0 trust board agenda (public) 25 september 2019...

GROUP TRUST BOARD MEETING IN PUBLIC1

The next meeting of the group trust board will take place on Wednesday 25 September 2019 at 1.00 pm in the 2nd floor boardroom, executive office, Royal Free Hospital.

Dominic Dodd Chair

A G E N D A

ITEM LEAD PAPERQUALITY IMPROVEMENT/CPG ITEM

2019/20-91 Quality improvement/clinical practice group project presentation CPG project – Induction of labour CPG – Mai Buckley and colleagues in attendance

Chief medical officer

Verbal

ADMINISTRATIVE ITEMS

2019/20-92 Apologies for absenceTo note apologies for absence – chief medical officer, chief executive of Barnet Hospital

Chair

2019/20-93 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

Chair 1.

2019/20-94 Minutes of meeting held on 24 July 2019To approve the minutes of the last meeting

Chair 2.

2019/20-95 Matters arising report To note updates on actions arising from previous meetings

Chair 3.

2019/20-96 Record of items discussed at the confidentialboard meeting on 24 July 2019 To note the report

Chair 4.

QUALITY, PATIENT SAFETY AND EXPERIENCE

2019/20-97 Patients’ voicesTo note the patients’ voices

J Tugendhat, non-executive director

Verbal

2019/20-98 Influenza vaccination 2019 campaign

To note the report

Chief nurse 5.

2019/20-99 Local clinical excellence awards – annual report

2017/18

To note the report

Chief medical officer (responsible officer)

6.

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 PAPER2019/20-100 Medical staff appraisal and revalidation annual

report To note the report

Chief medical officer (responsible officer)

7.

2019/20-101 North London Partners in Health and Care(North Central London STP) quarterly progress report To note the report

Chief finance and compliance officer

8.

2019/20-102 Go see visitsTo provide feedback on visits and note the report

Chief communications officer

9.

FINANCE AND PERFORMANCE

2019/20-103 Financial performance reportTo discuss the current financial performance of the trust

Chief finance and compliance officer

10.

2019/20-104 Operational performance reportTo discuss the current operational performance of the trust

Hospital chief executive

11.

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

2019/20-105 Chair’s and group chief executive’s report To note the report

Chair/group chief executive

12.

2019/20-106 Audit committee report –13 September 2019 To receive the report from the committee

Committee chair Verbal

2019/20-107 Clinical standards and innovation committee report – 11 September 2019 To receive the report from the committee

Committee chair Verbal

2019/20-108 People committee report –18 July 2019 To receive the report from the committee

Committee chair 13.

2019/20-109 Executive finance committee report – 27 August2019 To receive the report from the committee

Committee chair 14.

2019/20-110 Population health committee report – 4 September 2019 To receive the report from the committee

Committee chair 15.

OTHER BUSINESS

2019/20-111 Questions from the public Chair

2019/20-112 Any other business Chair

2019/20-113 Date of next meeting – 23 October 2019 Chair

of 1

REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS

Executive summary

The trust constitution requires trust board members to declare interests which are relevant

and material to the NHS board of which they are a member. The register of interests is

presented at each board meeting.

There have been no changes since the last meeting.

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, chairman Author Alison Macdonald, board secretary

Report to Date of meeting Attachment number

Trust Board 25 September 2019 Paper 1

Paper 1

Version 35 Updated 18/7/19

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

REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD

Board Member and position

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

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

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

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

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

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

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

Non-executive directors

Dominic Dodd, Chair

Director of UCLPartners

1

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

Non-executive director Skin Analytics

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

Nil Nil

Mary Basterfield Non-executive director 8/3/18

Flatberg Ltd (property management)

Chief finance officer, Just Eat Plc

Trustee, National Cancer Research Institute and UCL Union.

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

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

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Wanda Goldwag Non-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)

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

Chris Ham Non-execuvtive director

• Non-clinical chair, NHS Assembly

Visiting fellow, King’s Fund Advisor to Carnall Farrar

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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

HR consultancy with South London and the Maudsley NHS Foundation Trust

Akta Raja Non-executive director

• Director RFL Property Services Company Ltd

• Enhabit Ltd

• Passisah Ltd (dormant)

• Geneff Ltd

• Thornriver Management Ltd

• Jewelglen Ltd

• Selwyn Peters Ltd (not trading)

• Member of PSM Partners LLP

Nil Nil Trustee, The Royal Free Charity

Nil Nil Nil

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Professor Anthony Schapira Non-executive director

Upper Hampstead Walk Residents’ Association. AHV Schapira Ltd

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

James Tugendhat Non-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

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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 Royal Free

Dispensing Ltd


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 Chair of NHS Providers COO Network

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

Nil Nil

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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 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.

Unpaid advice to

ZPB on e-rostering

which will

contribute to a

report

commissioned

from them by

Allocate.. The trust

has a contract with

Allocate, but not

ZPB, for whom this

work was done.

Personal friend is

an investor with

Vitruvian, which

owns Healthcare

at Home, a

significant supplier

of services to the

trust.

Nil Nil

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Non-voting directors

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

Director, EK

Consulting Ltd


Steve Shaw

Chief executive BH

Nil

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MINUTES OF THE TRUST BOARD

HELD ON 24 JULY 2019

Present

Mr D Dodd Ms C Clarke Ms W Goldwag Ms A Raja Mr P Ridley Ms D Sanders Prof A Schapira Dr C Streather Mr J Tugendhat

Chair Group chief executive Non-executive director Non-executive director Chief finance and compliance officer Chief nurse Non-executive director Chief medical officer Non-executive director

Invited to attend

Mrs J Dewinter Ms Natalie Forrest Mr D Grantham Ms E Kearney Dr S Shaw Miss A Macdonald

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

Others in attendance

Ms M Buckley Group director of midwifery

2019/20-66 QUALITY IMPROVEMENT/CLINICAL PRACTICE GROUP PROJECT PRESENTATION

There was no presentation on this occasion.

2019/20-67 APOLOGIES FOR ABSENCE AND WELCOME

Apologies for absence were received from:

Ms M Basterfield Non-executive director Prof Sir Chris Ham Non-executive director Ms D Olulode Non-executive director Ms K Slemeck Chief executive, Royal Free Hospital

The chair welcomed those present.

2019/20-68 DECLARATION OF INTERESTS

The 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.

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

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noted.

2019/20-69 MINUTES OF MEETING HELD ON 26 JUNE 2019

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

Attendance Amend the list of those in attendance to include Mr Chris Burghes, chief executive of the Royal Free Charity.

2019/20-51 Care Quality Commission (CQC) action plan

Amend third paragraph to read:

The chairman then asked if there would be external validation of the trust’s assessment of CQC compliance and the chief nurse responded that she was considering asking other trusts. The trust’s director of quality was also researching on international bodies which might work with the trust on this.

2019/20-70 MATTERS ARISING REPORT

The report was reviewed and noted:

2019/20-71 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 22 MAY 2019

It was noted that the reference to Queen Mary’s Hospital should have read Queen Mary’s House. The report was noted.

2019/20-72 PATIENTS’ VOICES

The chief people officer read out a complaint which had been received from an MP on behalf of her constituent, the mother of the patient. She went to see the MP at her advice bureau about her son’s appointments at the dermatology clinic at the Royal Free. She told the MP that at every appointment she saw a different doctor and had to explain her son’s condition each time. Her son was disabled and unable to speak. She understood that she could not always see the consultant but would find it helpful if there was some continuity so that she did not have to relate her son’s medical history at every visit. Her son had a blue badge but she had been refused permission to park in the disabled bays by the car park attendant, despite her telling them that her son was in a wheelchair.

The response noted that the patient has a disability and is on the learning disability register. As a result, his mother had been given a hospital passport, as well as a health action plan. A hospital passport contained information regarding the patient, including their medical history, medications, mobility, likes and dislikes. The intention was for this to be handed over to clinicians to read in order to avoid asking questions where the information is already noted. Following receipt of the complaint, the patient’s next appointment was rescheduled to the consultant’s clinic list, which would decrease his chance of seeing a different doctor, although it could not be guaranteed that he would see the same doctor at each appointment.

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Regarding the parking issues the only reason that a blue badge holder should be refused access to one of the blue badge bays is if they are all occupied, and the patient’s mother was provided with advice about what to do if she experienced difficulties in the future.

The chief people officer then read out a compliment from a patient at the day surgery unit at the Royal Free Hospital. She was making her way to the hospital exit, and was struggling to carry her bag and feeling very weak due to her recent surgery. A member of staff, who she believed had the title ‘head of children’s services’ on her badge took her bag and helped her to the front of the hospital. Before leaving her the member of staff gave her a hug and said she was worried about leaving her. The patient was very grateful for the member of staff’s assistance and did not feel she could have managed without her help and compassion.

Mr Tugendhat, non-executive director, would present the patients’ stories item next time. James

Tugendhat

2019/20-73 PEOPLE STRATEGY

The chief people officer noted that the trust had delayed the development of this strategy a little in anticipation of the publication of the NHS Improvement interim people plan and the trust’s strategy was aligned with it. The strategy was for the period up to 2028, the Royal Free Hospital’s 200th birthday. The strategy had been developed in conjunction with staff, trade unions and hospital management teams and had close interdependencies with other strategies and group goals. Themes from the staff survey were incorporated. The strategy set out seven areas of change and improvement, each of which contained some further high level objectives. This would be refreshed at least annually to make sure it continued to meet the trust’s aspirations.

Mr Tugendhat, non-executive director, said this was an important framework and that the one page summary set out a clear vision of where the trust wanted to be. The people committee would be doing more work around goals to concentrate on those dimensions which would really move the organisation forward.

Ms Goldwag, non-executive director, suggested that it would be worthwhile to look at what colleagues in London and similar organisations were doing. The chief people officer responded that the strategy reflected work with other London trusts, particularly the workforce race equality standard (WRES) where RFL was an exemplar.

The group chief executive commented that although it was important to work with colleagues, and the trust would do so, this could cause delays and the trust should therefore press on with the strategy. She noted that other development, such as integrated care and digital, would gain pace during the life of the strategy and the strategy would therefore need to be fluid and dynamic to incorporate new developments.

Summarising, and building on, the discussion the chair noted that there were three themes:

• Setting out the key people priorities

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• Delivery of the strategy • Collaboration, partnership and reflecting new developments.

The board approved the strategy for organisational launch and awareness.

2019/20-74 WORKFORCE EQUALITY AND DIVERSITY REPORTS

Workforce race equality standard WRES)

The chief people officer highlighted that the key focus was on improving black Asian and minority ethnic (BAME) representation at senior levels of the organisation, which would be achieved by training recruiting managers and having diverse panels. It was proposed that from November 2019 it would not be possible to recruit at band 8a and above unless the panels were properly constituted, ie with appropriately trained and diverse panel members. In discussion it was noted that the evidence was that the likelihood of a BME candidate being appointed improved if the panel was constituted in this way.

Mr Tugendhat, non-executive director and chair of the people committee, said that the committee was confident that this was a very specific goal which would move the trust forward significantly. He said that imposing a cut-off date was an important step to take.

The chair asked why managers were not reporting to the group chief executive their reasons for not appointing any shortlisted BAME candidates and the next developmental steps as required by the board. The chief people officer responded that there was a process in TRAC (the electronic recruitment system) to escalate if the letter was not written but the process needed to be embedded and other processes around checking that this happened were mainly manual. The chief finance and compliance officer was concerned that this process was not happening and said that recruiting managers needed to be held to account on this.

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.

Summarising the discussion the chair noted that it was important to establish consequences for non-compliance with the agreed policy, to track compliance and provide support and training for managers.

The board noted the funding requirement to train all 186 senior managers and that the non-compliance date would be moved from 30 September to 1 November to allow more time for the training to be completed.

The board approved the WRES annual report.

Workforce disability equality standards (WDES)

The chief people officer advised the board that implementing the workforce disability equality standard (WDES) was a new requirement on all NHS providers and had been part of the standard NHS contract since 1st April 2019. The WDES was a data-based equality standard that intended to use a series of metrics to measure the experiences of disabled staff across the NHS for the first

Chief people officer

James Tugendhat

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and put action in place to address findings. He explained that this was more difficult than for WRES because the dataset was not good. This was demonstrated by the gap between staff who disclosed a disability on the electronic staff record (ESR) and those who responded that they had a disability on the anonymous staff survey. This might indicate a perception that staff would be treated less favourably if they disclosed a disability.

A staff network (ability @ the free network) had been in place for two years to support staff.

The group chief executive asked what interventions might be made as part of the WDES strategy. The chief people officer said that these could include a commitment to making reasonable adjustments, more flexibility for example helping people with learning disabilities into employment and highlighting stories of where people had been successfully supported and enabled in their working lives. He noted that the challenge was to remove the stigma attached to disability in order for staff to get the help they needed.

The chief nurse said that it was important to recognise that disability encompassed mental health as well as physical issues.

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.

The board approved the WDES annual report.

James Tugendhat

2019/20-75 CARE QUALITY COMMISSION (CQC) ACTION PLAN UPDATE

The chief nurse presented this report. She noted that action plan for the 11 must recommendations made by the CQC had been presented to the board last month and had been submitted to the CQC. A meeting had taken place with the CQC and no issues had been raised or comments made on the action plan. The report presented today related to the 82 should do recommendations. The CQC had indicated that they were open to discussion about the action plan if there was any recommendation which indicated actions which were not feasible or realistic. They were prepared to discuss mitigations or other actions which might be taken.

The board noted the summary actions taken and agreed the proposed governance arrangements and alignment of the key lines of enquiry to the board structures. The board would receive a quarterly update on the action plans. Chief nurse

2019/20-76 CLINICAL NEGLIGENE SCHEME FOR TRUSTS (CNST) MATERNITY STANDARDS EVIDENCE

Ms Buckley, group director of midwifery, was in attendance to present this item. She noted that there were ten maternity standards and evidence had been presented at the trust board and group executive committee demonstrating compliance with them. Evidence had also been reviewed with the clinical commissioning group maternity lead commissioner in July who was satisfied that the trust was compliant.

The chief nurse thanked the director of midwifery and her team for their hard

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work in bringing together a comprehensive evidence base of the trust’s compliance with the CNST’s maternity standard. This had been a significant undertaking and more onerous than in previous years.

The board formally confirmed full compliance with the CNST Maternity Incentive Scheme 2019/20 standards and agreed that the group chief executive could sign the self-certification on behalf of the board.

2019/20-77 COMPLAINTS ANNUAL REPORT

The chief nurse presented the annual complaints report which had been discussed at the last meeting of the people committee. The complaints ratio (number of complaints compared with the total of inpatient and outpatient episodes) had remained stable at 0.1%. The compliance rate at 78% had not been met for some time and had been driven by performance at Barnet Hospital where the average response rate for 2018/19 was 63% compared to the Royal Free Hospital’s 89% and Chase Farm Hospital’s 97%. However Barnet’s director of nursing had a robust plan in place and was bringing the hospital’s performance back to compliance. The number of reopened complaints was 5% and relatively static; four complaints out of the 1,642 complaints raised in 2018/19 had been escalated to the ombudsman. There had been an increase in complaints about non-emergency patient transport related to the application of eligibility assessment criteria. These had reduced slightly but were still an issue.

The board noted the report.

2019/20-78 DIRECTOR OF INFECTION PREVENTION AND CONTROL QUARTERLY REPORT

The chief nurse reported that there had been 20 cases of C. Diff since 1 April 2019. There were several cases on one ward at the Royal Free Hospital but testing concluded that there was no direct transmission so the cases were not related.

There had been no cases of MRSA bacteraemia since before 1 April 2019.

The flu vaccination for staff campaign had commenced earlier this year and staff vaccines have been ordered. However it was understood that there would be some delay in vaccines becoming available.

The board confirmed that the report provided sufficient information to provide assurance of sustained compliance with the Hygiene Code.

2019/20-79 GO SEE VISITS

The chief communications officer noted that governors had not accompanied non-executive directors on many of the recent visits and the lead governor and trust secretary would be following this up to see if there were any process or other issues preventing their attendance.

The chief medical officer reported on a visit to the planned investigation and treatment unit (PITU) which provided a very welcoming environment for patients and was notable for the amount of information provided. He had also visited the

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Barnet Hospital emergency department where he had been impressed by the teamwork.

Mr Tugendhat, non-executive director, had visited the discharge lounge at Barnet Hospital where he had met an inspirational matron.


2019/20-80 FINANCIAL PERFORMANCE REPORT

The chief finance and compliance officer reported that the financial position had improved in month 3, largely driven by clinical income. The trust’s position was £0.8m favourable to plan for month 3 and £2.7m adverse to plan year to date. As approved by the board the trust had set a more challenging internal target than was being reported to NHS Improvement in order to drive better performance. The externally reported position was a year to date favourable variance of £0.4m. It remained imperative to deliver the financial improvement programme (FIP) and the planned care activity levels set out in the trust’s annual plan.

The board noted the current financial position of the trust.

2019/20-81 OPERATIONAL PERFORMANCE REPORT

The chief finance and compliance officer noted that the trust continued to struggle to deliver the national constitutional standards for cancer. Regarding the 4 hour A&E target, performance had improved but Barnet Hospital continued to be challenged and the board would be receiving a briefing later on the recovery plan. Diagnostics waiting times (DMO1) were also challenged.

