters be more compassionate and friendly. KPI’s are under development to help ensure there are no unnecessary delays in processes.

The trust now has over 60 speaking up champions across the trust acting as independent support for staff and helping to raise concerns so that they can be addressed.

The trust recognises that bullying and harassment disproportionately affects staff from BAME, staff with disabilities and LGBT+. As a result the staff networks are key partners within the Bullying and Harassment working group.

A new Freenet 2 page for bullying and harassment has been developed to help staff access information and support. Further work is on-going with the delivery of the bullying and harassment videos which have now been watched by over 1000 staff across the trust.

9.0 Engagement with Trade Unions

The trust has a group joint negotiating committee with the trade unions in place to negotiate and formally agree workforce related policies in partnership.

The equality, diversity and inclusion staff group has trade union representatives on the group to represent staff.

The LGBT and BAME staff network joint chairs are trade union representatives working in partnership with staff.

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10.0 Public Sector Equality Duty

The trust is required under the Public Sector Equality Duty to report data on equalities annually, in line with the guidance issued by the Equality and Human Rights Commission (EHRC), the equality information in this Appendix examines key areas of focus within the employment cycle to demonstrate that the trust is paying “due regard” to quantitative analysis of its workforce data to support eliminating discrimination, advancing equality of opportunity and fostering good relations amongst its workforce under the Equality Act 2010.

Protected characteristics are examined against data available for the following activities set in Appendix 2, pages 30 - 74:

1. Recruitment; 2. Employee relation cases; 3. Appraisals 4. Training and development, i.e. non-mandatory , including 5. Mandatory and statutory training 6. Promotions 7. Leavers

The RFL’s planned actions in response to this analysis are set out in the future actions and priorities for 2020 section of the main report.

11.0 Workforce equality data analysis – 2019 summary

The trust is required to report data on equalities annually, in line with the guidance issued by the Equality and Human Rights Commission (EHRC). The equality information set out in the Appendix examines key areas of the employment cycle against equality data to demonstrate that the trust is taking “due regard” to ensuring its day-to-day activities support eliminating discrimination and advancing equality of opportunity and the fostering of good relations amongst its workforce under The Equality Act 2010. The key observations from the data analysis in the Appendix are highlighted below.

11.1 Age • Staff in age groups 36 – 55 are more likely to be subject to employee relation cases,

there is no adverse trend as this is in proportion to their workforce population. • Staff in age groups 21 – 35 are more likely to leave the trust, this is a similar trend in

the previous 12 months.

11.2 Disability • There has been a slight increase in staff disclosing their disability status on ESR over

the last 12 months, i.e. 38 staff, these are small numbers so no significant increase.

11.3 Sex (gender) • There is no adverse trend identified except within the gender pay gap highlighting

that female employees earn an hourly mean average pay of 15.74% less than men.

11.4 Marriage and Civil Partnership • There are no adverse trends identified in the workforce equality analysis in this area.

11.5 Maternity and Adoption • There are no adverse trends identified in the workforce equality analysis in this area.

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11.6 Pregnancy and Maternity • trust has a maternity leave policy and guidelines in place and there are no adverse

trends identified in this category.

11.7 Race/Ethnicity • There is still a higher proportion of BAME staff going forward for formal employee

relation cases than their overall representation in the workforce; however, this has reduced from a ratio of 2.21 in 2015 to 1.58 in 2019.

11.8 Religion or belief • Applicants with Atheists belief, other and undefined beliefs are more likely to be

successful in the trust’s overall recruitment process, similar trend to the previous 12 months.

11.9 Sexual Orientation • In the trust’s overall recruitment process, lesbian and gay candidates are more likely

to be appointed, though these are small numbers, similar trend to the previous 12 months.

These observations will feed into revised 2020 – 2021 equality, diversity and inclusion action plans highlighted below.

6.0 Future Actions and Priorities for 2020

The progress made so far in this report is acknowledged and areas requiring further work will form part of future actions for 2020 including:

• To continue the journey of transformation in becoming a model employer and an inclusive place to work.

• To consider reverse mentoring for trust Board members to mentor and sponsor AfC Band 8d or below.

• To continue to recruit Board members from a BAME background.• To review the trusts recruitment and selection training• To review the trusts equality, diversity and inclusion training • To continue to monitor progress, benchmark and share good practice. • To engage staff networks, staff side and other key stakeholders in planning and

delivering staff engagement events in 2020

7.0 Conclusions

The RFL recognises that the world of work is changing and employee’s expectation of their employer is also changing. Currently there are five different generations at work, bringing diverse perspectives to the workplace. This requires more inclusive ways of working, recognising growth will come with great employee experiences which inevitably lead to a productive place of work. This report demonstrates that the key areas of focus for inclusion continue to be;

• Improving the experience of staff with disabilities, BAME staff, and those experiencing bullying and harassment.

• Closing the gender and ethnic pay gaps with more communication to female staff about the trust’s Clinical Excellence Awards and ensuring proportionate representation at senior level across gender and ethnicity.

• Continuing to pursue and promote equality is all that we do.

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Appendix 1 – Workforce profile as at 31st October 2019

A. Age Profile

Chart 1 below shows that in the last 12 months the majority of staff employed in the trust are between the ages of 36 – 55 accounting for 48.8%, followed by age group 21 – 35, accounting for 35.3% and age group 56 – 71+ accounts for 15.6%. This has been a consistent pattern over the last 4 years.

Chart 1 – Age profile for under 20, 21 – 35, 36 – 55, and 56+

B. Disability

Chart 2 below shows that 2.12% of our total staff have disclosed that they have a disability on the trust’s Electronic Staff Record (ESR). This has increased by 0.21% from 2018 when 171 staff disclosed and 209 staff have now disclosed, an increase of 38 staff.

The 14.8% unspecified are staff not declaring whether they have a disability or not, these are the staff we need to target to disclose further in the coming 12 months.

Increasing the declaration rate for staff who have a disability underpins the work of Workforce Disability Equality Standards (WDES) in order to ensure disabled staff are able to have a conversation about their disability with their line manager, discuss any adjustments that may be required and seek further support from the Occupational Health and Wellbeing Centre, where needed.

It is also a fact that some staff are worried about disclosing that they have a disability or a medical condition as they feel it has nothing to do with their ability to do their job. To help staff to update their disability status via self-service ESR, a step-by-step guide has been developed and support surgeries for staff to get help are being developed in conjunction with the “Ability @ the free network”.

The staff network has been in place for two years and provides a supportive and confidential space for staff with disabilities to come together to share ideas and best practice, and raise awareness of a wide range of support networks available to staff at work.

In the coming months we will be developing staff campaigns around the benefits of disability declaration to improve the trust’s disability data sets which would inherently help to move the culture of openness forward and remove the stigma attached to disability in order for staff to get the help they need.

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Chart 2 – Disability profile

C. Gender

Chart 3 below shows majority of trust employees are female at 73.4% and male accounts for 26.6%, which is in line with the national pattern in the NHS. This has been a consistent pattern in the last 4 years.

Chart 3 – Gender profile

D. Race/Ethnicity

Chart 4 below shows that white staff accounts for 49.0%, BAME accounts for 49.8% and other accounts for 1.2%. BAME staff has increased by 1% in the last 12 months.

Overall, the trust’s workforce broadly reflects the local population it serves, although there is under-representation of BAME staff at senior levels.

Chart 4 – Race/Ethnicity profile

E. Marital Status & Civil Partnership workforce profile

Chart 5 shows majority of staff identify as are married or single in a fairly consistent pattern for the last 4 years. Non-disclosures have reduced.

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Chart 5 – Marital Status profile

F. Religious Belief

Chart 6 below shows that the largest religious belief in the trust is Christianity, followed by those in undefined and undisclosed group and those in the Atheist group.

Chart 6 – Religious Belief profile

G. Sexual Orientation workforce profile

Chart 7 below shows that the sexual orientation of the majority of staff employed in the trust over the last four years is heterosexual at 74.2% followed by those who have not defined or disclosed their sexual orientation at 23.07%.

Chart 7 – sexual orientation profile

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H. Maternity and Adoption workforce profile

Chart 8 – maternity and adoption profile

Chart 8 below shows that 4.41% of staff were on maternity leave & adoption leave in the last 12 months (435 staff).

I. Workforce equality data

Chart 9 below shows that over the last 3 years, the age, gender and ethnicity workforce information has been 100%. While data held for disability, sexual orientation, marital status and religious belief has been increasing slightly. Trust information and events ensures that staff are able to see what the trust uses the data for and the benefits of disclosure.

The trust’s electronic staff record (ESR) system nationally does not record gender re-assignment.

Chart 9 – workforce equality data

Age

10

0%

Age

10

0%

Age

10

0%

Gen

der

10

0%

Gen

der

10

0%

Gen

der

10

0%

Eth

nic

Co

de

10

0%

Eth

nic

Co

de

10

0%

Eth

nic

Co

de

10

0%

Dis

able

d 8

0%

Dis

able

d 8

3%

Dis

able

d 8

5%

Sexu

al O

rien

tati

on

84

%

Sexu

al O

rien

tati

on

86

%

Sexu

al O

rien

tati

on

88

%

Mar

ital

Sta

tus

92

%

Mar

ital

Sta

tus

93

%

Mar

ital

Sta

tus

94

%

Rel

igio

us

Bel

ief

83

%

Rel

igio

us

Bel

ief

85

%

Rel

igio

us

Bel

ief

87

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2017 2018 2019

% C

om

ple

te R

eco

rds

Workforce equality data gap analysis over 3 years

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Appendix 2- Further data analysis against protected characteristics

Appendix 2- Section – 1.0 - Workforce recruitment equality data

1.1 Applicant’s age profile

The trust’s workforce recruitment equality data covers the period 1st July 2018 – 30 June 2019, excluding bank recruitment.

A total of 19308 applications were received over a period of 12 months. 8422 were shortlisted and 3217 were successful at the end of the process. This accounts for 16.66% of all applications received, this is a decrease of 3.23% on last year’s successful applicants.

The age profile data in graph 1 below shows that the age group most likely to be recruited are 21 – 35, similar to last year’s trend, and the least likely age group to be recruited is age under 20.

Graph 1 – Applicants age profile

1.2 Applicant’s disability profile

Out of a total of 19308 applicants over the period stated above, 698 confirmed that they had a disability, 367 were shortlisted and 98 were appointed. This accounts for 14.04% of the total number of applicants with disability, a decrease from the 20.41% applicants with disability appointed last year. Please see graph 2 below.

Graph 2 – Applicant’s disability profile

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1.3 Applicants ethnicity profile

A total of 6483 white applicants applied for posts over a period of 12 months covering1st July 2018 – 30 June 2019 out of the total 19308 and 1463 were appointed accounting for 22.57% of the total number of applicants.

A total of 12019 BAME applicants applied for posts over the same period and 1439 were appointed accounting for 11.97% of the total number of applicants. Whilst across the same period, there were 6483 applications from White applicants, of which 22.57% were hired (1463). This is a decrease in the number of successful applications proportionally by both groups compared to last year. Graph 3 shows broadly the breakdown between White and BAME staff group.

Graph 3 - Profile of applicant’s ethnicity

1.4 Applicant’s Gender profile

This data covers a period of 12 months i.e. 1st July 2018 – 30 June 2019. The data in graph 4 below shows there is a higher proportion of females appointed from the recruitment process than men; this is a national trend and similar trend to the previous 12 months.

Graph 4 – Applicant’s Gender profile

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1.5 Applicant’s Marital Status profile

The data in graph 5 below shows that applicants in the undefined group are proportionally more successful at appointment than any other group. This is a similar trend in the last 12 months.

Graph 5 – Applicant’s Marital Status & Civil Partnership profile

1.6 Applicant’s Sexual Orientation profile

In the trust’s overall recruitment process, graph 6 below shows that the undefined group are more likely to be shortlisted and appointed, followed by the Gay and Lesbian group.

Graph 6 – Applicant’s sexual orientation

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1.7 Applicant’s Religious Belief profile

Applicants with Atheists belief, other and undefined beliefs are more likely to be successful in the trust’s overall recruitment process.

Graph 7 – Applicant’s Religion or Belief profile

1.8 Adverts over the last 3 years

The total number of adverts in the trust has increased to its highest levels for some time, with increases in adverts for Nursing and Midwifery and Healthcare Assistant staff groups. It is worth noting that this year we separated out the Healthcare assistants from the additional clinical services, explaining the apparent decrease in adverts for these staff groups. Other significant increases have occurred in the Estates and Ancillary staff group, possibly explained by the creation of Property Services.

A significant amount of organisational changes have taken place in the last 3 years, as a result the restructuring has led to a reduction in the number of posts to be advertised due to the need for redeployment.

Graph 8 – Adverts over the last 3 years

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1.9 Applications over the last 3 years

The trust’s workforce recruitment data in graph 9 below reflects the total number of applications over the last 3 years increasing by over 5000. Huge increases in Medical and Nursing applications accounted for over 67.83% of the additional applications. The administrative and clerical staff group recorded a decrease by over 543 applications while increases were recorded in Allied Health Professionals post applications by almost 28% (399 applications). These reductions are as a result of significant organisational changes as well as continuous improvement plans.

Graph 9 – Applications over the last 3 years

1.10 Appointments over the last 3 years

The trust’s workforce recruitment advert data in graph 10 below shows the total number of appointments over the last 3 years has increased by 387.

Graph 10 – Appointments over the last 3 years

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Appendix 2 – Section 2 - Workforce employee relations equality data

The trust monitors all employee relations cases with regards to seven protected characteristics on an annual basis. The employee relation cases in this report cover the periods 1st July 2018 – 30th June 2019, inclusive of managing sickness absence cases.

Overall there were 669 ER cases in the last 12 months period supported by the employee relations team. 229 of the cases were sickness absence cases with the remaining 312 consisting of bullying and harassment, capability, disciplinary and grievance. The employee relations team work with managers to monitor, investigate, and undertake hearings and appeals for all cases in the trust. In the last 12 months there has been a substantial decrease in the number of cases from 843 to 669 due to encouragement of informal routes/ action as the 1st option and more robust recording of all cases. A new system was implemented in April 2018, which has supported in better monitoring of lapsed times between stages. Legacy data was cleansed to ensure all information was accurate. In addition the trust has implemented freedom to speak and initiatives to address bullying and harassment. This has led to increased awareness amongst staff and invariably more reporting. The trust’s “speaking up” campaign enables staff to raise their concerns anonymously.

2.1 Age (employee relations)

Proportionally staff in the 36 – 55 and 56+ ages groups and above are more likely to go forward to an employee relations case process. See table and chart 1 below for details.

Table 1: employee relation cases by age

Chart 1: – employee relation cases by age

Age Group Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount

B&H Headcount % of B&H

Headcount

Under 20 28 0.29% 4 0.60% 0 0.00%

21 - 35 3314 34.38% 163 24.36% 19 25.33%

36 - 55 4807 49.87% 364 54.41% 48 64.00%

56+ 1490 15.46% 134 20.03% 8 10.67%

Undefined 0 0.00% 4 0.60% 0 0.00%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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2.2 Disability (employee relations)

177 staff have disclosed their disability in the trust out of which 21 were involved in employee relation cases, accounting for 11.86% of the overall cases. There were 2 staff with disability involved in bullying and harassment cases, this is an increase from one case in the previous 12 months which would be expected in the light of the bullying and harassment campaign held in the trust in the last 12 months. See table and chart 2 below.

Table 2 – employee relations by disability

Chart 2 – employee relations by disability

2.3 Gender (employee relations)

Female staff accounts for the majority of the employee relation cases i.e. 493 at 73.69% inclusive of 55 bullying and harassment cases and male staff had 176 cases at 26.31% inclusive of 20 bullying and harassment cases. This is in proportion to the gender distribution across the trust, a similar trend to the previous 12 months. See full details in table and chart 3 below.

Table 3 – employee relations by gender

Chart 3 – employee relations by gender

Disability Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

No 7737 80.27% 513 76.68% 58 77.33%

Not Declared 221 2.29% 13 1.94% 0 0.00%

Unspecified 1504 15.60% 122 18.24% 15 20.00%

Yes 177 1.84% 21 3.14% 2 2.67%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

Gender Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

Female 7053 73.17% 493 73.69% 55 73.33%

Male 2586 26.83% 176 26.31% 20 26.67%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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2.4 Ethnicity (employee relations)

Overall White staff account for 296 cases, this is 44.25% of all cases and they represent

49.69% of the workforce. While BAME staff accounts for 364 cases, this is 54.41% of the

cases and they represent 49.22% of the workforce. A higher proportion of BAME staff are

subject to formal and informal employee relation cases and this is disproportionate, please

see table and graph 4 below. This area requires further work in 2020 i.e. invite the Head of

ER to the BAME staff network meetings to discuss good practice and the type of cases that

comes through so that BAME staff can learn how to avoid being involved in these cases.

See table and chart 4 below.

Table 4 – employee relations by ethnicity

Chart 4 – employee relations by ethnicity

2.5 Marital status (employee relations)

Overall both married at 36.92% and single at 42.75% are more likely to go through an employee relation cases as well bullying and harassment cases than other status. However, these represent 42.29% and 43.87%of the workforce respectively, suggesting that single is in line with its proportion but people listed as married are significantly less likely to be involved in an ER Case. This is similar to the previous 12 months trend, and no adverse trend identified. See table and chart 5.

Ethnic BAME

Group

Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

BAME 4744 49.22% 364 54.41% 40 53.33%

Other 105 1.09% 7 1.05% 0 0.00%

White 4790 49.69% 296 44.25% 35 46.67%

Undefined 0 0.00% 2 0.30% 0 0.00%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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Table 5 – employee relations by marital status

Chart 5 – employee relations by marital status

2.6 Sexual Orientation (employee relations)

Overall the majority of staff represented in employee relation cases are the Heterosexual

group at 64.72%, the Not Stated group at 17.19% and Undefined at 16.14%. An interesting

note is that the not stated group only accounts for 11.70% of the workforce – suggesting a

larger proportion being represented in ER cases. Please see full detail in table and chart 6

below.

Table 6 – employee relations by sexual orientation

Marital Status Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

Civil Partnership 131 1.36% 8 1.20% 0 0.00%

Divorced 410 4.25% 44 6.58% 2 2.67%

Legally Separated 93 0.96% 8 1.20% 1 1.33%

Married 4076 42.29% 247 36.92% 32 42.67%

Single 4229 43.87% 286 42.75% 31 41.33%

Unknown 624 6.47% 69 10.31% 7 9.33%

Widowed 76 0.79% 7 1.05% 2 2.67%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

Sexual

Orientation


Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

Bisexual 73 0.76% 5 0.75% 0 0.00%

Gay or Lesbian 173 1.79% 7 1.05% 1 1.33%

Heterosexual or

Straight

7043 73.07% 433 64.72% 56 74.67%

Not stated

(person asked

but declined to

provide a

response)

1128 11.70% 115 17.19% 10 13.33%

Other sexual

orientation not

listed

2 0.02% 0 0.00% 0 0.00%

Undecided 10 0.10% 1 0.15% 0 0.00%

Undefined 1210 12.55% 108 16.14% 8 10.67%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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Chart 6 – employee relations by sexual orientation

2.7 Religious belief (employee relations)

Staff with no religion disclosed at 14.95% and those with Christian belief at xx% are represented in the majority of the cases. This is similar to the previous 12 months and no adverse trends identified. Please see detail in table and chart 7 below.

Table 7 – employee relations by religious belief

Chart 7 – employee relations by religious belief

Religious Belief Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

Atheism 935 9.70% 31 4.63% 3 4.00%

Buddhism 95 0.99% 4 0.60% 0 0.00%

Christianity 4072 42.25% 277 41.41% 35 46.67%

Hinduism 512 5.31% 29 4.33% 5 6.67%

Islam 676 7.01% 44 6.58% 8 10.67%

Jainism 41 0.43% 1 0.15% 0 0.00%

Judaism 202 2.10% 9 1.35% 1 1.33%

Not disclosed 1244 12.91% 100 14.95% 5 6.67%

Other 513 5.32% 46 6.88% 10 13.33%

Sikhism 53 0.55% 3 0.45% 0 0.00%

Undefined 1296 13.45% 125 18.68% 8 10.67%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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2.8 Length of service (employee relations)

Overall staff with more than ten years in service is more likely to go through employee relation cases including bullying and harassment cases. This is similar to the previous 12 months trend, and no adverse trend identified. Please see table and chart 8 below.

Table 8 – employee relations by length of service

Chart 8 – employee relations by length of service

2.9 Pay bands (employee relations)

Overall staff’s in pay bands 1-4 and 5-7 are significantly more likely to go through employee relation cases including bullying and harassment cases. The band 1-4 group accounts of 47.09% of all ER cases, but only account for 29.47% of the workforce – which seems a significant difference. This is similar to the previous 12 months trend, and no adverse trend identified. Please see table and chart 9 below.

Table 9 – employee relations by pay bands

Length of Service

Group


Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

< 1 year 2131 22.11% 41 6.13% 5 6.67%

1 - 3 years 1948 20.21% 138 20.63% 20 26.67%

3 - 5 years 1225 12.71% 115 17.19% 11 14.67%

5 - 10 years 1542 16.00% 128 19.13% 14 18.67%

> 10 years 2793 28.98% 233 34.83% 25 33.33%

Undefined 0 0.00% 14 2.09% 0 0.00%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

Band Group Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

1-4 2841 29.47% 315 47.09% 27 36.00%

5-7 4317 44.79% 277 41.41% 29 38.67%

8A+ 722 7.49% 45 6.73% 8 10.67%

Medical & Dental 1685 17.48% 31 4.63% 11 14.67%

VARY 73 0.76% 1 0.15% 0 0.00%

Non RFH 1 0.01% 0 0.00% 0 0.00%

Undefined 0 0.00% 0 0.00% 0 0.00%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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Chart 9 – employee relations by pay bands

2.10 Occupational Staff Groups (employee relations)

Overall staff in administrative and clerical and healthcare assistant staff groups, are more likely to be subject to employee relation cases inclusive of bullying and harassment cases compared to the proportion of each in the workforce. Staff in lower pay bands are also more likely to be represented in the employee relation cases in the trust, please see table and chart 10 below, for occupational staff groups. This is similar to the previous 12 months trend, and no adverse trend identified.

Table 10 – employee relations by occupational staff group

Staff Group Headcount % of Total

Headcount

Total ER Cases

Headcount

% of Total ER

Cases Headcount


Headcount

Add Prof

Scientific and

Technic

302 3.13% 28 4.19% 7 9.33%

Additional

Clinical Services

493 5.11% 54 8.07% 9 12.00%

Administrative

and Clerical

2086 21.64% 186 27.80% 24 32.00%

Allied Health

Professionals

611 6.34% 26 3.89% 1 1.33%

Estates and

Ancillary

368 3.82% 27 4.04% 2 2.67%

Healthcare

Assistants

884 9.17% 97 14.50% 5 6.67%

Healthcare

Scientists

185 1.92% 10 1.49% 1 1.33%

Medical and

Dental

1684 17.47% 31 4.63% 11 14.67%

Nursing and

Midwifery

Registered

3008 31.21% 210 31.39% 15 20.00%

Students 18 0.19% 0 0.00% 0 0.00%

Undefined 0 0.00% 0 0.00% 0 0.00%

Grand Total 9639 100.00% 669 100.00% 75 100.00%

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Chart 10 – employee relations by occupational staff groups

Appendix 2 - Section 3.0 Workforce training equality data

In addition to the statutory and mandatory training, the trust has in place a wide range of training and development programmes for staff, however, the trust does not have any compliance rate in place for non-mandatory training and development courses. The data below covers the period 1st July 2018 – 30th June 2019.

For the period there were 2657staff recorded attending non-mandatory training across the trust, decreasing from 3046 reported in the previous 12 months. Further work has taken place during this period to collate a lot more training and development data on the trust’s system with the aim to have a more accurate and robust data. This has led to a substantial increase in the numbers reported on the OLM system. The trust has also aligned its reporting in this area to the reporting criteria for Workforce Race Equality Standards (WRES), thereby including more continuous development programmes. This will enable more consistent reporting for the trust. It is worth noting that the work is on-going to ensure all trainers and departments responsible for training update the OLM system with all necessary training data on non-mandatory training.

3.1 Age (training and development access)

Overall proportionally staff age groups under 35 are more likely to access training and development in the trust. There are fewer members of staff attending this training type in the 56+ age group and more members of staff attending this training type in the 21-35 age group. Please see full detail in table and chart 1 below.

Table 1: Training and development access by age

Age Group Summary Headcount % of Total Headcount Headcount of those who

attended Development

% of Total Training Attendees

Under 20 28 0.29% 14 0.53%

21 - 35 3314 34.38% 1061 39.93%

36 - 55 4807 49.87% 1300 48.93%

56+ 1490 15.46% 282 10.61%

Grand Total 9639 100.00% 2657 100.00%

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Chart 1: – Training and development access by age

3.2 Disability (training and development access)

Staff with disabilities are broadly accessing training and development courses in the trust. Please see table and chart 2 for details.

Table 2: Training and development access by disability

Chart 2: – Training and development access by disability

Disability Headcount % of Total Headcount Headcount of those who



No 7737 80.27% 2291 86.23%

Not Declared 221 2.29% 42 1.58%

Unspecified 1504 15.60% 273 10.27%

Yes 177 1.84% 51 1.92%

Grand Total 9639 100.00% 2657 100.00%

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3.3 Gender (training and development access)

Overall the gender balance in the overall workforce is relatively reflected in staff numbers accessing training and development courses, 75.12% female and 24.88% male. Please see full detail in table and chart 3 .

Table 3: Training and development access by gender

Chart 3: – Training and development access by gender

3.4 Ethnicity (training and development access)

Overall White staff are accessing training and development proportionately. Please see full detail in table and chart 4 below.

Table 4: Training and development access by ethnicity

Chart 4: – Training and development access by ethnicity

Gender Headcount % of Total Headcount Headcount of those who



Female 7053 73.17% 1996 75.12%

Male 2586 26.83% 661 24.88%

Grand Total 9639 100.00% 2657 100.00%

Ethnic BAME Group Headcount % of Total Headcount Headcount of those who



BAME 4744 49.22% 1366 51.41%

Other 105 1.09% 21 0.79%

White 4790 49.69% 1270 47.80%

Grand Total 9639 100.00% 2657 100.00%

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3.5 Marital status (training and development access)

Single status staff are more likely to access training and development, possibly due to having more time to pursue careers. Please see full detail in table and chart 5.

Table 5: Training and development access by marital status

Chart 5: – Training and development access by marital status

3.6 Sexual Orientation (training and development access)

Heterosexual staff are more likely to access training and development than any other sexual orientation in the trust, please see full detail in table and chart 6 below.

Table 6: Training and development access by sexual orientation

Marital Status Headcount % of Total Headcount

Headcount of those who attended

Development Training % of Total Training Attendees

Civil Partnership 131 1.36% 40 1.51%

Divorced 410 4.25% 104 3.91%

Legally Separated 93 0.96% 25 0.94%

Married 4076 42.29% 1093 41.14%

Single 4229 43.87% 1257 47.31%

Unknown 624 6.47% 115 4.33%

Widowed 76 0.79% 23 0.87%

Grand Total 9639 100.00% 2657 100.00%

Sexual Orientation Headcount % of Total Headcount

Headcount of those who attended

Development Training % of Total Training Attendees

Bisexual 73 0.76% 20 0.75%

Gay or Lesbian 173 1.79% 65 2.45%

Heterosexual or

Straight 7043 73.07% 2091 78.70%

Not stated (person

asked but declined to

provide a response) 1128 11.70% 272 10.24%

Other sexual

orientation not listed 2 0.02% 0 0.00%

Undecided 10 0.10% 6 0.23%

Undefined 1210 12.55% 203 7.64%

Grand Total 9639 100.00% 2657 100.00%

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Chart 6: – Training and development access by sexual orientation

3.7 Religious belief (training and development access)

Proportionally staff with Christian and undisclosed beliefs are more likely to access training and development, though all other beliefs are widely represented overall. Please see full detail in table and chart 7 below.

Table 7: Training and development access by religious belief

Chart 7: – Training and development access by religious belief

Religious Belief Headcount % of Total Headcount Headcount of those who



Atheism 935 9.70% 262 9.86%

Buddhism 95 0.99% 34 1.28%

Christianity 4072 42.25% 1259 47.38%

Hinduism 512 5.31% 158 5.95%

Islam 676 7.01% 188 7.08%

Jainism 41 0.43% 15 0.56%

Judaism 202 2.10% 49 1.84%

Not disclosed 1244 12.91% 305 11.48%

Other 513 5.32% 153 5.76%

Sikhism 53 0.55% 11 0.41%

Undefined 1296 13.45% 223 8.39%

Grand Total 9639 100.00% 2657 100.00%

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Appendix 2 – Section 4.0 - Workforce appraisal equality data

Overall, the current trust’s compliance levels for staff appraisals is 72.43% as at 30th June 2019, all protected characteristics have similar levels of compliance. A total of 4988 staff were appraisal compliant during this period. Note the headcount used for measuring appraisal is based on eligible staff i.e. those with > 12 months service and excludes those on maternity leave/long term sick so it differs from the overall headcount reported in other sections, which stands at 6887.