The board noted the current operational performance of the trust.

2019/20-82 CHAIR’S AND CHIEF EXECUTIVE’S REPORT

The chair highlighted that the annual members’ meeting was taking place that evening and encouraged colleagues to attend.

The group chief executive congratulated the eight Royal Free London clinicians who had received professorships from UCL. The chief medical officer encouraged colleagues to attend their inaugural lectures.


2019/20-83 TRUST CONSTITUTION – PROPOSED AMENDMENT

The chair explained that the amendment was to follow the practice of other NHS Foundation Trusts by disqualifying chairs, non-executive directors, governors, trust secretaries, executive directors or chief officers of other trusts from being RFL governors.

The board approved the amendment to the constitution.

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2019/20-84 CLINICAL STANDARDS AND INNOVATION COMMITTEE – 3 JULY 2019The board noted the report from the committee.

2019/20-85 GROUP SERVICES AND INVESTMENT COMMITTEE REPORT – 9 MAY AND 11 JULY 2019 The board noted the report from the committee.

2019/20-86 PEOPLE COMMITTEE REPORT – 8 MAY AND 18 JULY 2019

Mr Tugendhat, non-executive director and chair of the committee highlighted the exceptional work taking place at RFL with the Point of Care Foundation to encourage patient involvement and find out what matters to patients.

The board noted the report from the committee.

2019/20-87 EXECUTIVE FINANCE COMMITTEE REPORT – 25 JUNE 2019

The board noted the report from the committee.

2019/20-88 QUESTIONS FROM THE PUBLIC

A member of the public raised a question about the application of eligibility criteria for non-emergency patient transport. He referred to a particular case and suggested that the policy to reassess patients before every visit when their medical condition would not change was perverse.

The group chief executive said that the hospital would apologise and put things right when there was a mistake in the application of the criteria. The chief nurse undertook to discuss the particular case with the member of the public to see what could be done.

2019/20-89 ANY OTHER BUSINESS

There was no other business.

2019/20-90 DATE OF NEXT MEETING

The next trust board meeting would be on 25 September 2019 at 1300 in the boardroom, 2nd floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 25 September 2019……………………………. Dominic Dodd, chair

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TRUST BOARD – PUBLIC

ACTION TRACKER AS AT 25 SEPTEMBER 2019

Ref Open actions – as at 25 September 2019

(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

2019/20-74 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 23/10/19 Mr

Tugendhat Next people

committee

meeting

23/10/19

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 23/10/19 Mr

Tugendhat

Next people

committee

meeting

23/10/19

2019/20-75 Care Quality Commission (CQC) action plan update

The board noted the summary actions taken and agreed the

proposed governance arrangements and alignment of the key

lines of enquiry to the board structures. The board would receive

a quarterly update on the action plans.

24/7/19 23/10/19 and

quarterly

thereafter

Chief nurse Programme for

23/10/19

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 23/10/19 Chief

medical

officer

To be included

in next report

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2019/20-30 Director of infection prevention and control reports

The staff response to the trust’s flu vaccination campaign had been very disappointing and the Royal Free London had the biggest drop in uptake relative to other London trusts. She intended to involve the trust’s public health team in next year’s campaign to try for a different approach. The chairman suggested bringing the plan to the board early enough so that the board could make suggestions and it was agreed that the September meeting would be a good time to do this

22/5/19 25/9/19 Chief nurse On agenda for

September

meeting.

Operational performance report

2018/19-221 Ms Goldwag, non-executive director, asked whether it would be

possible to give patients the option of going to another hospital

with a shorter waiting time so they could be treated more quickly.

The chief executive of the Royal Free Hospital responded that

patients were often reluctant to be treated by a different consultant

in the same hospital, let alone going to a different hospital and

other hospitals were also challenged. However she undertook to

pursue this idea further.

27/3/19 1/5/19 Chief

executive,

RFH

May 2019 –

update given,

action carried

forward.

Completed actions – as at 25 September 2019

(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)

2019/20-51 Care Quality Commission (CQC) action plan

There would be a further report to the group executive committee and to the next trust board meeting.

.

26/6/19 24/7/19 Chief nurse Closed –

on agenda

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ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 25 JULY 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 confidential meeting held on 25 July 2019 are outlined below. The board discussed the trust’s financial position and performance report, although a detailed discussion also took place within the public part of the meeting. The following matters were also discussed at the meeting:

• Referral to treatment time (RTT) update – the trust noted that additional resource was being put into the validation of information and the focus continued to be on treating patients with long waiting times. The board would continue to be updated on the RTT position.

• Trust’s financial position – the trust had met the quarter 1 financial plan as required by NHS Improvement’s financial undertakings.

• Capital programme – the board approved the revised capital programme.

• Integrated recovery plan – the board noted the updated recovery plan and the incorporated elements on activity, performance, workforce and quality.

• Operational performance – the board received detailed updates on

• Barnet Hospital emergency department recovery plan – a number of workstreams were in place as part of this, including improving patient flow and delayed discharges, demand management, improving the physical space and reviewing the workforce model.

• Cancer recovery plan – RFL receives the second largest number of suspected cancer referrals in England and is the second largest provider of treatments for cancer in London. The recovery plan is to reduce the backlog of patients and to return to compliance in the autumn

• Royal Free London NHS Foundation Trust and University College Hospital NHS Foundation Trust – the board received a report about closer working between the two hospitals on a number of topics

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

Action requiredFor the board to note.



Paper 4

Page 2 of 2

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


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 10 September 2019

Paper 5

Page 1 of 1

HEALTHCARE WORKER FLU VACCINATION 2019 CAMPAIGN

Executive summary

Employers of health and social care staff are responsible for providing occupational flu

vaccinations. Vaccination is offered free to NHS staff as a way to reduce the risk of staff

contracting the virus and transmitting it to patients in their care, protecting themselves and

their families. The target for this year is a vaccination rate of 80% of frontline healthcare

workers to be vaccinated.

The planning for this year’s campaign began in the early summer and has involved staff from

each hospital, the directors of nursing, divisional representatives, infection prevention and

control, pharmacy, public health, occupational health and communications and have been

following the NICE guideline NG103 Flu vaccination: increasing uptake and best practice

guidance that was issued in 2018.

This paper updates the board on the planning undertaken so far and the proposed

communications plan.

Action required

The board is asked to note the report, confirm its commitment to the programme and to be vaccinated

Meetings where this report has been discussed previously Meeting Date Decision LEC 24 September 2019

Board goals

GOALS BAF risks

1. Zero avoidable infections G-003

CQC standards impacted Safe / effective


Equality analysis No identified negative impact on equality and diversity

Compliance impact Not applicable

Report from Deborah Sanders, group chief nurse

Author Deborah Sanders, group chief nurse

Date 18 September 2019


Trust board 25 September 2019 Paper 5

Paper 5

Staff Influenza Programme 2019/20 Written by D Sanders, M Lanzman, D Irish, A Orminston, J Adeniji, V Pang

2019 – 20 Staff Influenza vaccination programme

Background

Each winter hundreds of thousands of people see their GP and tens of thousands are

hospitalised because of flu. Deaths attributable to flu are estimated to range from around

4,000 to 14,000 per year, with an average of around 8,000 per year (Public Health England

and the NHS prepare for unpredictable flu season, Public Health England).

Frontline healthcare workers are more likely to be exposed to the influenza virus, particularly

during winter months when some of their patients will be infected. It has been estimated that

up to one in four healthcare workers may become infected with influenza during a mild

influenza season representing a much higher incidence than expected in the general

population.

Employers of health and social care staff are responsible for providing occupational flu

vaccinations. Vaccination is offered free to NHS staff as a way to reduce the risk of staff

contracting the virus and transmitting it to patients in their care protecting themselves and

their families. Recent NICE (2018) guidelines highlight a correlation between lower rates of

staff vaccination and increased patient deaths. Up to 50% of confirmed influenza infections

are asymptomatic. Unvaccinated, asymptomatic (but infected) staff may pass on the virus to

vulnerable patients and staff. Flu related sickness affects service delivery impacting on

patients and other staff.

The CQUIN target for staff flu vaccination in 2018 – 19 was 75%. The performance across

the Royal Free London group was 49.4% (4294 staff). This was a significant drop from the

rate of 2017- 18 which was 71%.

The table below shows the vaccination rates for London in 2018:

The London data showed that the Royal Free London had that largest deterioration in its

performance as shown in the table below (RFL is the last bar on the right hand side):

Paper 5


Staff who declined the offer of a vaccination were required to fill in an anonymous form to

indicate the reasons for decline. Staff were reluctant to do this and we collected forms from

only 493 staff. The reasons they gave are shown below:

It is acknowledged that during last season’s campaign the trust was implementing the new

EPR and preparing for the CQC inspection which led to staff being pulled on different fronts.

The target for this year is a vaccination rate of 80% of frontline healthcare workers to be

vaccinated. The current total numbers of frontline staff are shown in the table below:

-25.0

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REASONS FOR DECLINE NUMBER I have had already at my GP/local pharmacy/elsewhere 0I have had an anaphylactic reaction to eggs/chicken protein in the past

18

I don’t like needles 37I don’t think that I’ll get flu 26I do not believe the evidence that being vaccinated is beneficial 101I’m concerned about possible side effects 133I don’t know how or where to get vaccinated 1It was too inconvenient to get to a place where I could get the vaccination

1

The times when the vaccination is available are not convenient 2Any other reason – please specify 163Other – we referred to GP 11Total 493

Paper 5


The planning for this year’s campaign began in the early summer and has involved staff from

each hospital, the directors of nursing, divisional representatives, infection prevention and

control, pharmacy, public health, occupational health and communications and have been

following the NICE guideline NG103 Flu vaccination: increasing uptake. A summary is

shown at appendix 1.

• The vaccination programme is due to start Monday 30 September 2019 across all

Royal Free London NHS Foundation Trust sites.

• The campaign will focus on the vaccination providing protection for staff and their

families, the people that they care for and their colleagues.

• The Trust has ordered 8250 quadrivalent vaccines for staff vaccination which it will

receive at three different time points across September and October. The first batch

is due to be delivered to the Trust on 27 September 2019

• Planning is ongoing to ensure staff have access to the vaccines in and out of hours,

on the wards via peer vaccinators and in areas where there is a high footfall via

occupational health staff working on site.

• Dedicated flu champions have been identified at each site involving high profile

leaders within the organisation.

• Each division has a lead for the programme and weekly vaccination rates will be

published on the intranet by division rather than hospital site as was the case last

year.

• The consent form has been changed this year to ask for consent from staff to allow

their manager to be informed that they have received the vaccine.

• The Royal Free Charity have funded the purchase of a branded insulated reusable

coffee cup for each staff who is vaccinated to have

• There is a comprehensive communications plan which is at appendix 2

Training for peer flu vaccinators has been delivered a number of times in August and

September with further sessions planned in September. The training involves a one hour

session delivered by virology, pharmacy, occupational health and infection control and

includes information on the flu virus, logistical information and truth and myths about flu. The

Table below shows total values by headcount

Headcount Location

Business Unit Bar

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Barnet Hospital 2038 65 34 469 2606

Chase Farm Hospital 257 257

Corporate 41 8 15 5 301 370

Group Clinical Services 152 63 7 6 392 620

Property Services 2 2

Royal Free Hospital 207 25 76 7 27 5 2838 34 34 3253

Grand Total 2438 8 425 117 5 7 27 5 6 4002 34 34 7108

Paper 5


aim of the session is to provide flu vaccinators with information and knowledge to challenge

any myths among their peers as well as to provide a forum for discussion.

Paper 5


Appendix 1

Healthcare worker flu vaccination best practice management checklist

A Committed leadership(number in brackets relates to references listed below the table)

Trust self-assessment

A1 Board record commitment to achieving the ambition of 100% of front line healthcare workers being vaccinated, and for any healthcare worker who decides on the balance of evidence and personal circumstance against getting the vaccine should anonymously mark their reason for doing so.

The Board will be recording its commitment at its meeting on 25 September 2019

A2 Trust has ordered and provided the quadrivalent (QIV) flu vaccine for healthcare workers (1).

The trust has ordered and is providing the quadrivalent flu vaccine for our health care workers

A4 Agree on a board champion for flu campaign (3,6)

The chief nurse is the board champion for the 2019 flu campaign.

A5 Agree how data on uptake and opt-out will be collected and reported

The Trust flu data on staff up-take is collected via flu consent forms and reported to the group weekly flu meeting chaired by the chief nurse. The data will be presented by division by hospital

A6 All board members receive flu vaccination and publicise this (4,6)

.For discussion at Board

A7 Flu team formed with representatives from all directorates, staff groups and trade union representatives (3,6)

The group has been meeting since early summer and will continue with weekly meetings during the campaign

A8 Flu team to meet regularly from August 2018 (4)

See above

B Communications plan

B1 Rationale for the flu vaccination programme and myth busting to be published – sponsored by senior clinical leaders and trade unions (3,6)

The trust’s communications team have published flu busting myths on the internal intranet and pictures of directors taking their flu vaccines will be published in trust Freemail and intranet.

B2 Drop in clinics and mobile vaccination schedule to be published electronically, on social media and on paper (4)

There are flu drop-in clinics set up on each of the main sites the information will be published via the intranet and social media by the communications team.

Paper 5


B3 Board and senior managers having their vaccinations to be publicised (4)

.For discussion at board, GEC and LEC week beginning 23 September 2019

B4 Flu vaccination programme and access to vaccination on induction programmes (4)

An occupational health nurse is attending corporate induction on the Royal Free Hospital site to vaccinate new starters.

B5 Programme to be publicised on screensavers, posters and social media (3, 5,6)

The communications team have an action plan which includes screen savers, posters and social media to publish the 2019 flu campaign.

B6 Weekly feedback on percentage uptake for directorates, teams and professional groups (3,6)

This will be published weekly and will be on each LEC/GEC weekly agenda

C Flexible accessibility

C1 Peer vaccinators, ideally at least one in each clinical area to be identified, trained, released to vaccinate and empowered (3,6)

The directors of nursing on each site co-ordinate and empower the flu peer vaccinators to go and vaccinate other staff.

C2 Schedule for easy access drop in clinics agreed (3)

The occupational health department has a drop in clinic for staff to have their flu jabs.

C3 Schedule for 24 hour mobile vaccinations to be agreed (3,6)

This still to be confirmed

D IncentivesD1 Board to agree on incentives

and how to publicise this (3,6) The Charity are funding the purchase of insulate coffee cups

D2 Success to be celebrated weekly (3,6)

The communications team will be using jabometer to celebrate the trust’s achievement via all communication channels on a weekly basis.

Reference links 1. http://www.nhsemployers.org/-/media/Employers/Documents/Flu/Vaccine-ordering-for-2018-19-influenza-

season- 06022018.pdf?la=en&hash=74BF83187805F71E9439332132C021EFA3E6F24C

2. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/Reviewing-your-campaign-a-flu-fighter- guide.pdf

3. http://www.nhsemployers.org/-/media/Employers/Documents/Flu/Flu-fighter-infographic-final-web-3-Nov.pdf

4. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/good-practice-acute-trusts-TH-

formatted- 10-June.pdf

5. http://www.nhsemployers.org/-/media/Employers/Publications/Flu-Fighter/good-practice-ambulance-trusts-TH- formatted-10-June.pdf

6. https://www.nice.org.uk/guidance/ng103/chapter/Recommendations

Paper 5


Appendix 2

Winter flu campaign 2019/20 –

Draft communications and activity plan

Background:

Every year the influenza vaccination is offered to NHS staff as a way to reduce the risk of

staff contracting the virus and transmitting it to their patients.

Flu can cause a spectrum of illness ranging from mild to severe, even among people who

were previously well. It is estimated that up to one in four healthcare workers may become

infected during a mild influenza season – a much higher incidence than expected in the

general population. The patient population found in hospital is much more vulnerable to flu’s

severe effects.

Aims and objectives:

1) To create awareness of the importance of frontline healthcare workers receiving a flu

vaccination in order to protect patients

2) To encourage staff in all roles to have the flu vaccine to protect themselves, patients,

family, friends and colleagues

3) To meet the trust target of 70% of frontline* staff vaccinated in order to improve on

last year and hit CQUIN target (worth £1million)

*Frontline staff are defined by the Department of Health as: “doctors, nurses, other

professionally qualified clinical staff and those that support clinical staff. This support clinical

staff group includes HCAs, nursing assistants and admin & clerical staff working “specifically

in clinical areas”.

Public Health England annual flu report 2018-19

Paper 5


Between week 40 2018 and week 15 2019, a total of 1,340 acute respiratory illness (ARI)

outbreaks in closed settings were reported in the UK compared to 2,146 in 2017 to 2018;

1,114 in 2016 to 2017 and 656 in 2015 to 2016 (Table 1).Of all outbreaks, 932 (69.6%)

occurred in care homes, 199 (14.9%) in hospitals, 158 (11.8%) in schools and 51 (3.8%) in

other settings.

Influenza vaccine uptake in 2018 to 2019 in England for the 65+ year olds was slightly lower

than that seen in 2017 to 2018. The vaccine uptake in 2018 to 2019 was also lower than the

2017 to 2018 season for those aged 6 months to under 65 years of age with 1 or more

underlying clinical risk factors (48.0%) and pregnant women (45.2%).