4.1 Age (appraisal)

Overall staff in age group 21- 35 recorded the highest numbers of appraisals, a similar trend to the previous 12 months and proportionate to the staff headcount in the age groups. Please see full detail in table and chart 1.

Table 1: appraisal by age

Chart 1: – appraisal by age

4.2 Disability (appraisal)

Overall staff with disabilities are having their appraisals and this is proportionate to their numbers in the overall workforce. This is similar to the trend in the previous 12 months. Please see full detail in table and chart 2 below.

Table 2: appraisal by disability

Age Group Summary Headcount % of Total Headcount Eligible for Appraisal

Headcount

% of Eligible for

Appraisal Headcount

Total Appraisals

Compliant

% Compliant Appraisals

Under 20 28 0.29% 11 0.16% 11 0.22%

21 - 35 3314 34.38% 1651 23.97% 1206 24.18%

36 - 55 4807 49.87% 3876 56.28% 2817 56.48%

56+ 1490 15.46% 1349 19.59% 954 19.13%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

Disability Headcount % of Total Headcount Eligible for Appraisal

Headcount

% of Eligible for

Appraisal Headcount

Total Appraisals

Compliant


No 7737 80.27% 5142 74.66% 3694 74.06%

Not Declared 221 2.29% 188 2.73% 130 2.61%

Unspecified 1504 15.60% 1428 20.73% 1077 21.59%

Yes 177 1.84% 129 1.87% 87 1.74%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

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Chart 2: – appraisal by disability

4.3 Ethnicity (appraisal)

Overall the ethnic balance is reflected in the appraisal pattern across the trust, the figures are proportionate and there is no adverse trend. Please see table and chart 3 below.

Table 3: appraisal by ethnicity

Chart 3: – appraisal by ethnicity

4.4 Gender (appraisal)

Overall the gender balance is reflected in the appraisal trend across the trust, 26.86% male and 73.14% female, this is a similar trend to the previous 12 months and there is no adverse trend. Please see full detail in table and chart 4 below.

Table 4: - appraisal by age

Ethnic BAME Group Headcount % of Total Headcount Eligible for Appraisal

Headcount

% of Eligible for

Appraisal Headcount

Total Appraisals

Compliant


BAME 4744 49.22% 3369 48.92% 2493 49.98%

Other 105 1.09% 58 0.84% 41 0.82%

White 4790 49.69% 3460 50.24% 2454 49.20%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

Gender Headcount % of Total Headcount

Eligible for Appraisal

Headcount

% of Eligible for Appraisal

Headcount

Total Appraisals

Compliant % Compliant Appraisals

Female 7053 73.17% 5052 73.36% 3648 73.14%

Male 2586 26.83% 1835 26.64% 1340 26.86%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

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Chart 4: – appraisal by age

4.5 Marital status (appraisal)

Overall all marital status are represented proportionately in the appraisal trend and there are no adverse trends identified. This is a similar trend to the previous 12 months; please see full detail in table and chart 5 below.

Table 5: - appraisal by marital status

Chart 5: – appraisal by marital status

Marital Status Headcount % of Total Headcount Eligible for Appraisal

Headcount


Headcount

Total Appraisals

Compliant

% Compliant

Appraisals

Civil

Partnership

131 1.36% 86 1.25% 56 1.12%

Divorced 410 4.25% 336 4.88% 235 4.71%

Legally

Separated

93 0.96% 74 1.07% 49 0.98%

Married 4076 42.29% 3114 45.22% 2256 45.23%

Single 4229 43.87% 2670 38.77% 1921 38.51%

Unknown 624 6.47% 547 7.94% 429 8.60%

Widowed 76 0.79% 60 0.87% 42 0.84%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

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4.6 Sexual Orientation (appraisal)

Overall all sexual orientation staff groups are proportionate in their appraisal rates in comparison to their overall numbers in the trust. There is no adverse trend and a similar trend to the previous 12 months. Please see full detail in table and chart 6 below.

Table 6: - appraisal by sexual orientation

Chart 6: – appraisal by sexual orientation

4.7 Religion and belief (appraisal)

Overall all religion and belief are proportionate in their promotion rates in comparison to their overall numbers in the trust. There is no adverse trend. Please see full detail in table and chart 7 below.

Table 7: - appraisal by religion and belief

Sexual

Orientation

Headcount % of Total Headcount Eligible for Appraisal

Headcount


Headcount

Total Appraisals

Compliant

% Compliant

Appraisals

Bisexual 73 0.76% 40 0.58% 25 0.50%

Gay or Lesbian 173 1.79% 110 1.60% 82 1.64%

Heterosexual

or Straight

7043 73.07% 4691 68.11% 3374 67.64%

Not stated

(person asked

but declined to

provide a

response)

1128 11.70% 890 12.92% 632 12.67%

Other sexual

orientation not

listed

2 0.02% 1 0.01% 0 0.00%

Undecided 10 0.10% 1 0.01% 0 0.00%

Undefined 1210 12.55% 1154 16.76% 875 17.54%

Grand Total 9639 100.00% 6887 100.00% 4988 100%

Religious

Belief


Headcount


Headcount

Total Appraisals

Compliant

% Compliant

Appraisals

Atheism 935 9.70% 548 7.96% 389 7.80%

Buddhism 95 0.99% 63 0.91% 46 0.92%

Christianity 4072 42.25% 2912 42.28% 2096 42.02%

Hinduism 512 5.31% 313 4.54% 236 4.73%

Islam 676 7.01% 392 5.69% 282 5.65%

Jainism 41 0.43% 28 0.41% 20 0.40%

Judaism 202 2.10% 124 1.80% 92 1.84%

Not disclosed 1244 12.91% 919 13.34% 647 12.97%

Other 513 5.32% 326 4.73% 223 4.47%

Sikhism 53 0.55% 26 0.38% 19 0.38%

Undefined 1296 13.45% 1236 17.95% 938 18.81%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

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Chart 7: – appraisal by religion and belief

4.8 Length of Service (appraisal)

Differing Lengths of Service appears to have no impact on the proportions of those who are compliant. Please see full detail in table and chart 8 below.

Table 8: - appraisal by length of service

Chart 8: – appraisal by length of service

4.9 Pay Band (appraisal)

Overall all pay bands are more likely to be appraised except for those in Bands 1 - 4 and Band 8a+. This area requires further investigation for the divisional data to be analysed and taken forward with management on each site. Please see full detail in table and chart 9.

Length of

Service Group


Headcount


Headcount

Total Appraisals

Compliant

% Compliant

Appraisals

< 1 year 2131 22.11% 3 0.04% 1 0.02%

1 - 3 years 1948 20.21% 1649 23.94% 1173 23.52%

3 - 5 years 1225 12.71% 1116 16.20% 817 16.38%

5 - 10 years 1542 16.00% 1433 20.81% 1040 20.85%

> 10 years 2793 28.98% 2686 39.00% 1957 39.23%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

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Table 9: - appraisal by pay band

Chart 9: – appraisal by pay band

Appendix 2 - Section 5.0 Workforce MaST equality data

The trust calculates mandatory and statutory training (MaST) compliance as the number of courses completed that were required, and this stands at 75.83%. However, for this report we have used a definition of members of staff who have got 100% compliance in all their required courses. Overall, the trust’s compliance levels as of 30th June 2019 for MaST using the latter definition is 27.08%.

All protected characteristics have similar levels of compliance. The headcount is different for MaST as it excludes those on maternity leave and long term sickness for whom compliance is not required.

5.1 Age (MaST)

Overall all staff age groups are widely represented proportionately in the MaST figures, there are no adverse trends identified. Please see full detail in table and chart 1 below.

Table 1 – (MaST) by age

Band Group Headcount % of Total Headcount Eligible for Appraisal

Headcount


Headcount

Total Appraisals

Compliant

% Compliant

Appraisals

1-4 2841 29.47% 2117 30.74% 1497 30.01%

5-7 4317 44.79% 3331 48.37% 2470 49.52%

8A+ 722 7.49% 658 9.55% 453 9.08%

Medical &

Dental

1685 17.48% 779 11.31% 568 11.39%

VARY 73 0.76% 1 0.01% 0 0.00%

Non RFH 1 0.01% 1 0.01% 0 0.00%

Grand Total 9639 100.00% 6887 100.00% 4988 100.00%

Age Group Summary Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

Under 20 28 0.29% 14 0.54%

21 - 35 3314 34.38% 814 31.19%

36 - 55 4807 49.87% 1318 50.50%

56+ 1490 15.46% 464 17.78%

Grand Total 9639 100.00% 2610 100.00%

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Chart 1 – (MaST) by age

5.2 Disability (MaST)

Overall staff with disabilities accessed MaST in proportion to their overall head count and there are no adverse trends identified. Please full detail in table and chart 2 below.

Table 2 – (MaST) by disability

Chart 2 – (MaST) by disability

5.3 Ethnicity (MaST)

Overall all ethnic groups are reflected in the MaST figures across the trust and are proportionate with the staff headcount for the ethnic groups, there is no adverse trend. Please see table and chart 3 below.

Disability Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

No 7737 80.27% 2141 82.03%

Not Declared 221 2.29% 45 1.72%

Unspecified 1504 15.60% 366 14.02%

Yes 177 1.84% 58 2.22%

Grand Total 9639 100.00% 2610 100.00%

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Table 3 – (MaST) by ethnicity

Chart 13– (MaST) by ethnicity

5.4 Gender (MaST)

Overall the gender balance is reflected in the promotion pattern across the trust, this is a similar trend to the previous 12 months and there is no adverse trend. Please see full detail in Table 4 below.

Table 4 – (MaST) by gender

Chart 4– (MaST) by gender

Ethnic BAME Group Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

BAME 4744 49.22% 1237 47.39%

Other 105 1.09% 29 1.11%

White 4790 49.69% 1344 51.49%

Grand Total 9639 100.00% 2610 100.00%

Gender Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

Female 7053 73.17% 1921 73.60%

Male 2586 26.83% 689 26.40%

Grand Total 9639 100.00% 2610 100.00%

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5.5 Marital status (MaST)

Overall the marital status for married and single shows the highest group of staff to be promoted in the trust. This is proportionate to their overall numbers in the trust. Other groups are proportionate. This is a similar trend to the previous 12 months and there is no adverse trend. Please see full detail in table and chart 5 below.

Table 5 – (MaST) by marital status

Chart 5– (MaST) by marital status

5.6 Maternity and Adoption (MaST)

Overall the marital status for married and single shows the highest group of staff to be promoted in the trust. This is proportionate to their overall numbers in the trust. Other groups are proportionate. This is a similar trend to the previous 12 months and there is no adverse trend. Please see full detail in table and chart 6 below.

Table 6 – (MaST) by maternity and adoption

Marital Status Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant


Divorced 410 4.25% 121 4.64%


Married 4076 42.29% 1165 44.64%

Single 4229 43.87% 1093 41.88%

Unknown 624 6.47% 151 5.79%

Widowed 76 0.79% 27 1.03%

Grand Total 9639 100.00% 2610 100.00%

Maternity & Adoption Headcount % of Total Headcount MasT Compliant Staff HC % of MaST Compliant

Maternity & Adoption 434 4.50% 36 1.38%

N/A 9205 95.50% 2574 98.62%

Grand Total 9639 100.00% 2610 100.00%

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Chart 6– (MaST) by maternity and adoption

5.7 Sexual Orientation (MaST)

Overall there are no adverse trends in the sexual orientation of staff groups accessing MaST in the trust. There is no adverse trend identified and trend is similar to the previous 12 months. Please see full detail in table and chart 7 below.

Table 7 – (MaST) by sexual orientation

Chart 7– (MaST) by sexual orientation

Sexual Orientation Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

Bisexual 73 0.76% 22 0.84%

Gay or Lesbian 173 1.79% 54 2.07%

Heterosexual or Straight 7043 73.07% 1904 72.95%

Not stated (person asked

but declined to provide a

response)

1128 11.70% 323 12.38%

Other sexual orientation not 2 0.02% 0 0.00%

Undecided 10 0.10% 2 0.08%

Undefined 1210 12.55% 305 11.69%

Grand Total 9639 100.00% 2610 100.00%

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5.8 Religion or belief (MaST)

Overall all religious beliefs are proportionate in accessing MaST in comparison to their overall numbers in the trust. There is no adverse trend. Please see full detail in table and chart 8 below.

Table 8 – (MaST) by religion and belief

Chart 8 – (MaST) by religion and belief

5.9 Length of Service (MaST)

Overall staff are widely represented in accessing MaST regardless of their length of service in the trust. There is no adverse trend. Please see full detail in table and chart 9 below.

Table 9 – (MaST) measured by length of service

Religious Belief Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

Atheism 935 9.70% 235 9.00%

Buddhism 95 0.99% 25 0.96%

Christianity 4072 42.25% 1182 45.29%

Hinduism 512 5.31% 137 5.25%

Islam 676 7.01% 172 6.59%

Jainism 41 0.43% 13 0.50%

Judaism 202 2.10% 44 1.69%

Not disclosed 1244 12.91% 320 12.26%

Other 513 5.32% 136 5.21%

Sikhism 53 0.55% 16 0.61%

Undefined 1296 13.45% 330 12.64%

Grand Total 9639 100.00% 2610 100.00%

Length of Service Group Headcount % of Total Headcount MasT Compliant

Staff HC

% of MaST Compliant

< 1 year 2131 22.11% 598 22.91%

1 - 3 years 1948 20.21% 538 20.61%

3 - 5 years 1225 12.71% 298 11.42%

5 - 10 years 1542 16.00% 431 16.51%

> 10 years 2793 28.98% 745 28.54%

Grand Total 9639 100.00% 2610 100.00%

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Chart 9– (MaST) measured by length of service

Appendix 2 – Section 6.0- Workforce Promotions equality data

There 835 promotions across the trust during the period 1st July 2018 – 30th June 2019.

These are staff numbers based on any one who moves up the pay bands in the period stated above. This may be as a result of direct promotion, restructuring or outcome of job evaluation process.

6.1 Age (promotion)

Overall all in all age groups were proportionally represented in promotion figures across the trust, please see detail in chart 1 below.

Table 1 – Promotion by age

Chart 1 – Promotion by age

Age Group Summary Headcount % of Total Headcount Promotions Headcount % of Promotions

Under 20 28 0.29% 0 0.00%

21 - 35 3314 34.38% 380 45.51%

36 - 55 4807 49.87% 382 45.75%

56+ 1490 15.46% 73 8.74%

Grand Total 9639 100.00% 835 100.00%

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6.2 Disability (promotion)

Overall staff with disabilities were widely represented in the promotion figures across the trust, although the sample size is very small. Please see full detail in table and chart 2 below.

Table 2 – Promotion by disability

Chart 2 – Promotion by disability

6.3 Ethnicity (promotion)

Overall there is a slight increase in the proportion of BAME’s that have been promoted in the last 12 months, these are specifically staff of Asian and Mixed Group origin, while promotion for staff from Black Caribbean and African origin have decreased. Please see table and chart 3 below.

Table 3 – Promotion by ethnicity - (BAME, White and Other)

Chart 3 – Promotion by ethnicity – (BAME, White and Other)

Disability Headcount % of Total Headcount Promotions Headcount % of Promotions

No 7737 80.27% 773 92.57%

Not Declared 221 2.29% 6 0.72%

Unspecified 1504 15.60% 40 4.79%

Yes 177 1.84% 16 1.92%

Grand Total 9639 100.00% 835 100.00%

Ethnic BAME Group Headcount % of Total Headcount Promotions Headcount % of Promotions

BAME 4744 49.22% 424 50.78%

Other 105 1.09% 8 0.96%

White 4790 49.69% 403 48.26%

Undefined 0 0.00% 0 0.00%

Grand Total 9639 100.00% 835 100.00%

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6.4 Gender (promotion)

Overall a small proportion of men are more likely to be promoted more than women in proportion to their overall head count in the trust. Please see full detail in table and chart 4 below.

Table 4 – Promotion by gender

Chart 4 – Promotion by gender

6.5 Marital status (promotion)

Overall singles proportionally are more likely to be promoted. Please see full detail in table and chart 5 below.

Table 5 – Promotion by marital status

Chart 5 – Promotion by marital status

Gender Headcount % of Total Headcount Promotions Headcount % of Promotions

Female 7053 73.17% 628 75.21%

Male 2586 26.83% 207 24.79%

Grand Total 9639 100.00% 835 100.00%

Marital Status Headcount % of Total Headcount Promotions Headcount % of Promotions


Divorced 410 4.25% 34 4.07%


Married 4076 42.29% 352 42.16%

Single 4229 43.87% 376 45.03%

Unknown 624 6.47% 42 5.03%

Widowed 76 0.79% 10 1.20%

Grand Total 9639 100.00% 835 100.00%

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6.6 Sexual Orientation (promotion)

Overall proportionally, staff in heterosexual category are more likely to be promoted and there is an increase in the proportion of Bisexual and Gay/Lesbian staff being promoted. Please see full detail in table and chart 6 below.

Table 6 – Promotion by sexual orientation

Chart 6 – Promotion by sexual orientation

6.7 Religion or belief (promotion)

Overall proportionally, staff with Christianity and atheist beliefs are more likely to be promoted, please see full detail in table and chart 7 below.

Table 7 – Promotion by religion and belief

Sexual Orientation Headcount % of Total Headcount Promotions Headcount % of Promotions

Bisexual 73 0.76% 10 1.20%

Gay or Lesbian 173 1.79% 24 2.87%


Not stated (person asked but

declined to provide a response) 1128 11.70% 75 8.98%

Other sexual orientation not

listed 2 0.02% 0 0.00%

Undecided 10 0.10% 1 0.12%

Undefined 1210 12.55% 37 4.43%

Grand Total 9639 100.00% 835 100.00%

Religious Belief Headcount % of Total Headcount Promotions Headcount % of Promotions

Atheism 935 9.70% 91 10.90%

Buddhism 95 0.99% 6 0.72%

Christianity 4072 42.25% 454 54.37%

Hinduism 512 5.31% 40 4.79%

Islam 676 7.01% 60 7.19%

Jainism 41 0.43% 4 0.48%

Judaism 202 2.10% 11 1.32%

Not disclosed 1244 12.91% 77 9.22%

Other 513 5.32% 53 6.35%

Sikhism 53 0.55% 1 0.12%

Undefined 1296 13.45% 38 4.55%

Grand Total 9639 100.00% 835 100.00%

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Chart 7 – Promotion by religion and belief

6.8 Length of Service (promotion)

Overall staff with 3 – 5 years of length of service are more likely to be promoted in the trust. Please see full detail in chart 8 below.

Table 8 – Promotion measured by length of service

Chart 8 – Promotion measured by length of service

Length of Service Group Headcount % of Total Headcount Promotions Headcount % of Promotions

< 1 year 2131 22.11% 75 8.98%

1 - 3 years 1948 20.21% 275 32.93%

3 - 5 years 1225 12.71% 181 21.68%

5 - 10 years 1542 16.00% 160 19.16%

> 10 years 2793 28.98% 144 17.25%

Grand Total 9639 100.00% 835 100.00%

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Appendix 2 – Section 7.0 - Workforce Leavers equality data

The leaver’s data covers the period 1st July 2018 – 30th June 2019 and excludes junior doctors on rotation. There was a total 1434 staff leaving the trust during this period.

Despite a lower staff headcount in the trust, the number of leavers has reduced from 1696 in 2017 – 2018 to 1434 in 2018 – 2019.

A key reason for a higher number of leavers is accounted for through TUPE transfers taking place due to organisational changes. A total of 226 staff were recorded under employee transfer in 2017/18 in comparison to a total of 12 that took place in 2016/17.

7.1 Age (leavers)

Leavers in age group 21 – 35 were the most likely to leave the trust, this is a similar trend in the last 3 years. The trust is currently implementing a wide range of initiatives to retain staff by having more accessible flexible working options available on e-rostering and introducing flexible working ambassadors.

Please see full detail in table and chart 1 below.

Table 1 – Leavers by age

Chart 1 – age (leavers)

7.2 Disability (leavers)

The numbers of staff with disabilities leaving the trust increased slightly, these are small numbers, and therefore, there is no statistical significance. Please see full details in table and chart 2.

Age Group Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Under 20 28 0.29% 13 0.91%

21 - 35 3314 34.38% 679 47.35%

36 - 55 4807 49.87% 500 34.87%

56+ 1490 15.46% 242 16.88%

Grand Total 9639 100.00% 1434 100.00%

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Table 2 – disability

Chart 2 – disability

7.3 Ethnicity (leavers)

Overall there are more White staff leaving the trust, while the numbers of BAME staff leaving the trust has also increased from last year i.e. more likely from the Black Caribbean and those from any other BAME background.

The increase in white staff leavers may be attributed to the Brexit effect; however, there is no clear indication that this is the case for BAME leavers.

Please see full details in table and chart 3 below.

Table 3 – Leavers by ethnicity

Chart 3 – Leavers by ethnicity

Disability Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

No 7737 80.27% 1223 85.29%

Not Declared 221 2.29% 29 2.02%

Unspecified 1504 15.60% 141 9.83%

Yes 177 1.84% 41 2.86%

Grand Total 9639 100.00% 1434 100.00%

Ethnic BAME Group Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

BAME 4744 49.22% 643 44.84%

Other 105 1.09% 9 0.63%

White 4790 49.69% 782 54.53%

Grand Total 9639 100.00% 1434 100.00%

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7.4 Gender (leavers)

The numbers of leavers by gender is proportionate to the overall gender balance in the trust, female staff account for 77% of leavers while male staff account for 23%.

There is no adverse trend in comparison to the previous year’s trend. Please see full details in table and chart 4 below.

Table 4 – Leavers by gender

Chart 4 – Leavers by gender

7.5 Marital status (leavers)

The numbers of leavers is proportionate to the overall marital status balance in the trust. There is no adverse trend. Please see full details in table and chart 5 below.

Table 5 – Leavers by marital status

Gender Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Female 7053 73.17% 1106 77.13%

Male 2586 26.83% 328 22.87%

Grand Total 9639 100.00% 1434 100.00%

Marital Status Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount


Divorced 410 4.25% 58 4.04%


Married 4076 42.29% 489 34.10%

Single 4229 43.87% 765 53.35%

Unknown 624 6.47% 76 5.30%

Widowed 76 0.79% 13 0.91%

Grand Total 9639 100.00% 1434 100.00%

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Chart 5 – Leavers by marital status

7.6 Maternity and Adoption (leavers)

The numbers of leavers who left the trust as a result of Maternity was 50 staff accounting for 3% of the overall leavers. Promoting flexible working to staff on maternity leave as part of the trust’s Timewise project would be an area to explore in the coming months. Please see full details in table and chart 6 below.

Table 6 – Leavers by maternity and adoption

Chart 6 – Leavers by maternity and adoption

7.7 Sexual Orientation (leavers)

The numbers of leavers is proportionate to the overall sexual orientation staff groups headcount. There is no adverse trend and is similar to previous year. Please see full details in table and chart 7.

Maternity &

Adoption Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Maternity &

Adoption 434 4.50% 50 3.49%

N/A 9205 95.50% 1384 96.51%

Grand Total 9639 100.00% 1434 100.00%

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Table 7 – Leavers by sexual orientation

Chart 7 – Leavers by sexual orientation

7.8 Religion or belief (leavers)

The numbers of leavers is proportionate to the overall religious belief staff groups headcount. There is no adverse trend and is similar to previous year. Please see full details in table and chart 8 below.

Table 8 – Leavers by religion or belief

Sexual Orientation Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Bisexual 73 0.76% 18 1.26%

Gay or Lesbian 173 1.79% 21 1.46%


Not stated (person asked but

declined to provide a

response) 1128 11.70% 143 9.97%

Other sexual orientation not

listed 2 0.02% 0 0.00%

Undecided 10 0.10% 1 0.07%

Undefined 1210 12.55% 113 7.88%

Grand Total 9639 100.00% 1434 100.00%

Religious Belief Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Atheism 935 9.70% 157 10.95%

Buddhism 95 0.99% 10 0.70%

Christianity 4072 42.25% 679 47.35%

Hinduism 512 5.31% 56 3.91%

Islam 676 7.01% 85 5.93%

Jainism 41 0.43% 5 0.35%

Judaism 202 2.10% 25 1.74%

Not disclosed 1244 12.91% 180 12.55%

Other 513 5.32% 97 6.76%

Sikhism 53 0.55% 7 0.49%

Undefined 1296 13.45% 133 9.27%

Grand Total 9639 100.00% 1434 100.00%

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Chart 8 – Leavers by religion or belief

7.9 Occupational Staff Groups (leavers)

The highest group of staff leaving the trust are the administrative and clerical, additional clinical services and the Healthcare workers in unqualified pay bands within Nursing and Midwifery. Please see full details in table and chart 9 below.

Table 9 – Leavers by Occupational staff groups

Chart 9 – Leavers by Occupational staff groups

Staff Group Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

Add Prof Scientific and Technic 302 3.13% 55 3.84%

Additional Clinical Services 493 5.11% 123 8.58%

Administrative and Clerical 2086 21.64% 319 22.25%

Allied Health Professionals 611 6.34% 103 7.18%

Estates and Ancillary 368 3.82% 54 3.77%

Healthcare Assistants 884 9.17% 167 11.65%

Healthcare Scientists 185 1.92% 27 1.88%

Medical and Dental 1684 17.47% 74 5.16%

Nursing and Midwifery Registered 3008 31.21% 496 34.59%

Students 18 0.19% 16 1.12%

Grand Total 9639 100.00% 1434 100.00%

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7.10 pay bands (leavers)

The highest group of staff leaving the trust are in pay bands 5 and 6, this is a similar trend to the previous year. The trust has recruitment and retention working focusing on this area. Please see full details in table and chart 10 below.

Table 10 – Leavers by Pay Bands

Chart 10 – Leavers by Pay Bands

7.11 Length of service (leavers)

The highest group of staff leaving the trust are staff with between 1- 3 years of service; this area is currently a priority for the trust’s recruitment and retention initiative. Please see full details in table and chart 11 below.

Table 11 – Leavers by Length of service

Band Group Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

1-4 2841 29.47% 513 35.77%

5-7 4317 44.79% 738 51.46%

8A+ 722 7.49% 90 6.28%

Medical & Dental 1685 17.48% 74 5.16%

VARY 73 0.76% 19 1.32%

Non RFH 1 0.01% 0 0.00%

Grand Total 9639 100.00% 1434 100.00%

Length of Service

Group Headcount % of Total Headcount Leavers Headcount % of Leavers Headcount

< 1 year 2131 22.11% 389 27.13%

1 - 3 years 1948 20.21% 460 32.08%

3 - 5 years 1225 12.71% 164 11.44%

5 - 10 years 1542 16.00% 165 11.51%

> 10 years 2793 28.98% 256 17.85%

Grand Total 9639 100.00% 1434 100.00%

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Chart 11 – Leavers by Length of service

7.12 Reason for leaving (leavers)

Relocation, promotion, and unknown reasons were the top 3 reasons for staff leaving the trust. Please see full details in table 12 below

Table 12 – Leaving Reasons

Leaving Reason Headcount % of Total Headcount

Death in Service 6 0.42%

Dismissal - Capability 6 0.42%

Dismissal - Conduct 9 0.63%

Dismissal - Some Other Substantial Reason 9 0.63%

Dismissal - Statutory Reason 3 0.21%

Employee Transfer 50 3.49%

End of Fixed Term Contract 65 4.53%

End of Fixed Term Contract - Completion of Training Scheme 19 1.32%

End of Fixed Term Contract - End of Work Requirement 1 0.07%

End of Fixed Term Contract - Other 9 0.63%

Flexi Retirement 1 0.07%

Has Not Worked 5 0.35%

Merged Organisation - Duplicate Record 1 0.07%

Mutually Agreed Resignation - Local Scheme with Repayment 4 0.28%

Redundancy - Compulsory 18 1.26%

Redundancy - Voluntary 17 1.19%

Retirement - Ill Health 11 0.77%

Retirement Age 107 7.46%

Voluntary Early Retirement - no Actuarial Reduction 7 0.49%

Voluntary Early Retirement - with Actuarial Reduction 3 0.21%

Voluntary Resignation - Adult Dependants 7 0.49%

Voluntary Resignation - Better Reward Package 48 3.35%

Voluntary Resignation - Child Dependants 39 2.72%

Voluntary Resignation - Health 35 2.44%

Voluntary Resignation - Incompatible Working Relationships 16 1.12%

Voluntary Resignation - Lack of Opportunities 33 2.30%

Voluntary Resignation - Other/Not Known 116 8.09%

Voluntary Resignation - Promotion 143 9.97%

Voluntary Resignation - Relocation 301 20.99%

Voluntary Resignation - To undertake further education or training 98 6.83%

Voluntary Resignation - Work Life Balance 247 17.22%

Grand Total 1434 100.00%

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Appendix 3: Staff Experience & Retention plan (SERP)

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Appendix 4: Glossary of abbreviations

1) BAME - Black, Asian and minority ethnic

2) EDS – Equality delivery system

3) ESR - Electronic Staff Record

4) CEO - Group Chief Executive officer

5) NHSE – NHS England

6) NHSi - NHS Improvement

7) PSED - Public Sector Equality Duty

8) RFL - The Royal Free London NHS Foundation Trust

9) SERP - Staff Experience & Retention plan

10) WDES - Workforce Disability Equality Standards

11) WRES - Workforce Race Equality Standards

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Final

Report from the people committee meeting

Executive summary

To follow is a report from the people committee held 4 December 2019.