Risks:

• Not hitting target = not getting £1million from CQUIN. This would mean not achieving

part of our financial improvement plan (FIP).

• Potential increase in percentage of staff who get flu – this impacts on sick days, and

therefore patient care, and can increase chance of patients getting flu.

• Whilst our campaign is aimed at a staff audience, we to reflect/enhance patient/public

angle/key messages as communications materials will be seen in all hospital areas

also visited by patients, carers and visitors.

Channels we will use

• Chief Executive’s briefings and Take 5

• Freemail banners

• Freemail all staff enewsletter

• Freenet banners

• Staff incentive - reusable flu fighter cups (6,000 due for delivery 20 February)

• Posters

• Social media campaigns

• Monthly managers’ briefings

• All staff emails

• Key messaging from senior staff

Paper 5


Activities we will publicise

• Profile the first member of staff / key members of staff to be vaccinated

• Highlight the certificates given to the vaccinators who reach 100, 150, 200, 200+

staff. Top vaccinator will receive a prize

Giving the NHSE flu fighter stickers to the vaccinators

• IPC winter roadshows

• Message to all staff directly from Debbie/Chris/both

• Putting up posters and distributing leaflets

• The national NHS ‘jabathon’ campaign

• The weekly percentage data of frontline and all staff who have had the jab

• Vaccine for vaccine incentive for social good

• Highlight the operational impact of flu with a case study (for example the impact of

shut beds)

Key messages

• Do your bit to help those who can’t get the jab

• You have a duty to protect patients, as stated in the staff code of conduct

• Easy and convenient. Dates and locations of clinics (drop in clinics)

• As well as getting your jab, you can help reduce the spread of flu by regularly

washing your hands and by keeping generally healthy

• If you have flu, stay away from work until you are better. The virus is highly infectious

and outbreaks can happen quickly

• The vaccine is one of the safest in the world and it is impossible to get flu from

having the flu jab!

Other

• Follow up on last year’s charity money

Paper 5


• The average number of vaccinations given to staff by the vaccinators, the information

will be supplied by the steering group

• Comms will facilitate a Twitter ‘Takeover’ of vaccinators

• Reusable cups with the trust’s values / I’m a flu fighter message / logos

Key timelines:

• Campaign launches mid-September and runs to end February 2020

Activity plan themes

September

- Prep comms collateral

o Interview staff for Freepress

o Create graphics for Freenet 2 and Freemail

October

- Launch month

o Chief exec briefings and Take 5

o Feature in Freepress

o Lead story in Freemail

- Autumn campaign (Get your flu jab before the clocks go back on 27 October)

November

- Pre-Christmas campaign (This is a time for festive cheer, not flu)

December

- Christmas campaign (Don’t give the gift of flu this winter)

January

- New Year’s resolution campaign (Add getting the flu jab to your resolution list)

February

- Valentine’s campaign (Give flowers this Valentine’s, not flu)

Activity plan

Date/week

Channel Message/activity

Purpose Requirements Responsibility & action status

20 Sept

N/A Flu cups arriving Incentive Comms to confirm from

Comms / Debbie Sanders

Paper 5


Debbie where they’re being stored / the charity’s role in storage / distribution

23 Sept

Freemail Get your jab next week

To ‘warm up’ the campaign

Comms to write article

Comms

23 Sept

Freenet As above As above As above Comms

23 Sept

Social media

Flu cup has arrived To create interest in the offer

Comms to take picture and to manage social media

Comms

30 Sept

Freenet Launch the campaign and new Freenet page including:

• staff incentives

• myths • clinic dates

and other vaccination locations

• Re-introduce the Jabometer

• Number of sick days we lost to flu last winter

• Let us know if you’ve been vaccinated by your GP

To motivate RFL staff to take part in this year’s campaign effort and to inform them of where and when they can receive their jabs

Comms to work with the steering group to ensure smooth roll out of messages

Comms

Freemail As above As above As above As above

Social media

RFL staff you can get your flu jab now etc

As above As above As above

Chief Executive’s briefings

As above As above As above As above

Managers’ briefing


Take 5 As above As above As above As above

Freenet banner


W/C 30

Sept

Screensaver One thing to do this autumn – get your flu jab

Incentivise staff

Comms to create screensaver

Comms

Date/week



W/C 7 Oct

Freenet

Update jabometer To create competition between the sites for who has the

Comms to receive the latest number on the weekly flu call

Freenet

Paper 5


most staff vaccinated

Freemail First week jabometer – broken down by site


Freenet

Case study: Staff member who got the jab for the first time this year



W/C 14 Oct

Freenet Update jabometer To create competition between the sites for who has the most staff vaccinated


Freenet

Freenet 2K stock arrives at RFH

To let staff know that they will be able to receive the jab soon

Comms need to be told of the logistics plan

Comms


Freenet Get ready for flu takeoff story – logistics etc



W/C 21 Oct



Comms

Freenet Get your flu jab before the clocks go back on 27 October

Weekly pre-autumn campaign

As above As above


Social Manager’s Briefing


Take 5’s As above As above As above As above

Date/week



W/C 28 Oct



Comms

Paper 5


Freenet Don’t be ghoulish! Get the vaccine for Halloween

Fun short push for the vaccine

Staff getting jab with witches hat / Halloween cape

Comms

Social media



Freenet Content with photos of execs being vaccinated

To encourage ‘top down’ buy-in of the jab

Comms to arrange time for site execs to have their jabs

Comms

Social media

Content with photos of execs being vaccinated

As above As above Comms

W/C 4

Nov



Freenet

Screensaver One thing to do this winter – get your flu jab

Incentivise staff


Comms

Freenet banner

“One month in” stats Incentivise staff

Comms to create Freenet banner

Comms

Freenet Remember, remember the fifth of November – get your flu jab!

Weekly incentivise campaign

Comms to create

Comms


Social As above As above As above As above

Date/week



W/C 11

Nov



Comms

TBC TBC TBC TBC As above




W/C Freenet Update jabometer To create Comms to Freenet

Paper 5


18 Nov

competition between the sites for who has the most staff vaccinated

receive the latest number on the weekly flu call

As above

TBC TBC As above As above As above



W/C 25

Nov



Freenet

Freenet One month until Christmas day – get your flu jab now

Christmas ‘push’ on vacinations

As above

Freemail As above As above As above Comms

Social As above As above As above Comms

Manager’s Brief

As above As above As above Comms

W/C 2

Dec


Incentivise staff


Comms

Freenet This is a time for festive cheer, not flu

As above As above Comms


TBC TBC As above As above Comms

W/C 9

Dec

TBC TBC TBC TBC Comms


TBC TBC TBC Comms


W/C 16

Dec

Freenet Give the gift of protecting your loved ones from flu this Christmas

Final pre-Christmas push

Picture of staff in Christmas hats / tinsel or pic of festive peer vaccinators

Comms


Social media


Paper 5


Freepress As above As above As above Comms

W/C 23

Dec

Freenet This Christmas week protect yourselves and your loved ones

Christmas week push

A different picture encapsulating staff, Christmas and Flu

Comms

Freemail As above As above As above A different picture encapsulating staff, Christmas and Flu

Social media


Manager’s Briefing


Date/week



W/C 6 Jan

Freenet

Update jabometer To create competition between the sites for who has the most staff vaccinated


Freenet

Screensaver Ring in the new year – get your flu jab

Incentivise staff


Comms

TBC New year, new resolutions, new flu jab

TBC As above As above As above Comms



W/C 13

Jan

Freenet

Update jabometer To create competition between the sites for who has the most staff vaccinated


Freenet

TBC TBC TBC TBC




W/C 20

Jan

Update jabometer To create competition between the sites

Comms to receive the latest number on the weekly

Freenet

Paper 5


Freenet for who has the most staff vaccinated

flu call

TBC TBC Comms




Date/week



W/C 27

Jan


Incentivise staff


Comms





W/C 3

Feb





W/C 10

Feb

Freenet Give flowers this Valentine’s, not flu

Weekly campaign

TBC Comms

Freemail Give flowers this Valentine’s, not flu

As above TBC Comms

Freepress Give flowers this Valentine’s, not flu

As above TBC Comms

Freenet banner

Give flowers this Valentine’s, not flu

As above TBC

Comms

W/C 17

Feb


TBC TBC TBC TBC

Comms

TBC TBC TBC TBC

Comms

TBC TBC TBC TBC

Comms

W/C 24

Feb

TBC TBC TBC TBC

Comms

TBC TBC TBC TBC

Comms

TBC TBC TBC TBC

Comms

TBC TBC TBC TBC

Comms

Paper 5


Date/week



W/C 2

Mar





W/C 9

Mar





W/C 16

Mar





W/C 23

Mar





W/C 30

Mar

Freenet Last week to get your flu jab

To create risk of loss

Comms need date confirm of when the stop date for providing the jab is

Comms


Manager’s Briefing


Take 5 As above As above As above Comms

of 2

Title of report

Local Clinical Excellence Awards - Annual Report 2017 2018

Executive summary

Since April 2018, the local clinical excellence scheme has been incorporated, via schedule

30, into the 2003 national terms and conditions of service for consultants and is now

therefore a contractual obligation for trusts to undertake annually.

Schedule 30 requires the trust to produce an annual report following the completion of the round which includes analysis of protected characteristics in addition to details of successful

applicants and the value of each award.

The full report provides transparency for the board on the revisions made to the process and

the effort to address the problems in the old scheme being felt, to varying degrees to be

disadvantaging female, BME and part time consultant staff but advantaging applications

from clinical academics.

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

For Information – no actions required

Meetings where this report has been discussed previously

The report and appendices will be sent to the next Joint Local Negotiating Committee in September 2019.

Meeting Date Decision N/A N/A N/A


GOALS – these are primary goals included against the 5 domains

from the local CEA application form

BAF

risks

1. Top 10% for education, training and workforce development



Paper 6

of 2

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

led

Financial/business implications Payment of awards part of contractual

obligation and oversight by the Local CEA

Committee.

Equality analysis Positive evidence that proposal has considered equality and diversity

Compliance impact Compliance with contractual obligation as

per 2003 terms and conditions of service for

consultant staff

Report from Dr Chris Streather, group medical director Author Jonathan Sockett, medical workforce project manager

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2017 / 2018 Local Clinical Excellence Awards(1)

Annual Report to the Trust Board and Joint Local Negotiating Committee

Prepared by Medical Workforce Projects Team

“The Clinical Excellence Awards (CEA) scheme in England and Wales is intended to recognise and

reward those consultants who contribute most towards the delivery of safe and high quality care to

patients and to the continuous improvement of NHS services”

Introduction

Since April 2018, the local clinical excellence scheme has been incorporated, via schedule 30, into

the 2003 national terms and conditions of service for NHS consultants and is now therefore a

contractual obligation for trusts to undertake annually.

One of the major changes included in Schedule 30 is that the awards become one off lumps sum

payments which are given for a specific period of time, rather than being paid as part of salary and

held potentially until retirement.

Prior to the 2017/2018 round being opened, both the Group Executive Committee and the Joint

Local Negotiating Committee discussed how the trust could use the opportunity to address the

problems in the old scheme being felt, to varying degrees to be disadvantaging female, BME and

part time consultant staff but advantaging applications from consultants with clinical interests.

It was agreed therefore to introduce a revised form which asked applicants to align the content of

their application to trust organisational goals and values.

This form is included in Appendix 1

Schedule 30 requires the trust to produce an annual report following the completion of the round

and the requirements for this report can be found in section 5.20 – 5.22 inclusive of the guidance

document published by NHS Employers and the BMA. See link below

https://www.nhsemployers.org/case-studies-and-resources/2018/07/local-clinical-excellence-

awards-guidance-2018-21

It should also be noted that although clinical academics are excluded from schedule 30 (by virtue of

not being employed on the 2003 consultant contract) it was agreed through the Joint Local

Negotiating Committee to allow them to participate in this round, in anticipation of a potential

agreement on the application of new LCEAs to them at national level.

Training sessions were undertaken for both applicants and panel members to understand and

support the new scheme and application form.

(1) : Awards were payable from April 2018 (activity included up until 31st

March 2018)

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Time line for the round

Dr Chris Streather formally opened the round on 14th December 2018.

A copy of that letter is included at Appendix 2

A time line for the round, including relevant deadlines is included as Appendix 3

Calculation of minimum investment

Details of consultants and clinical academics working in the trust were provided by the Workforce

Information Team and this list was used to determine the number of eligible consultants, which

equalled 503.

Ineligible consultants and academics, removed from that list, are those:

- employed as locums or on fixed term contracts

- who have been employed in a substantive NHS consultant post for less than 12 months

- who are in receipt of either a national award or local level 9 award

- who are employed on the pre 2003 consultant contract

Then in line with paragraph 5 of schedule 30, which refers to the “cost of the 0.3 per eligible FTE

ratio”, to determine the minimum investment for the round.

The following calculation was therefore used: Total FTE * 0.3 * £3016

RFH FTE 275 £248,820.00

BH FTE 172 £155,625.60

Total 447 £404,445.60

To ensure that successful doctors from Barnet hospital were not in receipt of less money than

successful doctors based the Royal Free, it was agreed at the LCEAC to combine two amounts into a

single pot of £404k and then divided between the successful applicants on both sites.

The amount of money allocated to each quartile would be applied using a 1 : 3 ratio. Therefore those

in the 1st quartile would receive 3 times as much as those in the 3rd quartile.

Local Clinical Excellence Awards Committee (LCEAC)

a. Constitution

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This committee (referred to as the “employer based awards committee” in the guidance) was

constituted in line with previous years and included consultant staff working at both RFH and BH

(nominated by the relevant consultant staff committee chairs), executive and lay representation and

a non-scoring chair.

Due to the relatively low number of applications (67) all panel members were asked to score all

application forms.

The panel for the 2017/2018 round are listed below.

Role Title Forename Surname

Non scoring Chair Dr Chris Streather

1 Exec Member Dr Steve Shaw

2 Exec Member Dr Robin Woolfson

3 Exec Member Dr Mike Greenberg

4 Consultant Dr Rahul Chodhari

5 Consultant Dr Dan Selo-Ojeme

6 Consultant Dr Judy King

7 Lay Representative Mr Peter Zinkin

8 Lay Representative Ms Frances Blunden

9 Consultant Dr Richard Orrell

10 Consultant Dr Bimbi Fernando

11 Consultant Dr Tabitha Mahungu

12 Lay Representative Mr Peter Atkin

b. Meeting on 28th February 2019

Chaired by Dr Chris Streather, the committee were presented with information from Gareth Jones

and the Medical Workforce Projects Team.

Discussion was held about:

- the eligibility criteria clearly outlined in the letter opening the round, those consultants who

failed to meet that criteria and actions required regarding those doctors

- the process used to determine the ranked lists for each site

- the amount and length of each award

- communication of results

- lessons learned and actions for future rounds

As above the value of awards given to successful applicants would be split in a 1: 3 ratio. Therefore

doctors finishing in the 1st quartile would receive 3 times as much as those finishing in the 3rd

quartile.

Although Schedule 30 does allow for awards to be given for up to 3 years, the committee agreed

that the awards in this round would be for a period of 12 months ie 1st April 2018 – 31st March 2019.

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The committee were in agreement as to the amount and duration of the awards.

c. Recommendations and comments for the next round

- on-going discussion about how best to assess demonstration of trust values

- giving doctors a longer period to complete MAST training prior to the round opening

- consideration of asking applicants to prove compliance with MAST, appraisal and job

planning criteria before application is accepted for scoring

- the round should be opened and run through the autumn rather than over the Christmas

period

Broadly the distribution of awards has been proportionate to the demographics of the consultant

workforce.

Analysis Reports

The NHS Employers and BMA guidance document requires reports relating to:

a. The number of consultants eligible for consideration and of these the number of:

- consultants in academic posts - female consultants - consultants from ethnic minorities - the age ranges of consultants - full-time / part-time status - information on other protected characteristics where available

b. The number of award holders and of these the number of:

- consultants in academic posts - female consultants - consultants from ethnic minorities - the age ranges of consultants - full-time / part-time status - information on other protected characteristics where available

This information is outlined in Appendix 4

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ROYAL FREE LONDON CLINICAL EXCELLENCE AWARDS SCHEME

APPLICATION FORM FOR 2017 – 2018

It is the applicant’s responsibility to ensure that this form is fully completed.

SECTION ONE: PERSONAL DETAILS

Surname:

Forename(s):

Professional Title:

Employing organisation: Choose an item.

Primary Site Choose an item.

Primary Specialty:

Department / service line:

Total number of programmed activities in job plan (including any additional PAs):

Any other employing organisation(s) (if any)

E-mail address for correspondence:

Mobile Telephone number:

SECTION TWO: QUALIFICATIONS

Year appointed to the consultant grade:

Date of primary medical qualification:

Date of any subsequent qualifications:

GMC number:

SECTION THREE: CURRENT CEA AWARDS Pre-2018 scheme

Year of most recent award:

Level (1-8) of most recent award: Choose an item.

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SECTION FOUR: ELIGIBILITY

Date of 2017/2018 appraisal:

Statutory and mandatory training complete Choose an item.