Future focus and goals presentation The committee held a discussion on re-stating its goals and 2019/20 priorities in respect of its emerging areas of staff experience / satisfaction. It reflected on the presentation and considered the aims and ambition for these areas, building on and informed by the current people and other strategies and considered the measures that could also be applied to track progress. A discussion on patient experience / satisfaction goals would be had outside the meeting.

Workforce race quality standards (WRES) The committee noted that traction was being made on the internal recruitment processes in respect of WRES; diverse interview panels were now being given authorisation to proceed and all recruiting managers were being reminded to undertake recruitment and selection training in order to progress with setting up interview panels. It was noted, however, that a review of recruitment and selection training was underway to help increase uptake.

The committee received the draft annual equality workforce report 2019-20 that summarised key equality data for the workforce and actions and initiatives to further improve equality where gaps were identified.

Staff survey 2019 It was noted that 41% of the workforce had completed the staff survey. This was up on the same period the previous year. The feedback from the survey would be used to evidence whether real traction was being made on the trust’s interventions in respect of bullying and harassment.

Hospital site patient and staff experience and workforce committees The committee received reports from each of the site PSE&WCs. It noted that the Royal Free Hospital has renamed the bi-monthly patient element of its committee to ‘What Matters To Patients’ committee. The chair was pleased to see the synergies across the three sites e.g. patient co-design with the Point of Care Foundation, a ‘What Matters To You’ approach and Joy in Work (JiW). Particular note was made of the following:

• A core issue for Royal Free Hospital staff in terms of improving their working experience was reducing instances of violence and aggression (patients to staff).

• There was recognition amongst staff across the Royal Free Hospital and Barnet Hospital sites of ‘kindness at work’, linked to JiW. Acts of kindness were appreciated by staff and patients but kindness was also an indicator of general good standards of behaviour.

• Chase Farm Hospital now had three ‘calm zones’ which enabled staff to find respite


Trust board 22 January 2019 Paper 9

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Final

from stressful situations and busy days.

Routine reports The committee recevied and noted the following:

• Staff health and wellbeing update • Organisational development and leadership • Bullying and harassment • Speaking up • Complaints and patient advice and liaison service (PALS) • Guardian of safe working reports – quarter 1 2019-20

Action required


Meetings where this report has been discussed previously Meeting Date Decision n/a n/a n/a


Top 10% vs peers staff recommend as place to work (FFT> 90%)

G-024

Directors developed and appointed to other trusts -

Top 10% for leadership G-028 / G-029 /

G-043

Promote equality and diversity G-027

Match leader on patient and staff engagement G-030



Financial/business implications N/a

Equality analysis No identified negative impact on equality and diversity

Compliance impact N/a

From from James Tugendhat, non-executive director and chair of the people committee Author Veronica Jackson, group committee administrator Date 10 December 2019

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Development of the RFL quality account 2019/2020

Executive summary

This report outlines the steps to be undertaken for the trust to meet its legal obligation and submit an annual quality report by the end of June 2020. The aim of the quality report is to improve public accountability for the quality of care provided by the trust. The quality report comprises:

• the requirements for the quality account each year – as required by the NHS Act 2009, in the terms set out in the NHS (Quality Accounts) Regulations 2010 and any subsequent amendments to those regulations and

• NHS Improvement’s additional requirements for quality reports for foundation trusts.

It is the requirement of the audit committee and the trust board to sign off the final version of the quality report and as in previous years, the trust board will delegate authority to the Group Executive Committee (GEC) to oversee the monitoring, consultation and completion of the quality account/report for 2019/20

Action required/recommendation

The committee are asked to note this report and to agree the delegation of authority to GEC.

Meetings where this report has been discussed previously

Not applicable


GOALS BAF risks






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Financial/business implications No financial or business implications identified


Compliance impact This report outlines processes to be undertaken to meet the legal obligation for the trust to submit an annual quality report by the end of June 2020

Report from Dr Chris Streather, Group chief medical officer

Author Dawn Atkinson, Deputy director of clinical governance and performance

Karen Gordon, Head of clinical governance and performance

Date 13 January 2020

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Development of the RFL quality account (report) 2019/20

Introduction

This report outlines the steps to be undertaken for the trust to meet its legal obligation and submit an annual quality report by the end of June 2020. The aim of the quality report is to improve public accountability for the quality of care provided by the trust. The quality report comprises:

• the requirements for the quality account each year – as required by the NHS Act 2009, in the terms set out in the NHS (Quality Accounts) Regulations 2010 and any subsequent amendments to those regulations and

• NHS Improvement’s additional requirements for quality reports for foundation trusts.

It is the requirement of the audit committee and the trust board to sign off the final version of the quality report and as in previous years, the trust board will delegate authority to the Group Executive Committee (GEC) to oversee the monitoring, consultation and completion of the quality account/report for 2019/20

There are several aspects of the quality report where engagement with stakeholders is crucial for the smooth completion of the quality report. This includes:

• The review on progress to meet the 2019/20 quality priorities; identifying what the trust is doing well in driving quality

• What the priorities for improvement are for the coming year; and how the trust has involved service users, staff and others in determining the priorities for improvement

• Presentation on the overall performance of the trust on key quality metrics; showing where improvements in the quality of services is required

Additionally, the trust is required to obtain a limited assurance report from our external auditors on the content of the quality report. The auditors will report on whether anything has come to their attention that leads them to believe that the content of the quality report has not been prepared in line with the requirements set out in guidance issued by NHS Improvement and/or is not consistent with the other information sources detailed in the detailed guidance.

The reporting guidance for 2019/20 is still to be published by NHS Improvement, however it is expected that there will not be any major changes from previous years.

The development plan

The development of the quality report (2019/20) creates the opportunity to illustrate our organisational structure as well as highlighting steps that the trust has taken in line with the NHS Long Term Plan (January 2019).

The quality report will also contain patient stories showing how we deliver high quality care driven through quality improvement initiatives and our Clinical Pathway Groups.

Process of engagement

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In order to set the quality priorities for 2020/21, the trust will organise a series of engagement exercises with key stakeholders and relevant committees. The executive lead for each respective quality domain will lead the engagement process to identify and agree the quality priorities for 2020/21.

The main stakeholder event is planned to take place in February 2020 and invitees will include members of the Council of governors, Healthwatch, patient representatives and commissioners.

The process of engagement will include:

• Clinical standards and innovation committee: to review progress made during 2019/20 to achieve the quality priorities and to propose priorities for 2020/21

• Population health committee: to review progress made during 2019/20 to achieve the quality priorities and to propose priorities for 2020/21

• Members of the council of governors: to participate in the choice of quality priorities for 2020/21, to select an indicator for testing by our external auditors and to submit a final statement for publication in the quality report

• The Group Executive Committee: to oversee the monitoring, consultation and completion of the quality account 2019/20, prior to final ratification by the trust board.

• Stakeholders’ consultation and engagement event: February 2020. Attendees will have the opportunity to as receive updates on our progress to achieve the proposed quality priorities (2019/20) as well from previous quality priorities which includes our CPGs and quality improvement initiatives.

• The audit committee are required to sign off the final version of the quality account prior to submission to the trust board.

• The trust board are required to sign off the quality account for 2019/20

Timeline for quality account completion

The 2019/20 quality account is required to be submitted to NHS Improvement by the end of May and published on the NHS website by the end of June 2020.

The timeline for publication will broadly follow that used in previous years. Appendix A presents a detailed timetable and reporting schedule which will be followed to meet the submission deadline.

The committee are asked to:

• Note the process in place for development of the quality account and the requirements to ensure that the report is completed and published within the required timeframe; therefore meeting the legal obligation.

• To agree the delegation of authority to the Group Executive Committee to oversee the monitoring, consultation and completion of the quality account/report 2019/20.

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Quality account development plan and committee reporting schedule for 2019/20

January 2020 February 2020

8 Clinical standards and Innovation committee (CSIC): Update on

progress on quality priorities 2019/20 and proposed priorities for 2020/21.

Consultation events across the trust. Key stakeholders to include:

Council of Governors, commissioners, healthwatches and members of the Health Overview Scrutiny Committee (HOSC).

16 Population Health Committee (PHC): Update on progress on quality

priorities 2019/20 and proposed priorities for 2020/21

March 2020

22 Trust Board (TB): Outline of plan for the quality account 2019/20 and

intention to delegate authority to GEC to oversee the development,

consultation and completion of the report.

4 Clinical standards and innovation committee (CSIC): Further

update on progress to achieve the quality account priorities and

proposed quality priorities for 2020/21.

29 Group Executive Committee (GEC): Outline of plan for the quality

account 2019/20 and requirements relating to delegated authority from

the trust board.

4 Population Health Committee (PHC): Further update on progress to

achieve the quality account priorities and proposed quality priorities for

2020/21.

April 2020 May 2020

1 Group Executive Committee: Approve final draft quality account

2018/19 for distribution to stakeholders

12 Population Health Committee (PPHC): draft quality account 2019/20

for noting

13 Clinical standards and innovation committee (CSIC): draft quality

account 2019/20 for noting

June 2020 20 Group Executive Committee: Approve final draft quality account

2019/20 which includes feedback from stakeholders

tbc Quality account to be laid before parliament as part of the annual report tbc Audit committee Approve final quality account 2019/20, prior to sign

off from the trust board.

26 NHS Choices: Final quality account to be published and uploaded 27 Trust Board: Sign off final quality account 2019/20

1

Director of infection prevention and control (DIPC) quarterly report

Executive summary This is the trust report from the director of infection prevention and control for the Royal Free London NHS Foundation Trust.

In line with the Health and Social Care Act (2008, rev 2015) Code of Practice on the prevention and control of infections and related guidance, trusts are required to have appropriate management and clinical governance systems in place to deliver effective infection control. Within criterion 1 of the Code of Practice is a requirement that there is a programme of activity and planned development for IPC within the organisation to keep to a minimum the risk for infection and the general means by which it plans to control such risks. . Included at appendix A are the ten compliance criteria from the Health and Social Care Act to assist the board in assessing the information provided.

Action required The board is asked to confirm that the report provides sufficient information to provide assurance of sustained compliance with the Hygiene Code.




GOALS BAF risks

1. Zero preventable infection G003

CQC standards impacted Safe



Compliance impact Compliance with Hygiene Code

Report from Deborah Sanders, chief nurse and director of infection prevention and control Author D Mack, microbiology consultant, IPC doctor

Anand Sivaramakrishnan, consultant microbiologist, IPC doctor



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Dianne Irish, consultant virologist I Balakrishnan, consultant microbiologist, chair, Antimicrobial stewardship committee V Pang, head of IPC nursing IPC team

Introduction The Health and Social Care Act (2008) Code of Practice on the prevention and control of infections and related guidance outlines the actions NHS Trusts in England must take to ensure a clean environment for the care of patients, in which the risk of infection is kept as low as possible. The 10 compliance criteria are attached at appendix A.

Monitoring Progress against the Health and Social Care Act, including internal audit. Hygiene code compliance will continue to be monitored through the infection prevention and control committee and through hospital unit divisional lead monthly meetings. The trust’s internal auditors annually assess trust arrangements and ensure robust evidence of compliance in all criteria. The CQC report published on 10th May 2019, in its summary of findings stated that:

“The trust generally controlled infection risk well and that staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection”

1. Infection report

1.1 Meticillin-sensitive and Meticillin-resistant Staphylococcus aureus bacteraemia. (MRSA and MSSA) Reduction of hospital acquired Staphylococcus aureus bacteraemias including those due to MRSA continue to be an important infection control priority for the trust. The MRSA target for 2019/20 is zero for all organisations.

From April 2019, post infection reviews are only required for CCGs with a rate of 1.6 or more community onset MRSA blood stream infections per 100,000 population and trusts with a hospital onset MRSA blood stream infection rate of 1.7 per 100,000 bed-days or more. Any CCG or trust with a rolling rate that breaches this threshold within year will also have to formally undertake and report post infection reviews. Royal Free London NHS FT is not on the list of trusts required to carry out reviews.

This financial year there has been one case of MRSA bacteraemia attributed to the trust. This case was reported from ward 7 North, Royal Free hospital. The patient was tested MRSA positive on admission and was treated promptly. The post infection review (PIR) identified scope for improvements around documentation for invasive devices, such as peripheral cannula and urinary catheter. Learnng from this PIR has shared with the relevant team on ward 7 North as well as the monthly hospital wide clinical performance and patient safety (CPPS)meetings for dissemination to all clinical teams. .

1.2 MRSA colonization trust acquisitions. The trust MRSA colonization acquisition rate remains low across all sites, (an acquisition is defined as any patient not previously known to be MRSA positive but has been swabbed whilst in the RFLNHSFT after the first 48 hours of admission and found to be positive). Although the national requirement has reduced, the Trust screening process remains inclusive of in-patient admissions as it is felt to be integral in reducing acquisition rates and contributes to safer patient care.

1.3 Clostridium difficile (C.diff) The threshold for the Trust for 2019/20 set by Public Health England (PHE) is 100 cases of Trust attributable C.diff. The definitions for assignment were re-defined on April 1st 2019 and are now:

- Healthcare onset, healthcare associated (HOHA) – cases detected 3 or more days after admission (reduced from 4 days)

- Community onset, healthcare associated (COHA) – cases detected within 2 days of admission where the patient has been an in-patient in the trust reporting the case in the previous 4 weeks.

- Community onset, indeterminate association (COIA) – cases detected within 2 days of admission where the patient has been an in-patient in the trust reporting the case in the previous 12 weeks but not the most recent 4 weeks

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- Community onset, community associated (COCA) – cases detected within 2 days of admission where the patient has not been an in-patient in the reporting trust in the previous 12 weeks.

There have been 57 cases from April 1 to December 31, 2019 against an objective trajectory of 75 cases

for this time period. Of these, 21 cases are from Barnet and 36 from the Royal Free Hospital. The rise in

cases seen in June has reduced to usual case numbers. Two lapses in care have been identified at the

Royal Free Hospital, one from 7 North in June and one from 8 North in October.

The Trust rates of both HOHA and COHA cases have both reduced in 2019, as shown in the graphs below

from the Public Health England (PHE) Fingertips website.

The actions to be focused on for C. difficile infection prevention and control for the next year include: • continue the deep clean programme across all sites

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• review of all cleaning audit reports at monthly divisional lead meetings • IT integration: stool chart/algorithm, antibiotic stewardship, patient tracking and isolation • clinical audit programme – continue Perfect Ward roll-out • promote clinical team engagement in RCA process • consideration of the documentation of infection prevention and control responsibilities and delivery

in annual appraisals, as recommended by the external expert report.

1.4 E.coli bacteraemias From April 2017 a government initiative extended the surveillance of bacteraemias caused by Gram-negative organisms to include Klebsiella species and P. aeruginosa in addition to the existing E. coli surveillance. The national ambition is to reduce healthcare associated Gram negative blood stream infections by 25% by 2021/22 and 50% by 2023/24. The reporting and reviewing of these cases will be driven through the hospital unit divisional leads group, the CPPS, and the Infection Prevention and Control Committee. A report will be provided once cases are reviewed according to PHE guidance. The reduction in these infections is one of the stated aims in the Quality Account for 2019/20.

The Trust rate of E. coli blood stream infection hospital-onset cases has reduced, as shown in the chart below from the PHE Fingertips website. Klebsiella species hospital-onset cases have increased while P. aeruginosa hospital-onset cases have decreased.

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Further work is essential to reduce Gram negative bacteraemias as identified in Appendix B. The graph below shows that E. coli cases are widely distributed across a range of specialties.

1.5 Carbapenemase producing enterobacteriaceae (CPE) and other non-fermenting (CP-NF) organisms. There have been sporadic cases of CPE and CP-NF identified through admission screening and individual cases of acquisition. All on-going activities are included in the IPC action log and are driven through the monthly divisional leads IPC group.

The number of screening tests per quarter is now reported to PHE and continues to increase across the Trust sites with over 26,000 screens tested in 2019, see chart below.

In 2019 at the Royal Free hospital 7676 patients were screened of whom 73 (1.17%) were positive, at the Barnet and Chase Farm hospitals 3760 patients were screened of whom 90 (2.39%) were positive. Outbreaks are detailed in section 4.

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1.6 Influenza

In December 2019 more patients were identified with flu than in the same month the previous year. Staff vaccination rate had reached 57% for patient facing staff by the end of December 2019. The graph below shows all positive flu cases including from the hospital and GPs, giving an overall measure of flu activity in the hospital and community, compared to last year winter.

The staff flu vaccination programme began very well but uptake of the vaccination by staff has now slowed down. Up to 10 January 6257 of our staff had been vaccinated. Of those:

• 5152 were patient facing staff (57.54%) • 1105 were non patient facing staff (45.85%) • 63.87% of doctors have been vaccintated • 59.71% of support staff in clinical areas have been vaccinated • 55.81% of AHPs have been vaccinated • 52.47% of nursing and midwifery staff have been vaccinated. • 401 staff had completed a form stating why they had declined a vaccine.

The campaign continues and is highlighting to staff the number of patients currently in each hospital with flu. An email from the chief nurse and chief medical officer asking staff to have a vaccine was sent to each member of staff.

1.7. Quality Improvement

The IPC team continues to use quality improvement initiatives to identify drivers for improvement in all infection indicators. The overall aim has four elements, as detailed in the previous quarterly report. Appendix B.

1. Reduce Gram negative bacteraemias as per national (PHE and NHSI) reduction target of 25% by 2020/21 and 50% reduction target by 2023/24.

2. Reduce C.diff to below threshold of 65 attributable cases from April 2018 to March 31st 2019, which has been achieved. The threshold for 2019/20 is 100 cases, which relates to revised definitions around C.diff attribution for the year ahead.

3. Zero MRSA BSIs by March 31st 2020.

4. Undertake mandatory surgical site infection surveillance for 2019/20 and maintain orthopaedic SSIs within national parameters.

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The trust is participating in the national NHSI collaborative to reduce catheter associated urinary tract infections (CAUTI). The collaborative was active until January 2019, but the work continues with the adoption of the National Urinary Catheter Passport in collaboration with primary care and CCG colleagues. Meetings with the NCL urology steering group and urology nursing group continue.

Two ‘roadshows’ have been undertaken at RFH and BH to introduce the catheter passport and this has raised awareness, educated and motivated care planning within the Trust wards.

2 Orthopaedic surgical site infection reportThe mandatory requirements from DH for surveillance is one category of orthopaedic surgery for one quarter within each financial year as a group requirement. Chase Farm undertakes elective hip and knee surgery surveillance and Royal Free hospital continue with three categories of orthopaedic surveillance each quarter. Barnet have fewer cases and only report trauma cases where case numbers meet PHE threshold as per mandatory requirements.

The surgical site infection surveillance (SSIS) committee drives the SSI programme within orthopaedic surgery across all the group hospitals. RCA’s from all infections are reported to the orthopaedic specialty team and surgery and associated services divisional board and reported to the SSI committee for learning and dissemination of best practice.

Learning from SSI RCAs in the past quarter include: Recommendations / solutions/ findings

Action to be taken Responsible person (name and job title)

Delay in administering first post-operative dose of cefuroxime and gentamycin not administered for removal of catheter

Learning from the incident to be shared with ward staff, RMOs, anaesthetists and surgeons

Lead for quality Governance

Change in recommendation to less broad spectrum antibiotic based on evidence and staff concerns of patient reactions to teicoplanin

Orthopaedic team will audit the infection data to compare infection rates pre and post the change in recommendation

consultant orthopaedic surgeon

A new generation broader spectrum antibiotic will be added to the formulary following approval from the drugs and therapeutics committee (D&TC). The guidance will then be amended.

pharmacy

• A gap analysis of the NICE SSI guideline is being developed by the group SSI committee and will be reported next meeting.

Hips and knees Reporting quarter for PHE: July to September 2019

Number of operations

Number of infections

Hospital rate National rate

CFH hips 113 0 0.0% (0.3% last 4 periods)

0.6%

CFH knee 108 3 2.8% (1.0% last 4 periods)

0.5%

BH fractured hip 91 0 0.0% 1.2% RFH hips 15 0 0.0% 0.6% RFH knee 18 0 0.0% 0.5% RFH fractured hip 36 1 2.8% ( 0.6% last 4

periods) 1.2%

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3.0 Viral infections

1010 laboratory-confirmed viral infections were identified between October and December 2019, which required IPC interventions from the virology doctors at the Royal Free Hospital.

Figure 1:

Virology IPC Activity from October – December 2019

93 % of the infections were due to respiratory viruses (See Figure 2).

5% of the infections were gastrointestinal infections

There were 12 cases of varicella zoster virus infections at the Royal Free hospital

Figure 2: Virology IPC Activity from July 2014 – December 2019

RFH Oct Nov Dec Total

Respiratory 100 182 265 547Gastro/Other 15 13 16 44Total 115 195 281 591

Barnet Oct Nov Dec Total

Respiratory 75 121 249 445Gastro/Other 2 3 2 7Total 77 124 251 452

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Figure 3: Viral infections requiring IPC interventions recorded from Oct-Dec2019

Respiratory Infections –Oct- Dec 19 Gastro/Other Infections – Oct- Dec 19

At the Royal Free hospital site, the predominant respiratory virus during this period was rhinovirus with 185 infections, with the highest numbers in October and November, whereas the majority (87%) of the 142 influenza A infections occurred during December. The predominant influenza A strain is AH3.

Figure 4: Common Viral Respiratory Infections Recorded from July 2014 – December 2019

RFH BarnetAdenovirus – NPS/BAL 14 14Coronavirus 30 15Enterovirus/Rhinovirus 30 64Human metapneumovirus 22 78Influenza A 185 85Influenza B 142 74Parainfluenza 5 5Parechovirus 36 89RSV 0 0Total 83 21

547 445

RFH Barnet Adenovirus - FAE 6 1Astrovirus 3 0Hepatitis A 0 0Hepatitis E 0 0Measles 0 0Norovirus 17 5Rotavirus 4 0Sapovirus 2 1VZV 12 0Parvovirus 0 0Total 44 7

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Gastrointestinal Illness

During this quarter there were 32 laboratory confirmed gastrointestinal infections at RFH site, with 17 of them norovirus infections.

Figure 4: Norovirus PCR Positive Stool Samples recorded from RFH: July 2014 – December 2019

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4. Serious Incidents, outbreaks related to HCAIs

CPE Outbreak MSSU PHE ref: 214070

A cluster of Carbapenemase Producing Enterobacteriaceae (CPE) cases was identified on MSSU at Barnet Hospital and the ward was placed on supportive measures from 4th October 2019. After further confirmed cases of the same organism from bay screening on 17th October, a CPE period of increased incidence was declared and regular weekly meeting were commenced. All positive samples were sent off for typing and it was confirmed that 4 isolated were the same (BARN24ES-3). PHE were informed and an outbreak was declared on 8th November 2019. Initially the outbreak affected side 1 of MSSU but eventually both sides were affected.

Measures that were put in place included, hand hygiene audits, sluice checks, antimicrobial stewardship, daily enhanced cleaning, a terminal clean and fogging of the ward, weekly CPE swabbing of all patients on the ward, swabbing of all new admissions, transfers and discharges.

Since the start of the outbreak approximately 23 OXA48 positive cases have been linked to the incident. Weekly outbreak meetings are continuing with PHE in attendance.

Influenza Outbreak CCU PHE ref: 217136

A flu outbreak declared on 18th December after reports of 2 confirmed and 2 suspected (later confirmed) flu A cases on the coronary care unit (8 bedded ward) . Regular outbreak meetings commenced and the ward was placed on supportive measures with additional processes, which included prophylaxis for all exposed and new admissions to the unit, restricted admissions to include only patients who needed CCU care. As CCU has no single rooms positive patients were therefore nursed in the open bay on bed space isolation. There was one additional flu A case, bringing the total to 5 for this outbreak. Staff were also reported being off sick with flu like symptoms. On the 30th December the outbreak was declared over as there were no new cases for over 7 days.

CPO outbreak 7 West Supportive Measures PHE reference 213273

Three patients identified CPO OXA-48 Citrobacter Freundii on 7 West ward within a 28 day period (September – October) which therefore triggered an outbreak incidence. The ward was put on supportive measures from 15 October 2019 for four weeks. The supportive measures were stopped after no further CPO cases identified.

5. IPC team activity

The team took part in clinical practice event across sites to futher enhance staff knowledge in infection prevention and control practice. Annual IPC winter roadshows acorss sites were conducted to ensure that clinical staff are equipped with necessary information needed in the management of influenza and gastro- entreristis infection.

The team continued to support staff flu vaccinators, train staff in the management of multi-drug resistant infections and roll out clinical audits in patient areas, particularly training with Perfect Ward App for clinical audit and reporting.

6. Hand hygiene

Hand hygiene is audited by staff within clinical areas and data entered on the Perfect Ward App. Verification audits are undertaken by the IPCNs and individual training and feedback provided within the clinical area directly to the staff. The Perfect Ward programme is rolled-out with reports available to ward staff and managers.

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All ward areas are lised in Appendix C.

The focus for the hand hygiene campaign for 2019/20 is focussed on reducing glove use and ensuring gloves are used appropriately following a risk assessment of the procedure or patient contact to be undertaken. This is being led by the clinical divisions with support from the IPC team in identifying risk procedures, training on IPC ‘roadshows’ and at face-to-face training sessions.

7. Serious Incidents. There have been no SIs this quarter relating to infection risks.

8. Antibiotic stewardship

The updated adult surgical prophylaxis policy has been launched and implemented across the Trust. Posters displaying the new policy have been placed in wards, anaesthetic rooms and other relevant clinical areas. Microguide has also been updated to this effect. The most significant change is to orthopaedic surgery, and has necessitated a new antibiotic (cefazolin) being brought onto the RFL formulary.

Discussions are ongoing for antibiotic prophylaxis for the insertion of implantable cardiac devices. The current policy is to use teicoplanin as first line, in keeping with national guidelines, but many other Trusts use flucloxacillin +/- gentamicin. It might be appropriate to change RFL Policy given the concerns about the high incidence of anaphylactic reactions related to teicoplanin use. However, no such reactions have been reported surrounding the use of teicoplanin for this indication at RFL for more than a year.

A paediatric surgical prophylaxis policy has been launched for the first time. Again, posters displaying the new policy have been placed in wards, anaesthetic rooms and other relevant clinical areas and Microguide has been updated to this effect.

A new antibiotic (meropenem-varbobactam) has recently been launched in the UK. This drug enables the treatment of carbapenemase – producing Enterobacteriaceae of a particular genotype (KpC). It may therefore be useful for the treatment of such infections caused by pathogens that are resistant to other agents, such as ceftazidime-avibactam. An application to the NCL Joint Formulary Committee is being drafted to this effect.

Discussions are underway with ENT in order to expand on the antibiotic policy for ths specialty that is currently on Microguide.

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Efforts to replace temocillin with more cost-effective options have been ongoing through the year. Current data indicates that the FIP reduction target to make a 5% saving on total temocillin spend across the Trust will be achieved by the end of the current financial year. It is envisaged that a further reduction in expenditure will be achieved once RFL policies for the management of hospital acquired pneumonia are reviewed.

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Appendix A

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Appendix B

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Appendix C

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Final

Clinical standards and innovation committee (CSIC) report

Executive summary

To follow is an update from the CSIC meeting held 8 January 2020 on key discussion items and agreed actions.

Action required

The committee is asked to note the report.