Note: in the interests of confidentiality, applicants do not need to declare disciplinary sanctions; however, staff records will be checked. Any applicant in receipt of a "live" disciplinary sanction during the period covered by the award round will be disqualified and his/her application will not be considered by the committee for an award. SECTION FIVE: JOB PLAN Please indicate the number of programmed activities set aside in your job plan for direct clinical care (DCC), supporting professional activities (SPA) and additional NHS responsibilities (ANR). Please also indicate any other remuneration you may receive, from the trust or elsewhere, and what this is for, along with any regular activities carried out for which you are not remunerated and which are "additional to contract" (ATC).

Type of activity Remuneration

DCC PAs

SPA PAs

ANR PAs

Additional remuneration (trust) : eg: Clinical Director

£

Type: eg: management allowance

Additional remuneration (other) £

For/from:

ATC (describe what these are):

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Please give a brief description of your "typical" working week for each post that you hold (e.g. as consultant, as manager/director etc) and any objectives associated with this work. This should include an outline of your various roles and responsibilities, such as clinical work, teaching/training commitments, management responsibilities etc. Please note that the box must contain no more than 1800 characters (inc.spaces)

Please indicate any other roles you have outside of the trust (e.g. college or editorial roles, trade union activity, consultancies, non-executive directorships, roles in spin-off companies between the trust/academia and the private sector etc) and any other remunerated activity. Please also indicate the amount of time spent on these activities.

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SECTION SIX: DOMAINS Please fill in the domain sections overleaf, highlighting those achievements which you consider to represent achievements over and above normal contractual expectations and how they align with trust goals. There is no need to include activity or achievements that might be considered to be the normal expectations of a member of consultant medical staff. Similarly, clinicians in management roles should not include activity that might reasonably be considered to be a normal part of a management role, but should instead include achievements that might be seen as being over and above what might normally be expected of a clinician in a management position. Applicants should note that the awards committee will be looking for evidence of actual achievement (outputs) rather than simple activity (inputs). Where an achievement is the result of activity across more than one year, applicants should indicate when and where the activity leading to the achievement took place. In particular, applicants are encouraged to include achievements linked to the work of clinical practice groups (CPGs) and to quality improvement (QI) initiatives. In each domain, where referring to a team activity or achievement, applicants should indicate the specific role you played in the activity/achievement (project leader, team member etc). For each domain box, please indicate in the spaces provided how many of the programmed activities (PAs) set aside in your job plan link to the work described in this domain box and whether you receive any other remuneration (e.g. management allowance or external remuneration) for this work. Please also indicate, in the spaces provided, which of the trust goals and objectives are supported by the activity described in this domain box and how you have demonstrated the trust values whilst contributing to the achievement of the goal. There are specific instructions for each domain; please make sure that you understand these and complete the domain box in accordance with these instructions. Please adhere to the limits on characters set out in each box; applications breaching these limits will not be submitted for consideration for an award. Applicants should if at all possible complete all five domains. While it is true that the lowest scoring domain will be discounted for ranking purposes, applicants will maximise chances of success by completing all five domains. Note that for one only of domains 3, 4 and 5, applicants may choose to complete the additional page included at section eight of this form in place of the relevant domain box; however, this is not obligatory and you may choose instead to simply complete the five boxes. Should you choose to use the additional page in section eight, please note in the relevant domain box "see section eight" and leave the remainder of the domain box blank; you must however still indicate in the lower sections of the box the programmed activities (PAs) set aside and/or remuneration received for this work. Applicants choosing to use section seven must still ensure that they show how the activity described links to the goals and how they have demonstrated the trust values during the activity.

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DOMAIN 1: DELIVERING A HIGH QUALITY SERVICE (Free text box limited to 1500 characters inc spaces) Please use this box to describe your achievements in the delivery of a high quality service and how they align with trust goals. Please make explicit reference to your own productivity data, patient/service user feedback, waiting time data, audit data etc, giving appropriate examples to support your application. This domain is most closely linked to the following trust goals/objectives: 1. All sites self-assessed as CQC outstanding 2. Zero never events 3. Zero avoidable infection 4. Patients would want to be treated at RFL (FFT>90%)

Remuneration for this activity: PAs

Allowance: £

Other: £

Goals supported by this activity (from the list above):

How trust values have been demonstrated during this activity:

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DOMAIN 2: DEVELOPING A HIGH QUALITY SERVICE (free text box limited to 1350 characters inc spaces) Please use this box to describe your achievements in the development of a high quality service and how they align with trust goals. Please make explicit reference to the outputs of quality improvement (QI) programmes or clinical practice group (CPG) work, productivity data for the service, patient/service user feedback and waiting time data for the service, audit data, staff survey results, GMC national training survey results, CQC data etc, giving appropriate examples to support your application. This domain is most closely linked to the following trust goals/objectives: 1. RTT 18 weeks target: 92% 2. Cancer access 62 days: 85% 3. Alternative appointments for cancelled operations (28 days) 4. ED access target: 95%


Allowance: £

Other: £



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DOMAIN 3: MANAGING AND LEADING A HIGH QUALITY SERVICE (free text box limited to 1350 characters inc spaces) Please use this box to describe your achievements in the management and/or leadership of a high quality service and how they align with trust goals. Please make explicit reference to your role as a manager and/or leader and to the outputs of quality improvement (QI) programmes or clinical practice group (CPG) work, productivity data for the service, patient/service user feedback and waiting time data for the service, audit data, staff survey results, GMC national training survey results, CQC data, HR metrics, budget statements etc, giving appropriate examples to support your application. This domain is most closely linked to the following trust goals/objectives: 1. CPG pathways embedded, monitored and digitised 2. QI embedded as our method of transformation 3. Promote equality and diversity 4. Develop partnerships with non-hospital providers 5. Match leader on staff and patient engagement


Allowance: £

Other: £



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DOMAIN 4: CONTRIBUTING TO THE NHS THROUGH RESEARCH AND INNOVATION (free text box limited to 1350 characters inc spaces) Please use this box to describe your achievements in research and innovation and how it aligns with trust goals. This is not limited to academic research but might include innovation in the field of clinical practice. Where this domain is being used to highlight research, indicate how many publications you have had, how many of these were in peer reviewed journals and list the 3 most important ones. No other text is allowed for an application based on research. Where this domain is being used to highlight clinical innovation, please make explicit reference to your role in any innovation work and to the outputs of quality improvement (QI) programmes or clinical practice group (CPG) work, productivity data for the service, patient/service user feedback and waiting time data for the service, audit data, CQC data, etc, giving appropriate examples to support your application. This domain is most closely linked to the following trust goals/objectives: 1. Top 3 for research citations 2. Top ten for clinical trials participation


Allowance: £

Other: £



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DOMAIN 5: CONTRIBUTING TO THE NHS THROUGH TEACHING AND TRAINING (free text box limited to 1350 characters inc spaces) Please use this box to describe your achievements in the areas of teaching and training and how they align with trust goals. Please make explicit reference to your role as a supervisor or educator and to the outputs of quality improvement (QI) programmes or clinical practice group (CPG) work in these areas. You should refer to and cite student and trainee feedback, staff survey results, GMC national training survey results, outputs from and responses to trainee exception reports, HR metrics etc, giving appropriate examples to support your application. This domain is most closely linked to the following trust goals/objectives: 1. Top 10% for education, training and workforce development 2. Promote equality and diversity 3. Match leader on staff and patient engagement


Allowance: £

Other: £



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SECTION SEVEN: ADDITIONAL FORM Applicants may complete this form in place of the domain box for either domain 3, domain 4 or domain 5. Alternately, you may use the boxes provided and leave this sheet blank.

This sheet is being used in place of domain number:

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SECTION EIGHT: VERIFICATION OF COMPLETION Applicants note that submission of this application form via the agreed trust electronic process will constitute an electronic signature to the above declaration.

I declare that to the best of my belief this information is accurate. I acknowledge that aspects of this form may be verified against other data held on me by the trust to ensure accuracy for the purposes of eligibility and that any discrepancies may lead to my application being ruled ineligible. Full Name Date: Applicants should now complete the equal opportunities monitoring form published alongside the application form and submit both forms via e-mail to:

[email protected] The equal opportunities monitoring form will be retained by the medical workforce team for monitoring and reporting purposes only and will not be circulated to the awards committee.

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mailto:[email protected]

PRIVATE AND CONFIDENTIAL 14

th December 2018

Dear Colleague,

Clinical Excellence Awards 2018

Local Awards for 2017/2018 – payable from 1

st April 2018

I am writing to you with information about applying for a local award under the new 2018 Clinical Excellence Awards scheme. These are awards which recognise contributions to excellence since your last award and up to 31

st March

2018. As you will know, earlier this year NHS England, following negotiation with the BMA, issued an additional schedule to the Terms and Conditions of Service for Consultants (2003), incorporating the new scheme into the terms of the contract. This scheme replaces previous schemes, which have been discontinued. A link to a full copy of that schedule is attached but the main changes are listed below.

Trusts will run annual LCEA rounds but new awards made from 1 April 2018 will be time-limited for

between one to three years.

New LCEAs will be non-pensionable, paid annually by lump sum and will not include uplifts for consultants

undertaking Additional Programmed Activities (APA).

Until 31 March 2021, there will be a minimum investment ratio for new LCEAs as per schedule 30 of the

2003 consultant contract.

Existing (pre-2018) LCEA shall remain pensionable and consolidated but will be subject to review from

2021.

In addition to the above, a local variation to the contract is being sought from the Local Negotiating Committee to allow clinical academics employed by the university but whose primary NHS service is for the trust to submit an application, should they chose to do so, in this round. As this is a new scheme, the form is significantly different from that used under the old scheme. The new form not only includes a request for supporting information regarding the five domains used in the old scheme, but also relating to how both your clinical and non-clinical activity aligns with our trust values and supports the meeting of trust goals. This year, we will be making separate allocations of awards to consultants working on each of the main sites (Royal Free Hospital or Barnet Hospital / Chase Farm Hospital). Applicants will therefore need to specify on their application the site at which they do the majority of their clinical activity

Applications that do not provide this information will not be scored. Applications can now be submitted.

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Completed applications must be submitted to by 23:59 on Sunday 13th January 2019 Applications received after that time / date will not be accepted.

Send to: [email protected]

Eligibility Details on eligibility and how to apply are outlined below. Please read carefully. To be eligible for a local award, an applicant must: - Have held a substantive NHS position as a consultant for a minimum of twelve months as of 31st March

2018.

- Have fulfilled all contractual obligations (including being up to date with statutory and mandatory training) by 23:59 on Sunday 13th January 2019.

- Have had a formal appraisal in the 12 months prior to 31st March 2018

- Have participated appropriately in the 2018 / 2019 job planning round, via the Allocate e-job planning software, prior to the round closure in October 2018.

- Have complied with the Private Practice Code of Conduct, 2017 -18

- Must be employed on the 2003 consultant contract or employed as a clinical academic by the university on equivalent terms and conditions.

- Not be subject to a ‘live’ disciplinary sanction for the period ending 31st March 2018 or with a sanction which either was or has since been applied with regard to a matter occurring during the period covered by the application. Consultants currently under investigation for a matter dating to this period which may end in a disciplinary sanction can still apply, but any award made would be withheld until the matter has been brought to a conclusion; in the event that a disciplinary sanction were to be applied, the award would be withheld. If no disciplinary sanction were applied, then the award would be paid.

Eligibility will be checked for all applicants.

Unless due extraordinary circumstances, applications from those not meeting the above criteria will be set

aside and excluded from consideration for an award.

How to apply If you wish to be considered for an award, you must apply by completing the application form and returning it by e-mail to [email protected] and to be received no later than 23:59 on Sunday 13th January 2019. The application form, which contains guidance on completing your form, the equal opportunities monitoring form and other relevant documents are available to download from the Medical Workforce and Recruitment page of the intranet at: http://freenetplus/sites/HROnline/Medical%20Workforce%20and%20Recruitment/Pages/default.aspx

Again late applications, or applications received via any other route, will not be accepted. It is each applicant’s responsibility to ensure that the information held on them is up to date and that applications are received.

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http://freenetplus/sites/HROnline/Medical%20Workforce%20and%20Recruitment/Pages/default.aspx

Personal compliance information with regard to your mandatory training appraisal can be checked on Freenet at the following location: http://freenet/freenetcms/default.aspx?&s=2&p=979&m=1259 Information on job planning is available via each consultant's individual log-in to the e-job plan system here. https://www.healthmedics.allocatehealthsuite.com/core If you are having difficulty accessing your e-job plan account then please email: [email protected] Support or guidance NHS Employers and the BMA have produced a guidance document which not only gives detailed information about the new scheme but also advice on how to complete the application. That can be located at: https://www.nhsemployers.org/case-studies-and-resources/2018/07/local-clinical-excellence-awards-guidance-2018-21

In consideration of the new application form, guidance on the content of your application has been included where needed into the application form itself. As in previous years, your divisional director will be able to provide advice about constructing your application. Note that there are limits on the maximum number of characters which can be used for each of the domains. The maximum number for each domain is specified on the form. Applicants should note that where a domain is left blank it will not be scored (except if that domains content is included in section 8). Applicants should avoid using abbreviations. Applicants should include dates for all achievements and are advised that entries which are undated will be disregarded by the scoring panel. Where an achievement or activity is on-going from a previous award, it should be made clear exactly what has been achieved since the receipt of the last award. Decision making – meeting of the Local Awards Committee The local awards committee will meet to consider local awards in February 2019 with a view to notification and payments being made in March 2019. Awards will be paid as a lump sum cash value and the mechanism for calculating the total amount to be awarded is set out in paragraph 5 of Schedule 30. Any queries about Clinical Excellence Awards may be referred to [email protected]. Yours sincerely Dr Chris Streather Group Medical Director Enclosed are:

1. Link to Schedule 30 of 2003 consultant contract https://www.nhsemployers.org/case-studies-and-resources/2018/03/schedule-30-clinical-excellence-awards

2. Scoring Guidelines (below)

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http://freenet/freenetcms/default.aspx?&s=2&p=979&m=1259

https://www.healthmedics.allocatehealthsuite.com/core


https://www.nhsemployers.org/case-studies-and-resources/2018/07/local-clinical-excellence-awards-guidance-2018-21

https://www.nhsemployers.org/case-studies-and-resources/2018/03/schedule-30-clinical-excellence-awards

Local Clinical Excellence Awards (CEA)

Briefing Notes for Scoring Members of the Committee The committee The committee will be chaired by Dr Chris Streather (non-scoring) and will comprise 4 management representatives, 3 lay (patient) representatives (2 apiece from Barnet / Chase Farm and the Royal Free) and 8 consultants (4 apiece from Barnet / Chase Farm and the Royal Free Hospital). The consultant members will be nominated by the chairs of the consultant staff committees in such a way as to reflect the gender and ethnic balance of the consultant body as a whole. Workshops will be offered to scoring members of the committee to review and discuss the new scoring process in mid-January 2019. Application process Applicants are invited to submit supporting text and relevant information via the application form, including dates and statistics, for consideration by scoring members of the panel. Each application will therefore be assessed against the five domains and the submissions relating to trust values and goals. Also for the first time applicants will be asked to describe their typical working week and any other external roles they may undertake. Trust Values Applicants are being asked to provide examples of how they are “living, embodying and demonstrating” the trust values below in their interactions with “patients / service users” and other “staff, managers and colleagues”. 1. Positively welcoming 2. Actively respectful 3. Clearly communicating 4. Visibly reassuring Domains and trust goals With support from the trust executive, specific trust goals have been linked with the 5 domains listed below. Applicants are not only being asked to “describe their achievements” in relation to each domain but also which trust goals those achievements have supported. Also for the first time, applicants are being asked to detail the PAs in their job plan which relate to each domain. 1. Delivering a high quality service

2. Developing a high quality service

3. Leadership and managing a high quality service

4. Research and innovation

5. Teaching and training Scoring Process All members of the local awards committee, except the chair, will be invited to score. For the first time, the round is not about the awarding of points but of one off lump sum cash bonuses, of which the total amount available, has been determined by the mechanism outlined in paragraph 5 of schedule 30. It is different from the previous rounds.

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Scoring members need to be mindful of the new application form and consider: 1. When scoring domains, how effectively has the applicant linked his or her supporting text to the

associated trust goals. 2. How clearly and effectively the applicant has demonstrated his or her “embodiment and demonstration”

of living trust values. 3. What facts, statistics and other measureable and clear data the applicant has provided in addition to any

supporting narrative. The scoring system to be used will remain the same as in previous years. 0 = No Contribution / No information provided

2 = Performing at contractual level

6 = Performing over contractual level within certain aspects (1 or 2 stand out areas)

10 = Outstanding delivery of service Further Tips and Advice You may find it easier to have a quick look through all the applications, before going back through and scoring the applications. Should applicants give the same examples for more than one domain (e.g. domain 1 ‘delivering a high quality service’ and domain 2 ‘developing a high quality service), the examples can only score highly once. All consultants should complete some teaching (e.g. bedside teaching and undergraduate teaching), but there may be some who complete more than this by leading modules, acting as educational supervisors, complete work with the deanery or the medical school, or write textbooks/chapters. All NHS work should be taken into account (not just the work completed at the Royal Free or Barnet and Chase Farm); this may include work that was completed overseas if it is shown to have a direct positive impact for the NHS. Applications from managers and others whose roles are already remunerated (medical director, divisional director, clinical director, director of medical education, guardian of safe working hours etc.) should not be scored for holding these roles alone, but should be scored based on what they have done in these positions. LAC members will therefore score such applications on the basis of evidence of exceeding normal expectations in discharging those responsibilities and not for simply holding the position. Scoring period All applicants should be scored on the work they have completed since their last award; please score using the dates on the score-sheet. Information on an application pertaining to activity carried out prior to the last award should not be considered in scoring the application. Awards should be made solely for activity carried out between the date of the last award and 31st March 2018. Job plans All doctors will be on the new contract with job plan in programmed activities (PAs), which are blocks of 4 hours (or 3 hours out-of-hours). 10 PAs is considered full-time. Any PAs over 10 PAs are ‘Additional Programmed Activities’.

When scoring applications, consideration should be given as to what a consultant is already paid for. For example: Clinical academics will usually have more time in their job plans for academic activity, and this should be considered when deciding whether an application is at or above the contractual level. Part-time consultants

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The forms will state how many PAs/Sessions a Consultant completes and when scoring committee members should take into account whether the doctor is full-time (10 PAs) or part-time. Ranking process The scores from the committee members will be used to create a rank, which in turn will be used to create a rank on ranking, which helps to mitigate against ‘doves’ and ‘hawks’. After scores have been received, two ranked lists will be compiled – one for consultants whose work is carried out predominantly at Barnet or Chase Farm hospitals and one for consultants whose work is carried out predominantly at the Royal Free hospital. Allocation of awards The committee is likely to make a larger award to the most highly ranked applicants, and a lower award to those less highly ranked, up to the total value of awards available Conflicts of interest It is anticipated that consultant staff on the committee will not have submitted an application in the current round. However, if in the unlikely case it is not possible to identify sufficient non-applicant consultants then the process will be as follows.

- Consultants on the committee who have also submitted an application may mark within their own specialities, but may not mark their own application.

Where there would be a real or perceived conflict of interest (e.g. an application from a family member), committee members should not score the application/s. Consultant members applying for an award will be asked to step out of the scoring meeting when their award is considered by the committee.

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Time Line - 2017 / 2018 Local CEA round

Timeline

Open the round with Chris’s Letter - Friday 14th December 2018

Final deadline for applications - 23.59pm Sunday 13th January 2018

Applications to scoring panel members - by Friday 18th January 2018

Final deadline for returned score sheets - 23.59pm Sunday 17th February 2018

Score Sheets collated / circulated - by Friday 22nd February 2018

Panel Meets - Week Commencing Monday 25th February 2018

Payroll instruction - by mid-March 2019 retro deadline

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Royal Free London NHS Foundation Trust

Medical Workforce Projects Teams

2017 / 2018 Local Clinical Excellence Awards - Annual Report for Trust Board

Source : ESR and local CEA process

Ethnicity

RFH % of RFH total BH % of BH

totalTotal %

BME 113 35.76% 93 49.73% 206 40.95%

Not BME 174 55.06% 90 48.13% 264 52.49%

Data not provided 29 9.18% 4 2.14% 33 6.56%

Totals 316 100.00% 187 100.00% 503 100.00%


totalTotal %

BME 24 66.67% 10 32.26% 34 50.75%

Not BME 11 30.56% 17 54.84% 28 41.79%


Totals 36 100.00% 31 100.00% 67 100.00%


totalTotal %

BME 18 69.23% 13 59.09% 31 64.58%

Not BME 8 30.77% 8 36.36% 16 33.33%


Totals 26 100.00% 22 100.00% 48 100.00%


totalTotal %

BME £155,841 69.81% £75,815 41.86% £231,657 57%

Not BME £67,391 30.19% £105,298 58.14% £172,688 43%

Data not provided N/A N/A N/A N/A N/A

Totals £223,232 100.00% £181,113 100.00% £404,345 100.00%

Total consultants

Total applicants

Successful applicants

Cash payout

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Gender

RFH% of RFH

totalBH % of BH total Total %

Total consultants 316 187 503

Male 113 93 206

Female 174 90 264

Data not provided 29 4 33

Female as %

RFH% of RFH


Male 17 47.22% 22 70.97% 39 58.91%

Female 19 52.78% 9 29.03% 29 42.58%


Totals 36 100.00% 31 100.00% 67 101.49%

RFH% of RFH


Male 9 34.62% 17 77.27% 26 54.89%

Female 17 65.38% 5 22.73% 23 47.20%


Totals 26 100.00% 22 100.00% 48 102.08%

RFH% of RFH


Male £75,815 33.96% £147,418 81.40% £223,233 55.21%

Female £147,417 66.04% £33,695 18.60% £181,113 44.79%

Data not provided N/A N/A N/A N/A N/A N/A

Totals £223,232 100.00% £181,113 100.00% £404,346 100.00%

Total consultants

Total applicants

Successful applicants

Cash payout

Paper 6





Academic Status

RFH% of RFH

totalBH

% of BH

totalTotal %

Non academic 270 85.44% 187 100.00% 457 90.85%

Academic 46 14.56% 0 0.00% 46 9.15%

Totals 316 100% 187 100% 503 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Non academic 34 94.44% 31 100.00% 65 97.01%

Academic 2 5.56% 0 0.00% 2 2.99%

Totals 36 100% 31 100% 67 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Non academic 23 88.46% 0 0.00% 23 88.46%

Academic 3 11.54% 0 0.00% 3 11.54%

Totals 26 100% 0 0% 26 100.00%

Total consultants

Total applicants

Total successful applicants

Paper 6





Full or Part Time Status

RFH% of RFH

totalBH

% of BH

totalTotal %

Full Time 203 64.24% 142 75.94% 345 68.59%

Part Time 105 33.23% 43 22.99% 148 29.42%

Unknown 8 2.53% 2 1.07% 10 1.99%

Totals 316 100% 187 100% 503 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Full Time 29 80.56% 26 83.87% 55 82.09%

Part Time 7 19.44% 5 16.13% 12 17.91%

Unknown 0 0.00% 0 0.00% 0 0.00%

Totals 36 100% 31 100% 67 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Full Time 19 73.08% 18 81.82% 37 77.08%

Part Time 7 26.92% 4 18.18% 11 22.92%

Unknown 0 0.00% 0 0.00% 0 0.00%

Totals 26 100% 22 100% 48 100.00%

Total consultants

Total applicants


Paper 6





Sexuality

RFH% of RFH

totalBH

% of BH

totalTotal %

Heterosexual 148 46.84% 98 52.41% 246 48.91%

Gay 1 0.32% 1 0.53% 2 0.40%

Undisclosed 83 26.27% 25 13.37% 108 21.47%

Undefined 84 26.58% 63 33.69% 147 29.22%

Totals 316 100% 187 100% 503 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Heterosexual 22 61.11% 15 48.39% 37 55.22%

Gay 1 2.78% 1 3.23% 2 2.99%

Undisclosed 9 25.00% 6 19.35% 15 22.39%

Undefined 4 11.11% 9 29.03% 13 19.40%

Totals 36 100% 31 100% 67 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Heterosexual 17 65.38% 12 54.55% 29 60.42%

Gay 0 0.00% 1 4.55% 1 2.08%

Undisclosed 6 23.08% 3 13.64% 9 18.75%

Undefined 3 11.54% 6 27.27% 9 18.75%

Totals 26 100% 22 100% 48 100.00%

Total consultants

Total applicants


Paper 6





Age

RFH% of RFH

totalBH

% of BH

totalTotal %

Under 35 1 0.32% 0 0 1 0.20%

35 - 44 126 39.87% 51 27.27% 177 35.19%

45 - 54 137 43.35% 94 50.27% 231 45.92%

55 - 64 36 11.39% 36 19.25% 72 14.31%

65 plus 8 2.53% 4 2.14% 12 2.39%

Unknown 8 2.53% 2 1.07% 10 1.99%

316 100% 187 100% 503 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Under 35 0 0.00% 0 0 0 0.00%

35 - 44 18 50.00% 12 38.71% 30 44.78%

45 - 54 15 41.67% 17 54.84% 32 47.76%

55 - 64 2 5.56% 1 3.23% 3 4.48%

65 plus 0 0.00% 0 0.00% 0 0.00%

Unknown 1 2.78% 1 3.23% 2 2.99%

36 100% 31 100% 67 100.00%

RFH% of RFH

totalBH

% of BH

totalTotal %

Under 35 0 0.00% 0 0 0 0.00%

35 - 44 14 53.85% 9 40.91% 23 47.92%

45 - 54 10 38.46% 12 54.55% 22 45.83%

55 - 64 2 7.69% 0 0.00% 2 4.17%

65 plus 0 0.00% 0 0.00% 0 0.00%

Unknown 0 0.00% 1 4.55% 1 2.08%

26 100% 22 100% 48 100.00%

Total consultants

Total Applicants

Total Successful Applicants

Paper 6

of 2

Appraisal and revalidation of medical practitioners

Executive summary

This constitutes a formal report for the board of the Royal Free London NHS Foundation

Trust, in accordance with the Framework of Quality Assurance for Responsible Officers and

Revalidation, published by NHS England in June 2014.

At the latest annual return for 2017/18 there were 1062 doctors with a prescribed connection

to the trust.

875 doctors completed an appraisal within the financial year (appraisal rate 82%). Of the

187 doctors who did not complete appraisal, 163 had a valid reason not to do so.

A new revalidation support manager took up post in March 2018 and a permanent team

member returned from secondment. The team continued to be supported by one temporary

staff member. The team moved to the management of the medical workforce department in

April 18.

With the establishment of group clinical services, a senior appraiser for GCS has been

assigned.

The trust will move to Allocate as the appraisal platform in October 2019.

The trust has arranged training and peer support for appraisers and will move to a

programme of quality assurance and improvement.

Action required/recommendation

The board is asked to accept the report, which will be shared with the higher level responsible officer. The Board is asked to approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is in compliance with the regulations

Trust strategic priorities and business planning objectives

supported by this paper

Board assurance risk

number(s

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

outcomes

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

peers on patient, GP and staff experience

x



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of 2

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

relevant peers on financial performance

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

external obligations effectively and efficiently

x

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

organisation for the future

x

CQC Regulations supported by this paper

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

Regulation 5 ⃰ Fit and proper persons: directors x

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

Regulation 7 Requirements relating to registered managers

Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 15 Premises and equipment

Regulation 16 Receiving and acting on complaints

Regulation 17 Good governance x

Regulation 18 Staffing

Regulation 19 Fit and proper persons employed x

Regulation 20⃰ Duty of candour

Regulation 20A⃰ Requirement as to display of performance assessments

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

Regulation 12 Statement of purpose

Regulation 13 Financial position

Regulation 14 Notice of absence

Regulation 15 Notice of changes

Regulation 16 Notification of death of a service user

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

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

Regulation 18 Notification of other incidents

Regulation 19 Fees

Regulation 20⃰ Requirements relating to termination of pregnancies

Regulation 22A⃰ Form of notifications to the Commission

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

Compliance with GMC guidance is a statutory requirement

Equality analysis

• No identified negative impact on equality and diversity

Report from

Author(s) Dr C Streather, Dr J M Hawdon

Date September 2019

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1

Annual Board Report, 2018/19

Revalidation and Appraisal

Template as recommended by NHS England

1. Executive summary

This constitutes a formal report for the board of the Royal Free London NHS Foundation Trust, in accordance with the Framework of Quality Assurance for Responsible Officers and Revalidation, published by NHS England in June 2014.

At the latest annual return for 2018/19 there were 1064 doctors with a prescribed connection to the Trust.

875 doctors completed an appraisal within the financial year, giving an appraisal rate of 82% representing a further annual increase. Of the 187 doctors who did not complete appraisal, 163 had a valid reason not to do so.

GMC connected Appraised Not appraised Not appraised doctors valid reason not valid reason

15/16 1001 716 (71%) 13 (1%) 282 (28%) 16/17 1032 760 (74%) 127 (12%) 145 (14%) 17/18 1111 853 (77%) 85 (8%) 173 (15%) 18/19 1062 875 (82%) 163 (15%) 24 (2%) Comparator 531 90% 6.7% 2%

A new revalidation support manager took up post in March 2018 and a permanent team member returned from secondment. The team continued to be supported by one temporary staff member. The team moved to the management of the medical workforce department in April 18. The checking of data against workforce records, welcoming of new doctors, sending appraisal reminders, support of appraisers and returns to NHSE continued.

With the formation of group clinical services, Florence Deroide kindly agreed to become senior appraiser for the doctors in these services in addition to her role as senior appraiser for transplant and specialist services.

The trust has arranged training and peer support for appraisers and will move to a programme of quality assurance and improvement.

2. Purpose of the paper

The purpose of this paper is to report on the situation with regard to appraisal, revalidation and managing concerns about the conduct or performance of doctors.

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3. Background

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider boards will oversee compliance by:

• monitoring the frequency and quality of medical appraisals in their organisations;

• checking there are effective systems in place for monitoring the conduct and performance of their doctors;

• confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

• Ensuring that appropriate pre-employment background checks (including pre-engagement for locums and academic staff) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

4. Governance Arrangements

a) Personnel

The role of Responsible Officer was delegated, with approval by the Board, from the personal portfolio of the Medical Director (now Chief Medical Officer). The new Responsible Officer took up post on 1.1.17 and reports to the Chief Medical Officer.

A new Revalidation Support Manager took up post in March 2018 and a permanent team member returned from secondment. The team continued to be supported by 1 temporary staff member. The team moved to the management of the medical workforce department in April 18. The checking of data against workforce records, welcoming of new doctors, sending appraisal reminders, support of appraisers and returns to NHSE continued.

With the formation of Group Clinical Services, Florence Deroide kindly agreed to become senior appraiser for the doctors in these services in addition to her role as senior appraiser for Transplant and Specialist Services.

1064 doctors were connected to the Trust on 31/03/2019. This is all the medical staff except for those in HEE training programmes.

1The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The

General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’

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Doctors for whom the team is responsible: Consultants Non consultant career grades Trust funded junior doctor posts Bank doctors if the majority of clinical work is at RFL Doctors with honorary contracts if the majority of clinical work is at RFL Others e.g. Military

Although GDC does not have a revalidation function, practitioners in the Trust with dental qualification only are offered annual appraisal through the same internal processes as doctors.

A running work book is kept of joining and leaving staff, scheduled appraisal date and actual appraisal date. Information is obtained from various sources by the revalidation team, with the requirement to access a number of systems. Staffing level within the team has limited the ability to data check and validate.

The revalidation support team works closely with workforce to ensure that they are aware of new starters and leavers and that the list of doctors connected to the Trust for revalidation is up to date.

b) Data checking and review of procedures.

Data checking:

The Revalidation Team, with support of Human Resources, Medical Recruitment, and divisional teams, undertakes regular reviews of the doctors listed as having GMC connection and removes the connection if not valid.

Bank doctors:

There is close working between the Revalidation Team and the RFL Bank compliance officer. The following information is shared with all Bank doctors:

Dear colleagueDoctors working on RFL Bank who carry out all or the majority of their clinical work at RFL have a GMC connection to RFL NHS Foundation Trust as their designated body. This means that RFL is responsible for their appraisal, revalidation, and professional issues. Doctors should be aware that for revalidation they must undergo annual ARCP or appraisal. Doctors requiring appraisal at RFL should contact the RFL revalidation team ([email protected]) to register with the system and be assigned an appraiser. If a doctor does not contact the team we will assume they have connected to RFL in error and we will decline the request for connection.

The RFL Bank sends to the revalidation team regular lists of leavers (including those who have not worked at RFL for 6 months) and joiners. The Revalidation Team informs Bank of any Bank doctors whose appraisal is overdue in order for Bank to consider suspending bookings until compliant.

The RFL Bank compliance officer is a member of the Revalidation Advisory Group.

New starters:

New starters are informed that their first RFL appraisal is at around 1 year after the last appraisal or ARCP date.

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RFL has been advised by NHSE that it is not necessary to offer appraisal to doctors with appointments of 6 months or less. However, for doctors who move frequently this places them at risk of not undergoing annual appraisal to inform revalidation. These doctors are asked to supply the date of their last appraisal or ARCP. If the next appraisal falls due in the period of their employment with FRL, they will be entered on appraisal database and offered appraisal. If doctors do not respond to the query regarding last appraisal or ARCP date, it will be assumed that they do not have an appraisal due and they will not be entered into the database or denominator (doctors due appraisal) of NHSE returns.

Scheduled appraisals:

Doctors who serially delay appraisal are at risk of having less than annual appraisal over the 5 year revalidation cycle. The on line revalidation management system automatically sets a due date of 1 year from appraisal rate. Therefore, manual correction of next appraisal date to anniversary of due date is required.

c) Internal and external review.

The Trust has a Revalidation Advisory Group (RAG) which meets as often as necessary to consider the appraisal records and other information about doctors whose revalidation is due. RAG provides advice to the RO who then makes revalidation recommendations to the GMC.

The RAG also monitors appraisal rates and ensures that appropriate support or other action is taken when doctors are under restrictions or sanctions from the GMC.