Meeting Date Decision n/a n/a n/a


Zero never events G-001

Continual reduction in avoidable deaths G-002

Zero avoidable infection G-003

Top 3 for research citation G-004

Top 10 for clinical trials participation G-005

Top 10% for education, training and workforce development

G-006

CPG pathways embedded, monitored and digitised G-007

£20m cost reduction through CPGs G-008

Quality improvement embedded as our method of transformation

G-031





Compliance impact NSHI, NHS Resolve, CQC

Report from Prof. Anthony Schapira, non-executive director and chair - CSIC Author Veronica Jackson, group committee administrator Date 9 January 2020



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Final

REPORT FROM CLINICAL STANDARDS AND INNOVATION COMMITTEE – 8 JANUARY 2020

PRESENTATIONS The committee received two presentations:

• Therapy partners - a QI project focussing on embedding the patient’s voice into therapy services’ operational and service development. It was noted that patients had so far provided good feedback on patient co-design across a number of disciplines within therapies services. The committee heard from a volunteer therapy partner on their experience of the project; they wanted to enable patients to have a voice and they found that bringing an independent view to discussions had been very helpful in identifying the real issues that mattered to patients. Going forward, the team would focus on measuring the qualitative outcomes and ensuring patient / partner diversity.

• Clinical practice groups (CPG) financial benefits – a presentation on the financial benefits realised since the adoption of 20 digitised pathways. The committee discussed the financial savings to the hospital and to the system, and the digitisation of the data to enable regular tracking of benefits. There was a continuous improvement model in place to continue to monitor the CPG benefits to patient care, clinical outcomes and safety. It was noted that discussions were being had on the deployment of electronic patient records (EPR) on the Royal Free Hospital site.

NEONATAL SERVICES The committee received a local update on the work being undertaken to address neonatal and maternity service pressures on the Royal Free Hospital site. Staff were being kept appraised of developments and work was underway on recruiting additional senior clinicians.

MORTALITY The committee received a report on published mortality indicators for the trust. It was noted that the trust had a statistically significantly lower risk of mortality than expected given its casemix and the characteristics of the patients it treated. The chief medical officer highlighted that he and the responsible officer and medical director – corporate had held preliminary discussions on establishing a new process for reporting into CISC on mortality metrics.

LOCAL CLINICAL PERFORMANCE AND PATIENT SAFETY COMMITTEE (CPPSC) REPORTS It was noted that work was ongoing on refocussing the CPPSCs with a view to improving safety, risk and clinical effectiveness plus improved engagement with the divisional quality and safety boards. There would also be greater alignment with QI and clinical practice groups (CPGs).

SERIOUS INCIDENTS (SIs) AND NEVER EVENTS The committee noted that progress was being made on the plan for the restructure of the trust’s SI management; a report would be presented to the March meeting. The trust’s internal auditors would be undertaking a follow up review of the trust’s SIs in the spring. In terms of Never Events, two had been report in November. However, the committee was pleased to note that commissioners had lifted the contract notice put on the trust in respect of Never Events.

NATIONAL PATIENT SAFETY STRATEGY GAP ANALYSIS The committee received a report on the key recommendations for the trust arising from the NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. All were outlined in the gap analysis, alongside the current compliance rate and implementation risk.

ELECTRONIC PATIENT RECORDS (EPR) DEPLOYMENT The committee received an overview of the risk burden and learning from the perspective of the EPR clinical risk management group on the deployment of EPR across Barnet Hospital, Chase Farm Hospital and maternity services on all sites (deployment 1). Discussion centred on the number of incidents reported in the first year since go live where it was noted that the trust had failed to achieve its aim of ‘zero avoidable harm to occur as a result of the implementation of the new EPR system’. However, the majority of incidents raised had resulted in no harm, with only one resulting in moderate harm and one in severe harm (both reported as SIs).

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Final

QUALITY ACCOUNT PATIENT SAFETY PRIORITIES – QUARTER 2 2019/20 The committee received its quarterly update; it noted that the trust would not achieve its aim of zero never events by the end of March 2020.

MEDICAL EXAMINER The committee noted that the group executive committee (GEC) had agreed to the funding of the medical examiner and administrator post. It was noted that the shadow lead medical examiner was confident that the role of medical examiner would improve the learning from deaths process.

RESEARCH AND DEVELOPMENT (R&D) A discussion was had on the distribution of resource to R&D projects, namely priority areas for resource allocation and achieving value for money. It was noted that there would be complex R&D areas where patient numbers may be small but where high levels of resource would still be needed. The committee noted that a further update on the creation of a clinical research facility on the Royal Free Hospital site would go to the next meeting.

NATIONAL EDUCATION AND TRAINING SURVEY (NETS) RESULTS 2018/19 The deputy director for education welcomed the first of Health Education England’s national education and training surveys. He considered the survey was helpful in filling the gap on understanding improvements in educational quality across all healthcare learners, not just postgraduate medical trainees as seen in the General Medical Council’s national trainee survey. It was noted that the trust outperformed slightly on all domains; there were no outliers. The trust would actively work with HEE to build on the survey in order to help refine the data collation and improve its overall effectiveness.

GROUP GOALS The chief medical officer explained that the board was undertaking a review of its group goals. The board’s aim was twofold; to reduce the number of goals and to re-express them in a way that would resonate with the trust’s staff and stakeholders and reflected the quadruple aim: excellent health outcomes, outstanding patient satisfaction, excellent staff satisfaction, and a sustainable organisation.

A discussion was had on the metric for the committee’s goal in respect of ‘zero avoidable harm’ and how that could be benchmarked. In addition, the committee felt it was important to maintain the goal in respect of ‘zero never events’ as this was clear aspiration of the trust. Further discussions on the committee’s goals would be had outside the meeting.

End

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Finance report M9 (December 2019)

Executive summary In December, the trust delivered an in month actual deficit of £4.2m. This was £0.1m better than plan. Year to date the trust delivered an actual deficit of £30.2m. This is £1.2m worse than plan.

Externally to NHSI the trust reported a year to date £1.7m favourable variance.

The financial improvement programme (FIP) target at end of December was £34.7m. The trust delivered £11.1m of recurrent FIP with a shortfall year to date of £23.6m. £17.0m of non-recurrent mitigation savings were delivered.

Cash at the end of December is better than plan by £76.0m. The forecast shows that due to

improved debt management and the additional cash received, the trust has reduced reliance

on working capital loans to £20m from the £50m anticipated at the beginning of the year.


The board is asked to note the current financial position of the trust.

Meetings where this report has been discussed previously Meeting Date Decision


GOALS BAF risks

Quality

Value

Top 10% for workforce efficiency (55% of clinical income) Deliver additional 2% year on year FIP G-047


CQC standards impacted Use of resources / Well led

Financial/business implications N/A


Compliance impact NHS Improvement

Report from Peter Ridley, group chief finance and compliance officerAuthor Senior Finance TeamDate 16th January 2019


Trust Board 22nd January 2020 Paper 13

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The Royal Free London

Finance Report M09Trust Board

1

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Current issues

The trust delivered an actual deficit of £51.9m at the end of December before PSF/FRF/MRET. This was £1.2m worse than plan. Key issues driving the year to

date variance are:

• Underperformance in clinical income. PPU contribution £1.5m adverse from plan.

• Adverse variance partly offset by non-recurrent mitigations and phasing of reserves including contingency

• Slippage against FIP target

Income and Expenditure

Pay and Workforce WTE AvgYTD Spend

£m

% of total pay

bill

Last Year % of

total pay bill

Substantive 8,691 (371.0) 86% 85%

Bank 1,098 (40.6) 9% 11%

Agency 291 (15.9) 4% 4%

Other Apprentice Levy - (1.7) 0% 0%

TOTAL 10,080 (429.2) 100% 100%

Last Year WTE Avg 9,975

Year to Date

Plan Actual Variance

£m £m £m £m

Income 1,082.7 809.7 818.3 8.7

Operating Expenditure (1,085.9) (816.8) (827.8) (11.0)

EBITDA (3.2) (7.2) (9.5) (2.3)

EBITDA % -1.2%

Non-Operating Expenditure (58.2) (43.6) (42.5) 1.1

Retained Surplus / (Deficit)

Before PSF/FRF/MRET(61.4) (50.8) (51.9) (1.2)

PSF/FRF/MRET 31.8 20.9 20.9 0.0

Adjusted Surplus / (Deficit)

incl PSF/FRF/MRET(29.6) (29.8) (31.0) (1.2)

Gain on disposal of assets 0.0 0.0 0.8 0.8

Adjusted Surplus / (Deficit)

incl PSF/FRF/MRET(29.6) (29.8) (30.2) (0.4)

Annual Plan

Change

from Prior

Mth Var

Royal Free Hospital Barnet Hospital Chase Farm Hospital Group Clinical Services Corporate/Central WOS

Actual £m Var £m Actual £m Var £m Actual £m Var £m Actual £m Var £m Actual £m Var £m Actual £m Var £m

Income 480.5 5.3 232.5 (0.8) 3.0 (0.0) 36.3 0.8 30.0 5.3 36.1 (1.8)

Pay (190.4) (0.1) (131.0) (2.8) (16.2) 0.5 (35.3) (1.3) (53.9) 2.2 (2.3) 0.8

Non-Pay (194.5) (7.7) (26.7) (1.1) (3.4) (0.5) (44.0) (3.3) (96.8) 1.3 (33.3) 0.9

EBITDA 95.6 (2.5) 74.9 (4.7) (16.6) (0.1) (43.1) (3.8) (120.7) 8.8 0.5 (0.1)

Non-Operating Expenditure 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (42.6) 1.2 0.1 (0.0)

Surplus / (Deficit) Before

PSF/FRF/MRET95.6 (2.5) 74.9 (4.7) (16.6) (0.1) (43.1) (3.8) (163.3) 10.0 0.6 (0.2)

Year to Date by Site

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Cash Balances

CashCash at the end of December is better than plan by £76.0m. The forecast shows that due to improved debt management and the additional cash received, the trust hasreduced reliance on working capital loans by £30m anticipated to be £50m at the beginning of the year.

CapitalAt £23.3m the capital expenditure position is £17.0m below the revised £40.3m YTD plan. The trust has plans in place to mitigate current slippage to ensure the trustmeets the £63.5m capital forecast.

Commentary

Statement of financial position Planned

Position

£m

YTD

Positon

£m

Variance

to Plan

£m

Non current assets 714.4 643.2 71.2

Cash and Cash Equivalents 38.8 114.8 (76.0)

Trade and Other Current Assets 75.3 136.6 (61.3)

Current Liabil ities (230.6) (322.2) 91.6

Non current l iabilities (230.3) (206.9) (23.4)

TOTAL ASSETS EMPLOYED 367.6 365.5 2.1

Balance Sheet

Annual Plan YTD ActualPrior Month

YTD Actual

£m £m £m

Building and engineering 21.4 11.0 12.6

Informatics 9.5 1.5 1.2

Plant and Machinery 11.6 1.4 1.0

Other 21.0 9.4 6.8

TOTAL CAPITAL EXP 63.5 23.3 21.5

Funded by:

Depreciation 37.5 27.7 24.6

Cash Reserves 10.3

Less: Repayments (Capital PFI/Loans/Finance Lease) (3.5) (2.3) 2.0-

PDC (Not yet drawn down) 4.2 - -

Loan 15.0 - -

TOTAL FUNDING 63.5 25.4 22.6

Capital Expenditure

Capital Expenditure

Business Units Target TargetActual

DeliveryVariance

Barnet Hospital 7,968 5,578 2,437 (3,141)

Chase Farm Hospital 496 347 385 38

Royal Free Hospital 16,359 11,451 4,476 (6,975)

Group Clinical Services 5,880 4,116 878 (3,238)

Corporate 18,897 13,228 2,943 (10,284)

49,600 34,720 11,119 (23,600)

Non-recurrent Mitigations 17,005 17,005

YTD Incl. NR Mitigations 34,720 28,125 (6,595)

M9 YTD FIP performance by Site

Balance Sheet, Cash, Capital and FIP Paper 13

4

Forecast Outturn, Normalised YTD Position and Underlying

FY20 - planned underlying to forecast underlyingUnderlying

Plan

2019/20 control total (incl. PSF, FRF and MRET) (29.6)

Non-Recurrent Items

MRET central funding (2.6)

Non recurring PSF allocation (14.4)

Non recurring FRF allocation (14.8)

Non-Recurrent FIP (14.5)

FYE FIP 1.8

Non-recurrent RTT cost 1.8

2019/20 Underlying Position (72.2)

Forecast increase in FIP slippage (6.4)

Forecast underlying FY20 (78.6)

7.6 -9.9

-51.9 -17.0

-71.3

Non-recurrent

Costs

Non-recurrent

Benefits

Non-recurrent

FIP

Normalised YTD Position

YTD deficit (excl.

PSF/MRET/FRF)

YTD Normalised

Position

Best caseMost

Likely

Worst

case

Bottom-up forecast outturn -72,362 -72,362 -72,362

RisksOther new cost

pressures/Business cases-500 -1,000 -2,000

OpportunitiesRelease of provisions/other non-

recurrent benefits12,000 12,000 12,000

Forecast outturn after risk and

mitigations-60,862 -61,362 -62,362

Plan -61,362 -61,362 -61,362

Gap from plan 500 0 -1,000

Further risks not included

aboveIncome risks -2,500 -7,700

Key risks to the FOT• Slippage on FIP forecast• NHSE have signalled their intentions to reopen the contract

for negotiations based on under performance on the block and QIPP sitting outside the block, and new pressures on drugs spend

Forecast Outturn

Underlying Position

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OPERATIONAL PERFORMANCE REPORT

Executive summary

This report outlines the latest submitted performance data for the key operational indicators (A&E, cancer and DM01 (diagnostics)) along with benchmarking information and key risks/mitigations.

Action required

The board is asked to note the current performance of the trust

Meetings where this report has been discussed previously Meeting Date Decision


GOALS BAF risks

1. ED access target 95% G-010

2. RTT 18 weeks target: 92% G -036

3. Cancer access 62 days: 85% G- 037


Financial/business implications None


Compliance impact NHS constitution standards

Report from Hospital chief executives

Author Senita Rani Robinson, Performance Measurement Lead

Date 17 January 2020



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Royal Free London –operational performance

January 2020

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Key Operational Indicators

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Operational performance summary report

Where we are Predictions Key Risks

Cancer – Nov 2019

• Performance in November was reported at 80%.

• The majority of breaches were within the prostate, HpB, Lung and Lower GI tumour sites.

• The largest backlog volumes are in the Lower GI (25) and Prostate (23) tumour sites.

• Un-validated December performance is 79.3%.

• Backlog may continue to be inflated whilst services work through FDS preparation.

• Undiagnosed backlog volume has increased over the Christmas period to 159, though this has reduced from the 180 visible on w/b 06 January.

• The largest proportion of diagnosed patients in the backlog is within prostate (13).

A&E –Dec 2019

• Trustwide performance in December was 79.9%

• BH performance was reported at 72.3%

• RFH performance was reported at 79.4%.