Membership and terms of reference were reviewed in 18/19. 2 patient and lay governors have joined the group.

There has been no formal external review of revalidation arrangements in 18/19.

There is an annual organisational audit report to NHS England and an annual Board report which is also submitted to NHS England (this document) along with the Statement of Compliance.

a. Policy and guidance

The policies for Medical Appraisal, Revalidation, and Handling Concerns Regarding Doctors and Dentists, and guidance for remediation were last updated in 17/18 in line with current group organisational structure and were agreed by local negotiating committee and group executive committee.

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5. Medical Appraisal

a. Appraisal and revalidation performance data

Appendix 1 shows data presented to NHS England in the Annual Organisational Audit, compared to other providers

The rate of missed appraisals is high compared to other secondary care providers but has improved over the last 3 years, in part representing the size and complexity of the organisation. This is likely also to reflect the practice at RFL of offering short term contract doctors the opportunity to have appraisal. Other Truts may remove these doctors from the denominator.

Doctors who are not permanent staff are over-represented in those who have missed appraisal. Strategies and procedures to address this are being developed by the clinical appraisal leads and revalidation team.

b. Appraisers The Trust has 135 appraisers, including 3 trained non-medical appraisers. All have been invited to appraiser fora, appraisal refresher training, and training in managing concerns about doctors.

There are 6 divisional senior appraiser posts, each attracting 0.5 supporting programmed activity. To align with Trust Group structure, there are 2 site based clinical appraisal leads (1.5PAs each).

c. Quality assurance

Outline of quality assurance processes: • All appraisal outputs are examined by the RO at the time of revalidation • The clinical appraisal leads will commence a rolling programme of quality assurance

with appraiser peer review •For the individual appraiser • Doctors provide appraiser feedback via the appraisal portfolio, this can be collated and

provided back to the appraiser by the revalidation office For the organisation

• The appraisal portfolios provide information which can be used to identify themes for organisational learning from operational difficulties, complaints and significant events

d. Access, security and confidentiality

Appraisal portfolios are secured within an IT system which is GDPR compliant. The information is confidential to the doctor, their appraiser, the Responsible Officer and the RO’s support team. Only anonymised information is used in organisational audit.

Doctors have been informed that the Revalidation Team will not communicate with them via any email address other than nhs.net.

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e. Clinical Governance

Up to 2017/18, the Trust provided information from Datix about complaints, incidents and litigation to doctors for their portfolios. Upon review in 18/19 it was agreed that this would no longer be provided for the following reasons:

• The download often includes a large number of incident reports that do not generate useful learning

• The download may be inaccurate, eg a complaint is about an un-named doctor but allocated to the CD of the service

• Very few reports include the name of a doctor so by simply getting a download and assuming it is complete, a doctor overlooks incidents that would be important

• Doctors who are integral to significant incidents or complaints should be made aware and be consulted with at the time of the investigation, this is a service governance responsibility, being made aware up to a year later is not helpful

• The doctor may have moved on between incident and appraisal • Incidents that a doctor has observed and could learn from, but is not named in, are

missed • Good outstanding events are missed • It is the professional duty of a doctor to observe what is going on and to learn from this

Portfolio guidance was changed to: Incidents/PALS/ complaints you have had some input into. You may have been present when the problem occurred or may have been involved in investigating or managing the issue. Reflect on whole department learning as well as personal learning, if you are uncomfortable about this, then it can be discussed at the meeting and the appraiser will summarise appropriately. If you have been named in a SUI or complaint and there is no reflection or mention of it at appraisal, this would be considered unusual. Include any incidents within private practice or other places of work, as your appraisal is whole scope or practice, and these SUI reports may be shared with the RO. Equally, upload details of and reflections on outstanding events that have gone well.

Some doctors have access to and upload specialty specific national audit data.

Doctors are encouraged to upload details of quality improvement projects that they have participated in.

6. Revalidation recommendations

Number of recommendations between 1/4/18 and 31/3/19: 277 (17/18 69)All were made on time

Positive recommendations: 227 Deferral requests: 48 Non engagement notifications: 2 (1 subsequently left RFL, 1 subsequently engaged)

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7. Recruitment and engagement background checks

The Trust, including the Trust Bank, has robust pre-employment checks and only uses ‘Framework’ Locum Agencies.

NHS England has recommended that even with Framework agencies, there should be a final identity (usually passport) check when a locum arrives for work, even out of hours.

Academic staff receive honorary contracts after a standard checking process fit for the purpose of their clinical activities. There has been review of issue of honorary contracts and there are current discussions with UCL regarding robust application of Follett principles.

8. Medical practitioner information transfer (MPIT) forms

New employers and private providers frequently request completion of MPIT forms. For the latter category, to reflect that this relates to external private practice and the time required for the RFL team to make the necessary checks, a fee of £120 is charged to the consultant. This decision was endorsed by the Trust education and workforce development committee.

9. Responding to concerns and remediation

The trust has a policy for handling concerns about the Performance and conduct of doctors and dentists, which follows national guidance, “Maintaining high professional standards” (MHPS) and “Protecting patients, supporting professionalism, improving quality: addressing concerns about medical practice”.

Moderate concerns are dealt with within directorates and serious concerns are escalated to the Site Medical Director, RO or group chief medical officer for discussion with other appropriate senior personnel regarding management.

The responsible officer has delivered training on managing concerns to divisions and to clinical directors attending a development programme.

In 2018-2019 there were 22 cases of serious concerns which were being dealt with formally

under MHPS. The breakdown of these is as follows:

Opened before 1/4/18 13

Opened during 2018/19 9

Closed during 2018/19 15

Ongoing at 31/03/2019 7

Main nature of concern/s (but overlap of nature in some cases)

Capability 2 Health 1 Conduct 19

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All cases are discussed regularly and confidentially with PPA (previously NCAS), GMC local advisers and the chair, who has kindly taken non-executive oversight. The management of cases has also been supported as necessary by occupational health and/or external support agencies.

10. Risk and issues

The trust’s appraisal rate was below target and below that of peers, but is improving. The trust’s quality assurance for the content of appraisals required improvement. Appraisers reported some difficulties having their appraisal role recognised within their job plans. For all of 18/19 the revalidation support team was not permanently staffed to its establishment. In 19/20 RFL is transferring to a new appraisal platform, Allocate, which is the same platform as used for job planning and eroster

11. Corrective actions, improvement plan and next steps

1. An implementation plan has been made for the transfer to Allocate and optimisation of its functionality.

2. The revalidation team has implemented a formal process for reminders about forthcoming appraisals and an escalation process for missed appraisals.

3. The trust continues to recruit and train appraisers, including trained non-medical appraisers.

4. The responsible officer and appraisal leads ensure that there are regular update sessions for appraisers, with mandatory attendance for appraisers of 2/year.

5. The RO and appraisal leads will set up a process for peer review of appraisal outputs to improve appraisal quality.

6. The RO and appraisal leads will work with hospital medical directors, divisional directors and clinical directors to ensure that the appraisal role is included and recognised within the SPA allocation of the department and the doctor. 0.25 SPA/10 appraisees should be allocated to appraisers for their role. Oversight of appraisal rates within directorates and divisions is included in the job plans of new hospital medical directors, divisional directors and clinical directors.

7. The trust will ensure that identity checks are carried out for all locums, even those from framework agencies, and will ensure UCL carries out appropriate checks as per Follett principles.

8. The trust has developed remediation guidance and has reviewed and updated existing policies and guidance.

9. Recommendations

The Board is asked to accept the report, which will be shared with the higher level responsible officer.

The Board is asked to approve the ‘statement of compliance’ confirming that the organisation, as a designated body, is in compliance with the regulations

Dr Chris Streather, Group CMO

Dr Jane Hawdon, RO

September 2019

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OFFICIAL

A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex E - Statement of Compliance

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OFFICIAL

2

Statement of Compliance

Version number: 2.0

First published: 4 April 2014

Updated: 22 June 2015

Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England

Classification: OFFICIAL

Publications Gateway Reference: 03432

NB: The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

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OFFICIAL

3

Designated Body Statement of Compliance

The board of Royal Free London NHS Foundation Trust can confirm that • an AOA has been submitted, • the organisation is compliant with The Medical Profession (Responsible

Officers) Regulations 2010 (as amended in 2013) • and can confirm that:

1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer;

Yes

2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;

Yes

3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;

Yes

4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers1 or equivalent);

Yes

5. All licensed medical practitioners2 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken;

Yes

6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal;

Yes

7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;

Yes

1http://www.england.nhs.uk/revalidation/ro/app-syst/

2 Doctors with a prescribed connection to the designated body on the date of reporting.

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OFFICIAL

4

8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;3

Yes

9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners4 have qualifications and experience appropriate to the work performed;

Yes

10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.

Yes

Signed on behalf of the designated body Chairman

Official name of designated body: Royal Free Hospital NHS Foundation Trust

Name: _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _

Role: _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _

3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents

Paper 7

North London Partners in Health and Care North Central London sustainability and transformation programme (STP) quarterly update

Executive summary

The North Central London (NCL) sustainability and transformation programme (STP) is now known as North London Partners in Health and Care. This is a partnership of health and care organisations from the five London boroughs of Barnet, Camden, Enfield, Haringey and Islington.

It includes:

• Barnet, Camden, Enfield, Haringey and Islington CCGs • Barnet, Camden, Enfield, Haringey and Islington Councils • Barnet, Enfield and Haringey Mental Health NHS Trust • Camden and Islington NHS Foundation Trust • Central and North West London NHS Foundation Trust • Central London Community Healthcare NHS Trust • Moorfields Eye Hospital NHS Foundation Trust • North Middlesex University Hospital • Royal Free London NHS Foundation Trust • Royal National Orthopaedic Hospital NHS Trust • The Tavistock and Portman NHS Foundation Trust • University College London Hospitals NHS Foundation Trust • Whittington Health NHS Trust

The STP sets out how local health and care services will transform and become sustainable over the next five years, building and strengthening local relationships and ultimately delivering the Five Year Forward View vision.

A quarterly update is attached which includes examples of progress made so far.

Action required

The board is asked to note the report


Meeting Date Decision n/a n/a n/a



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GOALS BAF risks

Demonstrable organisation health (group governance) G042/044


Financial/business implications N/a


Compliance impact N/a

Report from Peter Ridley, chief finance and compliance officer Author Alison Macdonald, board secretary Date 13 September 2019

Paper 8

North London Partners in Health and CareNorth Central London STPQuarterly update report19 August 2019

Paper 8

• Medium Term Financial Strategy (MTFS) Mark Hackett has started in post as the lead director for the Medium Term Strategy, replacing Peter Herring. Mark will be working with Commissioners, Providers and the existing STP workstreams on recovery plan to address the underlying financial position and support the NCL Long Term plan. Updates will be shared with STP CEOs and Director of Finance and will be presented to regulators later in the year.

• Clinical delivery model and options appraisal process for Orthopaedic Services Review agreed The Joint Commissioning Committee of the five north central London (NCL) CCGs discussed and agreed the clinical delivery model and options appraisal process for NCL’s Adult Elective Orthopaedic Services Review in May. Following this NHS providers of adult elective orthopaedic care were asked to set out how they can meet the new delivery model. Proposals were reviewed through an options appraisal process over the summer involving patient and resident representatives. The aim is to go to public consultation in the autumn

• Clinical Advice and Guidance referrals up by 63% There were 1,381 referrals to the Clinical Advice and Guidance (CAG) service in March 2019 compared to 512 in March 2018 - an increase of 63%. Each of the four main acute trusts exceeded their target of responding to 80% of CAG requests within 2 working days.

• Asthma conference launches whole-system plan to improve outcomes for children Nearly 80 people from across north central London came together on World Asthma Day, 7 May, to discuss how to improve outcomes for children and families that live with asthma. Topics delegates spoke on included: Integration across health and social care and what this means for children and young people; the role of the atopy nurse and the benefit of utilising expertise in primary care; asthma-friendly schools and; the use of phone conferences in conducting 48 hour reviews

• £600,000 award to fund service to help people with severe mental illness find work North Central London STP has been successful in gaining £600,000 to fund the Individual Placement and Support service to help people with severe mental illness get support to return to work. Five IPS workers from the boroughs of Barnet, Camden, Enfield, Haringey and Islington will provide support to help 300 people with severe mental illness find employment.

• Barnet and Enfield to roll out First Contact Practitioner model A six-month First Contact Practitioner (FCP) pilot aimed at managing patients has been successful and is being considered for roll out across Barnet and Enfield. Haringey is also considering a pilot. FCP is a new model of primary care that involves placing specialists in GP practices to see patients instead of following a traditional model where patients are seen by a GP first. During the pilot FCPs carried out 869 appointments with patients, of these, 68% were seen by the FCP once and then discharged with advice on how to self-manage their condition.

• Next Quarter This report will include who from each Trust is involved at any level in each of the workstreams

Headlines from across the programme

1.

Paper 8

Pharmacist-led telephone triage system reduces face-to-face contacts

Some examples of enabling transformation

2.

New bank staff framework predicted to save £9m in two years

Using agency staff costs the NHS £480m in 2018, according to NHS Improvement. UCLH and other partners in North London wanted to address this, not only to save money but also ensure safer levels of staffing, to deliver outstanding patient care and to make it more attractive for staff across all professions and grades to work flexibly.

North London Partners in Health and Care worked with UCHL to create a temporary staffing framework to increase collaboration, maximise the use of banks and reduce agency spend and, ultimately, move towards a fully shared bank for the sustainability and transformation programme.

Since the successful launch of the framework in June 2018, savings of £3.7m were achieved in 18/19 and there are predicted a further saving of £5.4m in 19/20.

Barnet practice is the first to launch joined-up records

The first GP practice in north central London has gone live with a new electronic joined-up health and care record for patients. Health and care professionals in Penshurst Gardens surgery in Barnet and the Royal Free, Barnet and Chase Farm hospitals now have access to the joined-up record which shares patient information across organisations. This will be rolled out across health and care organisations across North Central London.

A pharmacist-led telephone triage system piloted by St John’s Way Medical Centre, in Islington, has reduced face-to-face contacts for urgent on the day appointments by over 50% in the first three months. Patients now are either managed entirely on the phone without the need for a face-to-face GP appointment, or are signposted to an alternative service such as a community based health provider.

Initial feedback from patients and staff has been positive It is planned that the system will run for an initial 12 month period, during which time outcomes will be measured to assess the overall value it adds.

Pictured left are clinical pharmacist Amira Shaikh and practice manager Jack Johnson-Rose who are leading the pilot.

Paper 8

North central London’s primary care networks now in place

Some examples of enabling transformation

2.

North central London's primary care networks launched on 1 July. These are groups of GP practices working closely together with other primary and community care staff and health and care organisations to provide integrated services to their local populations.

Each network has appointed a clinical director, and, during 2019/20, will have access to funding for a clinical pharmacist and a social prescribing link worker, followed by funding for other roles from 2021 onwards.

Dementia care across North Central London shining example of best practice

North Central London (NCL) has been identified as one of only three areas in England delivering best practice dementia care, the other two are; West Yorkshire and Harrogate STP and Birmingham and Solihull STP.

The Prime Minister's Challenge on Dementia is for England to be the best country in the world for dementia care and support, for people with dementia and their carers / families to live. Part of this challenge is to identify those with dementia. North Central London are in the top 5 areas with the highest dementia diagnosis rates in the country.

Enfield Care Home Assessment Team and Camden and Islington’s Home Treatment Team have both selected as examples of best practice care in dementia care. NHS England and NHS Improvements National Clinical Director for Dementia and Older People’s Mental Health, Professor Alastair Burns, visited NCL in April and talked to the teams to hear about their work.

Area Number of networks

Barnet 7

Camden 7

Enfield 4

Haringey 8

Islington 4

Healthy London Partnership has showcased the excellent work of north central London Primary Care Networks Islington GP Federation in a video and written case study. This featured the work of Whittington Health and Age UK Islington, Camden and Islington Foundation Trust, Primary Care and Care Close to Home programme as well as the Islington GP Federation.

Paper 8

Planned

Care

SRO:

Marcel Levi

Overall workstream objective

Deliver better value planned care through new models of care and reducing unwarranted variation across providers.

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)

1. First outpatient initiative workshop delivered, great attendance across system2. Secured funding to support the evaluation -design via NHS E 3. Gastroenterology workstream implemented and in progress

1. Agree an audit / monitoring process for EBICS Policy via NCL Governance Group as next step towards BAU

2. Work with providers to agree outpatient initiatives and specialties 3. Conclude Tele-derm proof of concept and evaluation

Priority project Impact* Major Independencies Key Care Settings Partner involvement

Outpatient Transformation £, Q, C HCCH, Digital Acute Providers Partners involved:• Acute Providers, CCGs, GPsPotential future commitments:Clinical Pathway Design £, Q, P, E, C HCCH GPs, Acute Providers

Demand Management £, Q, C HCCH GPs, Acute Providers

Orthopaedic review £, Q - Acute Providers

UEC

SRO: Sarah

Mansuralli

Overall workstream objective:

A consistent and reliable Urgent and Emergency Care (UEC) service by 2021 that is accessible to the public, easy to navigate, inspires confidence, promotes consistent standards in clinical practice and leads to a reduction in variation of patient outcomes. Key areas of work focus on admissions avoidance, ambulatory care, end of life care and discharge to assess.


At the request of NCL CFOs, the July UEC PDB developed an action plan to address the increase in ED attendances and ED admissions. 1. NHS 111 direct booking to GP practices via GP connect was agreed by the NCL

Digital Programme Board and implementation across NCL is underway 2. Developed LAS Appropriate Care Pathway (ACP) for Whittington AEC Unit and

NCL District Nursing services. NCL LAS plan developed to reduce 900 LAS incidents via increasing pathways from the clinical hub.

3. D2A Delirium Pilot evaluated for pathway 1 and this will be discussed at the upcoming NCL discharge forum.

Agree system priorities for the UEC PDB action plan to support the demand management of ED attendances and admissions and assign owners. 1. Progress NHS 111 direct booking to GP practices across NCL via GP connect (national solution) and

increase GP practice sign-up to data sharing agreements. 2. Agree SDEC programme milestones as part of HLP regional programme and pilot LAS ACP to the

Whittington Ambulatory Emergency Care (AEC) Unit. 3. Agree scope and support for system-wide evaluation of D2A pathways across NCL focused on outcomes

and sustainability. D2A Delirium Pilot to be discussed at upcoming NCL forum.


Integrated urgent care £, Q, P, E, C Digital Acute, GPs, Pharmacies, NHS111 Partners involved:• Acute Trusts, Community services, MH providers GP Practices;

Care HomesPotential future commitments:• Last phase of life single point of access model

Admission avoidance £, Q, P, E, C Digital, Workforce Acute, GPs / Community

Simplified discharge £, Q, P, E, C Digital, Social Care Acute, Care Homes, Community

Last Phase of life £, Q, P, E, C Digital, Social Care Care Homes, NHS111, Remote

Mental

Health

SRO: Paul

Jenkins


• Working to address inequalities for those with Serious Mental Illness and provide consistent care. • Deliver services closer to home, reducing demand on the acute sector and mitigating the need for additional MH inpatient beds.

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)1. Submitted CAMHS T4 NCM business case to NHS England.2. Submitted Mental Health Compact implementation plan to NHSE.3. Post-suicide intervention bid successful.

1. Draft MH chapter for Long Term Plan 2. Review of Acute’s specialising cost on patients with mental health needs.3. Agreed project implementation timelines to support NHSE transformational funding.


Mental Health provision within acute care

E HCCH, Social Care, UECAcute, MH Trusts, Community Partners involved:

• CCGs, Acute, GPs/CHINs, MH Trusts, HEEPotential future commitments:• Development of frontline mental health services across settings • Agree single approach to Psych Liaison services in Acute services• Expand workforce to ensure capacity to meet national targets for

improved access.

Improve CAMHS Q CYP Schools, GPs, Community, MH Trusts

Urgent Mental Health Services – Improving access to MH Services

Q, P, £UEC

Acute, MH Trusts, Community

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Maternity

SRO: Rachel

Lissauer


Delivery of the National Maternity Transformation programme through improved continuity and safety of perinatal care for women, working across professional and organisational boundaries todrive better patient experience and integrated care.

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)1. Maternity transformation funding plan approved by NHSE 2. Maternity Voice partnerships in place at all 4 providers. Funding agreed.3. Continuity of carer pathways operational across all 5 sites. NCL rate 14%

1. Complete Local Maternity System (LMS ) Plan Refresh & sign off at LMS Board2. Recruit to the 2 clinical lead posts for Postnatal & Choice & Personalisation3. Undertake GAP analysis of postnatal provision across NCL


Quality & Safety Q Digital Acute, community Partners involved:• Acute trusts

Potential future commitments:• Portability of staff across services • Single point of booking across NCL

Personalisation & choice Q Digital Acute, community

Postnatal £,Q Digital , Workforce Acute, community

Continuity of Carer Q HCCH Community settings

NCL Workforce £, Q Workforce Acute, community

* £ = Savings, Q = Quality, P=Performance, E=Efficiency, C=Clinical Outcomes

Cancer

SRO: Dr

Claire

Stephens


Delivery of improved survival, patient experience, efficiency of service delivery - including services closer to home; reduced costs £ financial sustainability; reduced variation.


Early Diagnosis – Development of Rapid Diagnosis Centre Model begun; Set up of Prevention and Screening Board; Scaling up of SUMMIT Lung Study Operational Performance – Provider performance dipped between April and June. Development of NCL strategy for digital image sharing; Employment Licence in progress; Agreement to run funding round for trusts and other stakeholders to bid for money to develop pathology and radiology related initiatives Living With and Beyond Cancer – Latest data (Q4, 2018/19) provides evidence that 4 of 7 Trusts have developed local colorectal protocols.

1.Early Diagnosis – Agreement on plan for move to RDC model in NCL; funding of screening uptake interventions through prevention and screening board; SUMMIT Study scaled up recruitment (100% of practices in NCL); ethical approval of HP Self sampling study2. Operational Performance – 62 day performance improvement against trajectory; accurate assessment of current 28 day performance in preparation for go live; 3. Living With and Beyond Cancer – Continued progress against SFU take up and recovery package metrics; Launch of Health and Wellbeing events website; report on rehab mapping across London


Operational Performance Q, P Diagnostics capacity Acute, Primary Care , community Partners involved:• Acute providers, GPs

Early diagnosis Q, P HCCH, Prevention Acute, Primary Care , community

Living w & beyond cancer Q HCCH Acute, Primary Care , community

Workforce

SRO:

Siobhan

Harrington


To attract people to live and work in NCL so we have the best possible workforce to deliver high quality services to our community


1. Leadership capacity expanded - clinical lead for new roles & 4xStrategic Leads 2. Medium Term Financial Plan - financial benefits developed with CEOs & HR

Directors 3. Transformation programme priority roadmaps confirmed

1. Bring together system leaders to agree ways of working 2. Work with productivity / finance to scope financial benefits 3. Mobilise all priority projects 4. Confirm funding and start to mobilise delivery capacity


Training Hubs £, Q HCCH All Partners involved:• All Potential future commitments:• Standardisation of mandatory training to aid portability • Standardisation of employment contracts to aid portability

Collaborative Bank £, Q All All

Proud to Care Portal £, Q Social Care Social Care

Employment licence,Rotations, Pipeline of new roles

£, Q All All

Mandatory & StatutoryTraining

£, Q AllAll

Paper 8

Health and

Care Closer

to Home

SRO: Tony

Hoolaghan


‘Place-based’ population health system of care; based around neighbourhoods of 50-80k; drawing together social, community, primary & specialist services; underpinned by a systematic focus on prevention & supported self-care.

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)1. Drafted paper on Quality Improvement Support teams for August HCCH Board2. Further engagement carried out on draft HCCH workforce action plan3. Key discussions held with CCG Directors of Primary Care on alignment on Transformation

& GPFV funding and PCN Development funding.

1. HCCH Board review & discuss output of social prescribing task and finish groups2. Support CCGs to finalise plans for delivery of GPFV funding.3. Primary Care Networks complete PCN maturity matrix and diagnostic tool.


Improved Access C Workforce, Estates, Digital GP practices, social care, community Partners involved:• CCGs, GP, community pharm , Mental Health & Social CarePotential future commitments:• North Central London (NCL)-wide approach to Atrial Fibrillation

improvement • NCL model for social prescribing• Enhanced services review• Contracting for Care & Health Integrated Networks

Quality Improvement £, Q Workforce Virtual, GP practices

Workforce & Estates £, Q, E Workforce, Estates, Digital CCGs, GPs

Social Prescribing £, Q Workforce GP practices, social care, community

Primary Care Networks & Primary Care at Scale

£, Q, P, E GP practices

Children

and Young

People

SRO:

Charlotte

Pomery


‘Right care, right place, right time’. Transformed health & social care services: equitable, accessible, efficient & delivers improved outcomes. Enabling high quality, responsive services for children, young people & families, delivered locally where possible, with a shared focus on promoting wellbeing, reducing health inequalities & improving health & social outcomes.


1. Development of paediatric asthma dashboard2. Review first NCL asthma baseline analysis3. Serious Youth Violence CYP programme board roundtable

1. Agree and roll out first iteration of paediatric asthma dashboard2. DTOC workshop to review housing related DTOC and agree next steps3. Plan implementation of Ask About Asthma campaign

Priority project £, Q Major Independencies Key Care Settings Partner involvement

Paediatric Asthma £, Q Prev, HCCH, workforce, digital Acute, Primary Care , community Partners involved: Acute Trusts, Primary Care, Commissioners, Pharmacy, Public Health, Local AuthorityPotential future commitments:• System approach to managing & preventing asthma in C&YP• Developing a surgical network across NCL• Preventative approach to care & support for CYP & families

Complex Needs £, Q UEC, HCCH, Mental Health Acute Trusts, LA Placements

Paed. admissions avoid. £, Q UEC, Prev, HCCH, workforce, digital Acute, Primary Care , community

Provider

Productivity

SRO: Tim

Jaggard


To scope and take forward areas of savings requiring collaboration across providers

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)1. MTFS workshop – Existing initiatives within workstream reviewed and challenged by

CFO/CEOs. Key agreement to ensure providers challenged on any decision not to use STP shared service offerings.

2. De-prioritised initiatives around shared acute rotas and digital services.Decontaminationinitiative completed with all trusts confirming go live or rejection of offer.

3. Handover to new Head of Finance for workstream

1. Submission of Long Term Plan Implementation Framework returns – including quantification of MTFS impacts, covering Provider Productivity initiatives

2. Arrange Provider Productivity workshop to review areas of work3. Clarity on next steps on all workstreams to maximise savings


Workforce £ Workforce NHS Trusts Partners involved:• ProvidersPotential future commitments:• Consideration of collaborative bank option • Ongoing engagement in modelling, scoping and emerging

programme of work

Procurement £ - NHS Trusts

Patient Transport £ - NHS Trusts

Diagnostics £, Q Planned Care NHS Trusts

Meds Optimisation £

Paper 8

8

Estates

SRO: Simon

Goodwin


To provide a fit for purpose, cost-effective, integrated, accessible estate which enables the delivery of high quality health and social care services for our local population.

Notable progress made this reporting period (Q1 2019/20) Notable progress planned for next reporting period (Q2 2019/20)1. Haringey and Islington Locality Planning workshops to kick off programme 2. Criteria workshop held to set process for capital prioritisation, linkage to MTFS3. Initial meeting of Operational Stakeholder group for projects in SPH critical path

1. Barnet Locality Planning workshop to build STP consistency 2. Initial findings on current and historic arrangement keyworker housing with housing associations in

NCL3. Agree brief, funding and procurement for MTFS programmes


Locality Planning / OOH £, Q All All STP partners Partners involved:• CCGs and TrustsPotential future commitments:• Partnership working on NCL estates strategy iteration

Investment £, Q Mental Health All STP partners

Optimisation £, Q All All STP partners

Disposal £, Q All STP partners

Digital

SRO: David

Probert


1. HIE now live in the 1st practice in Barnet 2. HIE: upgrade process initiated and UCLH config and test underway 3. HealtheIntent on-boarding and code validation for GP data has begun (1st 3

Islington practices)

1. HIE: Upgrade of Live HIE and commence roll-out to next 16 practices 2. HIE: Complete testing of HIE interface with UCLH (new EPIC EPR) 3. HealtheIntent: Agree 1st analytics package progress GP on-boarding validation


Health Information Exch Q, £ Clinical Workstreams All Partners involved: Acute Trusts, Primary Care, Commissioners, Pharmacy, Public Health, Local Authority

Pop Health Management Q, £ Clinical Workstreams All

Person Held Record (PHR) Q, £ Clinical Workstreams All

Health and

Prevention

SRO: Julie

Billet


Driving a system-wide approach to prevention and population health, working to enable success in the overall STP strategy for care


1. Started needs assessment for smoking2. Secured October QI event slot3. Started recruitment for smoking in pregnancy coordinator

1. Complete LTP response2. Finish smoking in pregnancy coordinator recruitment3. Start alcohol needs assessment framework


Tobacco E, P Acute, MH Trusts, Community Partners involved:• GP practices Potential future commitments:• Working towards healthier workplaces • Alignment of organisational strategies • Commitment to prevention (primary and secondary)

Alcohol O Acute, MH Trusts, Community

Healthy Weight C, Q All partners

Social Care

SRO: Dawn

Wakeling


Working to address care inequalities in provision and improving longer term strategic approach to workforce and care market.


1. Agreed heads of terms with 3 major care homes that manages placement cost2. Developed out of hospital paper on apprenticeships3. TNA event held for care homes

1. Develop plans to strengthen redesignation from residential to nursing care2. Strengthen cost containment strategy for residential care3. Finalise NEF report on the contribution of ASC to the social care economy


Ind. Care Sector Workforce £, E, Q HCCH, UEC, Workforce Home Care, Care Homes Partners involved: Local authorities, CCGs, care providersPotential future commitments: Joint commissioning strategy

Social Care Markets Q, £, E HCCH, UEC, MH, Workforce Home Care, Care Homes

Paper 8

Ambition for the STP is built on existing CCGs, Local Authorities

and Providers values and strategy

Improve the health and wellbeing of the local

population

Reduce health inequalities

Maximise out of hospital care and build resilient well

supported communities

A partnership of the NHS and local authorities, working together with the public and patients where it’s the most efficient and effective way to deliver improvements.

Ambitions of the STP A1

Paper 8

Clinical and Senior Leadership across North London Partners

A2

10

Prevention Planned care Mental Health

Maternity Urgent and Emergency

Care

Health and care closer

to home

Children and young people

Cancer

Dr Julie Billett(Camden and

Islington)

Prof. Marcel Levi

(UCLH)

Paul Jenkins(TAVI)

Rachel Lissauer

(Haringey)

Sarah Mansuralli(Camden)

Tony Hoolaghan

(H&I)

Charlotte Pomery

(Haringey LA)

Dr Clare Stephens(Barnet)

Dr Clare Stephens(Barnet)

Dr Karen Sennett

(Islington)

Dr Dee Hora(Camden)

Dr Vincent Kirchner

(C&I)

Professor Donald Peebles

Dr Shakil Alam(Haringey)

Dr Katie Coleman, (Islington)

Dr Oliver Anglin

(Camden)

Prof Geoff Bellingan(UCLH)

Clin

ical

lead

s

Dr Tom Aslan (Camden)

Dr Jonathan Bindman

(BEH)

Dr Alex Warner

(Camden)

Mai Buckley(Royal Free)

Dr Chris Laing(UCLH)

Borough based leads

for each CCG

Social Care

Dawn Wakeling (Barnet)

Workforce: SRO - Siobhan Harrington (Whittington), Programme Director – Sarah Young

Digital: Clinical lead – Dr Cathy Kelly (UCLH), SRO – David Probert, Programme Director – Martyn Smith

Estates: SRO – Simon Goodwin (NCL CCGs), Programme Director – Nicola Theron

Provider Productivity: SRO – Tim Jaggard (UCLH); Programme Director – Peter Sharpe

Communications and Engagement: SRO – Will Huxter; Head of Communications and Engagement – Chloe Morales-Oyarce

SRO

SC

are

Wo

rkst

ream

sEn

able

rs

This workstream also has a joint Chief Medical Officer position: Prof

Muntzer Mughal; Dr Afsana Bhuiya

Dr John Connolly

(RFL)

Paper 8

Dedicated capacity now in place across majority of workstreams to facilitate working across partner organisations to deliver agreed STP initiatives.

Workstream Programme lead Email Address

Adult Social Care Richard Elphick [email protected]

Cancer Naser Turabi [email protected]

Children and Young People Sam Rostom [email protected]

Digital Martyn Smith [email protected]

Estates Nicola Theron [email protected]

Health and Care Closer to Home Sarah McIlwaine [email protected]

Maternity Kaye Wilson [email protected]

Mental Health Chris Dzikiti [email protected]

Planned Care Donal Markey [email protected]

Prevention Mubasshir Ajaz [email protected]

Productivity Peter Sharpe [email protected]

Orthopaedic review Anna Stewart [email protected]

Urgent and Emergency Care Alex Faulkes [email protected]

Workforce Sarah Young [email protected]

Capacity to delivery change A3

Paper 8

Paper 9

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

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




Report from Emma Kearney, chief communications officer

Author Sue Little, executive support manager



Paper 9

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.

Since the establishment of the programme in December 2017, nearly 100 visits have taken

place to 40 different areas, including on the three main hospital sites and group services. In

addition all areas at Barnet Hospital and Chase Farm Hospital were visited by executive

directors to support the EPR implementation in November 2018. The newly appointed non-

executive directors have visited the three main sites as part of their induction. 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 new group chief executive will also be carrying out visits

across all the sites where the trust has services.