• Performance up to September 2019 has been resubmitted for the RFH site.

• NHSE are likely to open the resubmission window in Jan 2020 which will allow us to resubmit performance for the RFH site from October onwards.

• BH performance affected by continued high attendances, limited space, insufficient workforce cover and challenged downstream patient flow.

• RFH have cited high attendances against planned activity, bed occupancy increased to 99% (expected 95%) and persistently high long length of stay as key challenges.

DM01 –Nov 2019

• November performance was reported at 93.97%.

• The largest number of breaches were reported in the non-obstetric US (889), cystoscopy (39) & MRI (27) modalities.

• The overall number of breaches has halved compared with September, largely driven by non-obstetric ultrasound & MRI who have been maximising internal and outsourcing capacity.

• The MRI position is fragile until the installation of new machines in March 2020.

• Gynae cystoscopy breaches are increasing, however the team are working with urology in order to secure equipment for an additional list.

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62 Day Cancer – Performance Summary

Current Period November: above 2018/19 performance, below standard and trajectory at trust level

Relative position Nov 2019: 3rd quartile at trust level

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

Source: NHS England, 2019

*Note* November performance reflects our internally calculated position. There are currently discrepancies between the reallocation calculation we make and

that which is published by NHSE. We have assured our internal logic and are in the process of escalating this to NHS Digtial.

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In November, 4 out of 16 tumour sites accounted for 41% of the trust’s total excess breaches:

● RFH sites HpB – 4.5 breaches (performance 40%)

● RFH sites Renal – 4.5 breaches (performance 65.4%)

● BCF sites Prostate – 4 breaches (performance 69.2%)

● RFH sites Lung – 1.5 breaches (performance 0%)

62 Day Cancer – Sources of Current Performance

November Performance by Tumour Site Observations

Number of excess patient breaches*

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

41% of total RFL excess breaches

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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. Persistent backlog

2. Radiology Access

3. 28 Day FDS

4. Calculating reallocated performance

1. The backlog has increased from approximately 120 prior to the festive holidays to 160 in early January, which follows a similar pattern to previous years and other providers, as patients choose to delay their investigations until the New Year. The backlog is 40 at Barnet hospital and 120 at Royal, reflecting the overall size of the Cancer PTL. Specialties are challenged on their backlog position in the weekly cancer performance meetings and throughout the week in the individual PTL meetings. The patient choice delays are still being worked through and therefore the backlog will gradually reduce over the next four weeks into early February.

2. Radiology access remains a significant challenge across many tumour sites, with particular pressure on MRI, Head & Neck Ultrasound and PET. The report turnaround times are also too long for effective cancer pathways. The MRI replacement programme has introduced new challenges, particular the Prostate on-stop pathway cannot be supported and has convert to a triage and straight to test model temporarily.

3. As from April 2020, we will be required to record the day we communicated diagnosis or exclusion of cancer to each patient. Focus is currently on data completeness, which is improving.

4. Reallocated performance is calculated by CWT and the information team are unable to accurately replicate this logic for predicting performance. We have assured our internal logic and are now escalating to NHS Digital.

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A&E – Performance Summary

Current Period December: performance is below 2018/19 performance, standard & trajectory at trust level

Relative position Dec 2019: 3rd quartile at trust level

% patients waiting < 4 hours in A&E

*Note* The above reflects submitted performance, which for RFH will be resubmitted when NHSE opens the window, likely Jan 2020.

Chelsea & Westminster and Imperial are both part of the A&E waiting times trial and will not be submitting their performance nationally during this period.


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A&E – Barnet Sources of Current Performance

Current Period Performance

Performance against 4 hour standard

DTOC and MOs

Total DTOC and MO bed days – November 2019 DTOC by borough – November 2019

Performance was 72.3% in December 2019 against a trajectory of 81% and continues to be challenging due to the following primary drivers:

• Increasing demand • Insufficient acute beds, assessment space

and Urgent Care capacity• Poor downstream patient flow & delayed

discharges • Workforce mismatch with increasing demand

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A&E – Barnet Sources of Current Performance

12 Hour breaches (trustwide) Mental health breaches

Long Length of Stay (21+ days) 60 minute ambulance handover waits

w/e 12/01/2020 - 82 w/e 12/01/2020 - 51

w/e 12/01/2020 - 55

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A&E – Barnet Diagnosis and Actions

What is our diagnosis of what is driving current performance?


1. Increasing demand

2. Insufficient acute beds, assessment space and Urgent Care capacity

3. Poor downstream patient flow & delayed discharges

4. Workforce mismatch with increasing demand

• ED attendances at BH ED continued to increase during November, totaling 10,745) .

• CCG are supporting pilot of Waitless app: dialogue 2 to be presented at A&E Delivery Board

• New streaming rooms in ED opened in December• Work to provide additional capacity for UTC

completes end of March• Additional AMU trolleys to be available by June

2020• Real-time patient flow system being explored

• Long waits continue for patients requiring complex D2A Pathway 3 patients

• “winter” funding for care home placements and non weght bearing patients received but not yet effective

• Digitised discharge workflows to be tested January to increase speed of communication and visibility of delays

• ‘Go with the Flow’ week scheduled for w/c 6 January, supported by system partners.

• Business case to increase budgeted ED workforce has been drafted – to be reviewed by BH Executive team

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12

A&E – Royal Free Sources of Current Performance

Current Period Performance

Performance against 4 hour standard Headlines

4-hour A&E performance was 79.4% in December 2019, with increase number of A&E activity against RFL plan by circa 2000. October performance onwards will be resubmitted following breach corrections. Key challenges are:

• Increased attendances, ambulances and paediatrics (reduced paediatric beds causing a block at RF)

• Bed occupancy increased to 99% (expected 95%)• Long length of stay (over 21 days) remains high

DTOC and MOs

Total DTOC and MO bed days – November 2019 DTOC by borough – November 2019

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13

A&E – Royal Free Sources of Current Performance

12 Hour breaches Mental health breaches

Long Length of Stay (21+ days) 60 minute ambulance handover waits

w/e 12/01/2020 - 99 w/e 12/01/2020 - 47

w/e 12/01/2020 - 30

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A&E – Royal Free Diagnosis and Actions



1. Barriers to flow

2. Capacity

3. Nursing staffing

• D2A P1: issues identified with PoC availability in specific postcodes pre-Christmas thus impacting on ability to accept/discharge from acute. Contingency plans put in place but some mis-match to therapist availability. If re-invoked additional work recommended on understanding revised governance and escalation points within LBB to support.

• Walk in Centres – day to day variations in demand or acuity. A&E flow issues recognised as a knock-on impact in WICs through Dec with high attendances and some breaches of 4 hour waits at both sites.

• Rosters fully staffed in line with CLCH agreed policies. Temporary staff backfill used to cover vacancies and sickness as required

• Some seasonal issues through December with short-term sickness impacting on daily roster and increasing demand pressures. Most relevant in community nursing and walk-in centres (with ENP and doctor sickness).

• Vacancy rate remains as approx. 9% with continued reasonable fill rate with bank/agency. Main hot spots remain in bedded areas (B5 nurses, B5, 6 OT) and Walk in Centres (ENP) with both working to safer staffing levels using temporary staffing.

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15

Diagnostics (DM01) – Performance Summary

Current Period November 2019: below standard, trajectory and 2018/19 performance at trust level

Relative position November 2019: 4th quartile at trust level


93.97%

% patients waiting < 18 weeks from request to diagnostic test

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DM01 – Royal Free Diagnosis and Actions



1. Non-obstetric US

2. MRI

3. Cystoscopies

4. Other endoscopies

• We have reduced breaches in ultrasound as outsourcing to BMI is now in place and the service are maximising all internal capacity. Additional resources have been provided by NHS England to further reduce the backlog.

• We have substantially reduced breaches for MRI and are now close to compliance. The position will remain fragile until the new machines are installed in March 2020, however the service are using all available capacity and are responsive to machine breakages.

• Breaches are mainly within gynaecology. They have the staffing for an additional outpatient list per week and have potentially found clinical space to undertake this.

• Flexi sigmoidoscopy, colonoscopy and gastroscopy are all reporting relatively low numbers of breaches. The service have been working closely with Hadley Wood to improve utilisation of lists and ensure quick turnaround of bookings.

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Other performance alerts

• Workforce• Appraisal rates remain below the baseline mean in December at 71.9% against a target of 90%. This

does, however, represent three consecutive months of improvement. • Positive shift and outlier for voluntary staff turnover. This was reported at 13%% in December which

is the first time the target has been met.• We continue to see MaST rates increase, with 80.6% of staff compliant in December.

• Inpatient• There were 9 breaches of the 28 day cancelled operations standard; RFH: 6, BH: 2, CFH: 1.

Alert summary

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Goal Performance

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19

Group Executive Dashboard

19

Goal name Alert Type Commentary

Alternative appointments offered for cancelled operations within 28 days

Target There were 9 breaches reported in December; against a target of 2.

RTT 18 weeks target: 92%Target Outlier ▼

Performance at 59.8% in December, with x 373 breaches of the >52 week standard.

ED access target 95%

Target Outlier ▼

Trustwide performance in December was 79.9% which is below 2018/19 performance and 19/20 trajectory. This is a third consecutive negative outlier compared to usual performance:• Barnet Hospital: 72.3% • Royal Free Hospital: 79.4%

Cancer access 62 days: 85%Target Performance out-turned at 80% with 157 patients currently waiting >62

days.

99% diagnostics target across 15 modalitiesTarget November performance was reported at 94% which represents two

months of consecutive improvement. Non-obstetric US remain the largest breach contributor.

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Clinical Standards and Innovation Committee Dashboard

20


MRSA BacteraemiasTarget

Clostridium difficile infections (including lapses in care)

Target 1 reported in December, against a target of 60 attributed to lapses in care

Top 10 for Clinical Trials participationTarget 267 in December, against a baseline mean of 369 and a target of

423

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21

People and Population Health Dashboard

21


Patients would want to be treated at RFL (FFT >90%)Target • Inpatient, Outpatient, Maternity and A&E FFT shows

stable performance within control limits and above target.

Top 10% of peers for staff recommending RFL as a place to work (FFT)

Target • Quarterly data from September shows 13.87% negative respondents on staff FFT, within target of 32%.

• Quarterly data from September shows 56.74% of staff would recommend RFL as a place to work.

Match leader on staff & patient engagement (Staffengagement score)

Target • 3.8 for Q2 against a target of 3.9

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Paper 15

FINAL

Report from finance and compliance committee

Executive summary

To follow is a report from the finance and compliance committee meeting held on 18 December 2019 on key discussion items and agreed actions. A verbal update will be provided on the January meeting.

Action required



Meeting Date Decision N/a N/a N/a


GOALS BAF risks






Compliance impact NHS Improvement, CQC

Report from Akta Raja, committee chair, and Peter Ridley, chief finance and compliance officer Author Veronica Jackson, committee administrator Date 15 January 2020



Paper 15

FINAL

COMPLIANCE

Referral to Treatment (RTT) The committee received an update on RTT performance with focus on validation of RTT data, 52 week waiters and the trust’s return to reporting on RTT nationally. The committee noted that good progress was being made in respect of the historic cohort and DEC 99A, with action plans for both in place and trajectories on track. The committee considered it would be helpful to integrate the RTT performance data into a single view of supply and demand. It was also noted that the group chief nurse and interim chief executive – Barnet Hospital was working with the responsible officer and medical director – corporate on capacity to help with clinical harm reviews.

FINANCE

Divisional finance review The committee’s discussion focussed on understanding the challenges to improving the financial position on the Barnet Hospital site including those areas where real progress could be made, such as neonates investment and estates, and improving the FIP position.

Finance report – Month 8 The trust delivered an actual deficit of £44.6m at end of November; this was £1.2m worse than plan. Key drivers for the year to date variance were underperformance in clinical income predominantly within day case and outpatient procedures and adverse variance due to slippage against the FIP target.

It was agreed that the next meeting would do a deep dive on private patient unit (PPU) finances, and capital spend.

Financial improvement plan (FIP) – Month 8 The FIP target at end of November was £30.2m. The trust delivered £9.4m of recurrent FIP and £14.7m of non-recurrent mitigations against this year to date target. It was currently forecasting recurrent in year FIP delivery of £20.9m and non-recurrent mitigations of £25.7m for financial year 2020.

Debt report and action plan – Month 8 The committee noted the good cash position at the end of November which was better than plan by £75.4m due to in part to a better than plan net VAT position and cash received from clinical commissioning groups (CCG’s) for prior years' debts.

New approach to budget management, waste and sustainability The committee noted that in some areas budgets were set without there being sufficient an expectation that they would be met; the mitigation to this was to keep substantial central reserves which were then played in. The new proposed budget setting approach aimed for greater ownership of budgets and looked at the longer term as well as the short term. There would be no separate FIP and total budget spend would be monitored. The committee supported this approach.

North Central London Sustainability and Transformation Partnership (NCL STP) The committee received an update on the NCL STP medium term financial strategy.

End.

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Final

Report from group services and investment committee

Executive summary

To follow is an update from the group services and investment committee meeting held on 12 December 2019 on key discussion items and agreed actions.

The committee discussed the following:

• Disposal of Queen Mary’s House • Barnet Hospital disposal opportunities • Routine reports:

- RFL property services Wholly Owned Subsidiary (WOS) - Decontamination WOS - Pharmacy WOS - Health Service Laboratory (HSL) investor perspective - Procurement / other commercial - Capital / other funding

The following actions were agreed:

• The trust board would be asked to agree the removal of the goal in respect of private patients from GSIC’s remit.

• A report on how to deliver Barnet outpatients service would go to GSIC in March 2020.

• The GSIC would review the post-tender evaluation of the provision of the trust’s non-emergency patient transport service.

• The January 2020 GSIC would receive a decision paper on RFL group digital transformation and would also discuss HSL’s current bid opportunity.

Action required



Meeting Date Decision n/a n/a n/a


Efficiency leader on corporate services G-012



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Final

Efficiency leader on middle office operations G-013

Double contribution private patients G-014

Benefit from improved asset financing G-015

CFH deficit eliminated G-017

Proceeds from QMH G-016

Benefits from group members & commercial opportunities G-019

Deliver regulatory undertakings (NHSI / ICO) G-020, G-021

Be a digital exemplar (HIMMS level 7) G-040, G-041

Urgent and emergency care transformation delivered G-010





Compliance impact N/a

Report from Wanda Goldwag, non-executive director and chair – group services and investment committee Author Veronica Jackson, committee administrator Date 24 December 2019

0 trust board agenda (public) 22 january 2020...

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