2. Visits in July / August / September 2019

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

in since the last board meeting on 24 July 2019 and up to 24 September 2019. These

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

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

Date

24 July to 24

Sept 2019

inclusive

Area

8 North (medical admissions) Royal

Free

Estates workroom, Barnet

6 South (neurology) Royal Free

Visited by

Debbie Sanders (chief nurse)

Glenn Winteringham (chief digital

officer)

Chris Ham (non-executive director) &

Anthony Isaacs (G)

Paper 9

Page 3 of 5

3 West (Theatres) Royal Free

Support Hub, Royal Free Charity

BAME staff network meeting, Royal

Free

Frailty Journey Team, Barnet

8 South (gastroenterology) nutrition

nurses, Royal Free

Pharmacy, Barnet

Medicine & Urgent Care wards,

Barnet

11 West (infectious diseases) Royal

Free

Rowan ward (cardiology) Barnet

Juniper ward (respiratory), Barnet

ITU, Barnet

Walnut ward, Barnet

Emergency department, Royal Free

Chris Ham & Jude Bayly (G)

Chris Ham & Linda Davies (G)

Caroline Clarke (group chief

executive)

Caroline Clarke

Caroline Clarke

Caroline Clarke

Caroline Clarke

James Tugendhat (non-executive

director) & Frances Blunden (G)

Doris Olulode (non-executive director)

& Jude Bayly (G)

Doris Olulode & Jude Bayly (G)

Mary Basterfield (non-executive

director) & Marva Sammy (G)

Chris Streather (chief medical officer)

Wanda Goldwag (non-executive

director) & Judy Dewinter (G)

3. Forthcoming confirmed visits

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

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

below, indicated by (G).

Date

25 – 30 Sept

2019

Area

Breast screening unit, Edgware

Visited by

Peter Ridley (chief finance and

compliance officer)

Oct 2019 4 East (ICU), Royal Free Doris Olulode & Peter Atkin (G)

Paper 9

Page 4 of 5

5 North B (foetal monitoring), Royal Free

2 North A , Royal Free

5 West (labour/birth centre) Royal Free

Emergency department, Barnet

Operations centre, Barnet

Obstetric team, Royal Free

Back to the Floor – Telecommunications,

Royal Free

Chris Streather

Chris Streather

James Tugendhat & Sneha Bedi

(G)

Chris Ham & Richard Stock (G)

Chris Ham & Richard Stock (G)

Caroline Clarke

Caroline Clarke

Nov 2019 11 East (acute oncology) Royal Free

6 West B (special care baby unit), Royal

Free

Back to the Floor – Portering, Royal Free

Medical education senior faculty, Royal

Free

Royal Free Radio, Studios, Chase Farm

Doris Olulode & Judy Dewinter (G)

Doris Olulode & Anthony Isaacs

(G)

Caroline Clarke

Caroline Clarke

Wanda Goldwag

Dec 2019 IM&T & Finance, Enfield Civic Centre

Spruce ward (acute stroke unit) Barnet

Phlebotomy, Chase Farm

Back to the Floor – Security, Royal Free

Max Fax & Orthodontic team, Chase

Farm

Mary Basterfield & Ian Bretman (G)

Doris Olulode & Marva Sammy (G)

Wanda Goldwag & George

Verghese (G)

Caroline Clarke

Caroline Clarke

Paper 9

Page 5 of 5

4. Forthcoming unconfirmed visits

Below are the non-executive and executive directors’ unconfirmed visits. Once dates for non-

executive directors’ have been confirmed, they will then be advertised to governors.

Date Area Visited by

Sept 2019 Chase Farm (area to be confirmed) Emma Kearney (chief

communications officer)

Oct 2019 Barnet (area to be confirmed)

PITU, Royal Free

2 North A, Royal Free

Chase Farm (area to be confirmed)

Emma Kearney

David Grantham

Chris Streather

Dominic Dodd (chair)

Nov 2019 Royal Free (area to be confirmed)

Barnet (area to be confirmed)

Royal Free (area to be confirmed)

Emma Kearney

Dominic Dodd

Dominic Dodd

Dec 2019 Finchley Memorial hospital (area to be

confirmed)

Emma Kearney

The programme of further confirmed visits is currently being collated. An update will be

provided at the next Board meeting.

Title of report Finance report M5 (August 2019)

Executive summary At end of August, the trust delivered an in month actual deficit of £4.8m. This was £0.9m better than plan. Year to date the trust delivered an actual deficit of £20.9m. This is £2.4m worse than plan.

Externally to NHS Improvement (NHSI) the trust reported a year to date £2.1m favourable variance.

The finance improvement programme (FIP) target at end of August was £17.2m. The trust delivered £4.9m of recurrent FIP with a shortfall year to date of £12.3m. £5.4m of non-recurrent mitigation savings were delivered.

Cash at the end of August is better than plan by £54m due to additional cash received for

VAT (£18m), CCGs significantly front loading service level agreement (SLA )payments and a

reduction in the capital programme. Additional cash was also received in August from CCGs

for prior year debts. It is anticipated that loans will be required from January 2020 onwards,

later than originally planned.

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

The board is asked to note the current financial position of the trust

Meetings where this report has been discussed previously Meeting Date Decision Finance and performance committee

17 September 2019 Discussed


GOALS BAF risks

Quality

Value

Top 10% for workforce efficiency (55% of clinical income) Deliver additional 2% year on year FIP G-047

Deliver regulatory undertakings (NHSI / ICO)

CQC standards impacted Use of resources / Well led

Financial/business implications N/A



Trust Board Part 1 25th September 2019 Paper 10

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Compliance impact NHS Improvement

Report from Peter Ridley, group chief finance and compliance officerAuthor Senior Finance TeamDate 17th September 2019

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The Royal Free London

Finance Report M05 Trust Board Part 1

1

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YTD Performance at M5

2

Performance against Plan

In Year Performance FY20

Agency Spend Vs. Last year

• YTD adverse variance of £2.3m from plan. Adverse variance driven by underperformance in clinical

income and slippage against FIP target

FIP Status at M5

At end of M5, the trust has identified £18.2m of FIP plans and £6.7m pipeline schemes. Not included in the above is £11.9m of non-recurrent mitigations

M5 YTD FIP performance by Site

Agency ceiling for FY20 is £20m. Agency spend £0.6m above ceiling at end of

August.

Cash Flow forecast

The Trust delivered £4.9m recurrently against FIP target of £17.2m – slippage of £12.3m. Slippage

partly offset by £5.4m of non-recurrent mitigations

Capital

Cash at the end of August was better than plan by £54m due to front loading of SLA payments

In Month YTD

Plan Actual Variance Plan Actual Variance

£m £m £m £m £m £m

4.5 2.5 2.0 26.8 11.1 15.7

Business Units Target TargetActual

DeliveryVariance

BARNET HOSPITAL 7,968 2,776 979 (1,796)

CHASE FARM HOSPITAL 496 173 212 39

ROYAL FREE HOSPITAL 16,359 5,698 1,742 (3,956)

GROUP CLINICAL SERVICES 5,880 2,048 223 (1,826)

CORPORATE 18,897 6,582 1,806 (4,776)

49,600 17,277 4,962 (12,315)

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CFO Message

Trust delivered an

actual deficit of

£30.3m - £2.3m

adverse to plan at

end of August

1 The trust delivered an actual deficit of £30.3m (excluding PSF, MRET and FRF) at end of August. This was £2.3m

worse than plan. Key drivers for the year to date variance are

• Underperformance in clinical income predominantly within day case and outpatient procedures

• Adverse variance due to slippage against FIP target phased into the position

• Adverse variance partly offset by phasing of reserves including contingency and non-recurrent benefits relating

to release of prior year accruals/provisions

FIP performance at

M5 - £12.3m

adverse to target

2 FIP target at end of August was £17.2m. The trust delivered £4.9m of recurrent FIP and £5.4m of non-recurrent mitigations against this year to date target. The Trust is currently forecasting recurrent in year FIP delivery of £24.9m and non-recurrent mitigations of £10.3m for FY20

Cash at end of M5

is £111m 3 Cash at the end of August was better than plan by £54m due to additional cash received for VAT(£18m), CCGs

significantly front loading SLA payments and a reduction in the capital programme. Additional cash was also received in August from CCGs for prior year debts. It is anticipated that loans will be required from January 2020 onwards, later than originally planned. The current forecast also shows that due to improved debt management and the additional cash received this month, the trust has reduced reliance on working capital loans by £20m. This is dependent on the trust maintaining its current income, expenditure and capital forecast.

3

M05 Performance FY20 Paper 10

Income and Expenditure

August-19

4

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M05 Overview

5

M05 Performance FY20

Key drivers • YTD adverse variance from plan of £2.3m due

to under recovery on clinical income and slippage against FIP target

• The trust delivered £4.9m of recurrent FIP and £5.4m of mitigations at end of M5. The YTD target for FIP delivery was £17.2m

• Pay overspend predominantly driven by unidentified FIP, overspends within medical pay and unqualified nursing.

• Though non-pay is underspent at group level due to release of contingency and reserves some of the non-pay pressures are

• Burst water pipe at Barnet Hospital - £0.6m

• Increased rent relating to Edgware £0.2m

• Catering non-pay overspend (£0.4m) offset by income

• Bad debt above plan by £0.5m

Annual Budget

Plan Actual Variance Plan Actual Variance

£ '000s £ '000s £ '000s £ '000s £ '000s £ '000s £ '000s

NHS Clinical Income 58,127 58,803 676 307,764 306,680 (1,084) 740,126

TEDD Income 15,011 15,260 248 74,970 78,026 3,056 182,070

Non NHS Clinical Income 2,462 2,370 (92) 12,454 12,486 32 32,605

Other Operating Income 6,828 7,049 221 33,222 33,926 704 75,979

Inter-Company Income 6,960 4,022 (2,938) 18,829 18,503 (326) 47,852

Total Income 89,389 87,503 (1,885) 447,239 449,621 2,383 1,078,633

Pay (46,330) (46,753) (423) (234,460) (237,299) (2,839) (556,752)

Other Pay (Apprentice Levy) (187) (191) (5) (933) (901) 32 (2,240)

Non-Pay Expenditure (Excl. TEDD) (24,667) (24,555) 113 (126,348) (125,423) 924 (304,435)

TEDD Expenditure (14,338) (14,490) (152) (70,612) (74,235) (3,624) (170,876)

Inter-Company Expenses (6,930) (3,706) 3,224 (18,680) (18,529) 151 (47,495)

Total Operating Expenditure (92,452) (89,694) 2,758 (451,033) (456,388) (5,356) (1,081,798)

SLR

EBITDA (3,063) (2,191) 873 (3,794) (6,767) (2,973) (3,165)

Interest, Dividends & Depreciation (4,832) (4,758) 74 (24,158) (23,538) 620 (58,197)

Profit/Loss Of Disposal Of FA

Investment In Joint Ventures

Other Gains/Losses

Surplus/Deficit before PSF, MRET, FRF (7,895) (6,948) 947 (27,952) (30,305) (2,353) (61,362)

Frf Income 987 987 4,195 4,195 14,807

Mret Income 218 218 1,091 1,091 2,620

Psf Income 957 957 4,067 4,067 14,355

Total FRF, MRET, Psf 2,162 2,162 9,353 9,353 31,782

Reported Surplus/deficit (5,733) (4,786) 947 (18,599) (20,952) (2,353) (29,580)

In Month YTD

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of 1

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

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

Financial/business implications None


Compliance impact NHS constitution standards

Report from Hospital chief executives

Author Senita Rani Robinson, Performance Measurement Lead

Date 17 September 2019



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Royal Free London –operational performance

September 2019

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2

Operational performance summary report

Where we are Predictions Key Risks

Cancer – July2019

• Performance in July was reported at 82.2%

• The majority of breaches were within the prostate, haematological and lower GI tumour sites.

• The largest backlog volumes are in the BH lower GI (20), gynae(12), prostate (16) & renal (12) tumour sites.

• Un-validated August performance is 79.85%.

• Change to reporting reallocated performance has made predictive performance difficult.

• The STP have moved to validating shared care pathways first which should make this more accurate going forwards.

• Backlog volume has gradually increased to 134, above the long-term target of 48.

• 28 day FDS standard preparations continue, and in the month of August 69.7% of diagnosed patients had an FDS date entered.

• We continue to be non-compliant against the subsequent surgery standard, driven by HpB and Lower GI.

A&E –August 2019

• Trustwide performance in August was 86.41%

• BH performance was reported at 81.91%

• RFH performance was reported at 86.23%.

• NHSE are likely to open the resubmission window in Jan 2020 which will allow us to resubmit performance for the RFH site from February onwards as we can now make breach corrections in Cerner.

• BH performance affected by continued high attendances, limited space, insufficient workforce cover and challenged downstream patient flow.

• We now have a breach correction workflow for RFH developed by the DQ team and are awaiting resubmission window.

DM01 –July 2019

• We were last compliant against this standard in August 2018.

• July performance was reported at 96.7%.

• Largest number of breaches were in the non-obstetric US (894), MRI (175) & colonoscopy (84) modalities.

• We are due to report 1,859 breaches in August compared to 1,361 in July.

• The issues in non-obstetric US persist. This service is discussing redirecting referrals with the CCG and is maximising outsourcing and sonographer support in the meantime.

• Endoscopy capacity and reporting continues to be a challenge.

• MRI are reliant on outsourcing until April 2020 when they will have 4 additional machines.

• Gynaecology require clinic 9 space in order to provide an additional outpatient list and reduce cystoscopy breaches.

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3

62 Day Cancer – Performance Summary

Current Period July: above 2018/19 performance, below standard and trajectory at trust level

Relative position July 2019: 3rd quartile at trust level

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

Source: NHS England, 2019

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4

In July, 4 out of 16 tumour sites accounted for 43% of the trust’s total excess breaches:

● RFH Renal – 4 breaches (performance 33.3%)

● RFH Lower GI – 3 breaches (performance 50%)

● BCF Haematological – 3 breaches (performance 71.4%)

● BCF Lung – 2 breaches (performance 60%)

62 Day Cancer – Sources of Current Performance

July 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

43% of total RFL excess breaches

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5

62 Day Cancer – Diagnosis and Actions

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

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

1. Persistent backlog

2. CPG

3. Calculating reallocated performance

1. The overall backlog persists above trajectory and is currently at 130. The largest backlog volumes are within the BH lower GI (20), gynae (12), prostate (16) & renal (12) tumour sites. This is managed through local PTL, weekly cancer performance and fortnightly oversight meetings.

2. Most of the 7 day task & finish groups have now finished and planning is underway for when the “double running” will take place. This is where specialties will run double capacity for outpatients, diagnostics and treatment to bring wait for first event down to 7 days.

3. Reallocated performance is calculated by CWT and the information team are unable to accurately replicate this logic for predicting performance. This is due to shared care pathways being uploaded by other providers. The STP have now agreed to validate and upload shared care pathways first which should resolve the problem.

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6

A&E – Performance Summary

Current Period August: performance is below 2018/19 performance, standard & trajectory at trust level

Relative position Aug 2019: 1st 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 – August 2019 DTOC by borough – August 2019

Performance was 81.9% in August 2019 against a trajectory of 87% and continues to be challenging due to the following primary drivers:

• Increasing demand • Insufficient acute bed capacity and space in

ED • Poor patient flow & delayed discharges • Workforce mismatch with increasing demand

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8

A&E – Barnet Diagnosis and Actions

What is our diagnosis of what is driving current performance?


Increasing demand

Insufficient acute bed capacity and space in ED

Poor patient flow & delayed discharges

Workforce mismatch with increasing demand

• Healthwatch report & patient comms action plan presented at August UEC Board

• UEC QIPP delivery report to be discussed in Sept

• Phase one of the Emergency Floor Reconfiguration project is due for completion in November 2019.

• Timeframes & costings for revised Phase 2 plans to be confirmed on 3 September; this will include the creation of increased assessment space and an Urgent Treatment Centre.

• Reviews of bed modelling data undertaken again by BH & BCCG on 19 June & 6 September.

• Potential opportunity to reduce bed occupancy through teletracking being explored.

• Discharges before lunch remain below 33% target, however structured projects focused on patient flow and discharge are being progressed to improve this.

• Delays continue due to long waits for CHC assessment for Barnet patients; Pathway 3 session schedule for October.

• Clinical workforce plan reviewed at Barnet Executive Committee on 3 September.

• eRoster being implemented for junior doctors during September.

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9

A&E – Royal Free Sources of Current Performance

Current Period Performance

Performance against 4 hour standard Headlines

Submitted performance was 86.2% for August 2019 against a trajectory of 90%.

Strong July performance was driven by good flow through assessment areas and wards, which reduced the volume of breaches due to lack of available beds by 52% compared to June.

DTOC and MOs

Total DTOC and MO bed days – August 2019 DTOC by borough – August 2019

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10

A&E – Royal Free Diagnosis and Actions



1. Staffing

2. Capacity

3. Barriers to flow

1. UTC GP rota fully staffed and good skill mix with ENP availability meant these did not have to be reallocated to other areas.

1. UTC performance increased above 97.5% in July, despite high attendances.

1. Ambulance handover: Performance steadily increased through July / August and is now on trajectory. Longest recorded period of time without reporting a 60 minute ambulance breach.

2. D2A pathway delays: Delays continue to be experienced due to long waits for CHC assessment for Barnet patients. Pathway 3 action plan developed jointly by BCCG & LBB presented at RFH UEC Board in June; awaiting date for system workshop which has been delayed.

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Diagnostics (DM01) – Performance Summary

Current Period July 2019: below standard, trajectory and 2018/19 performance

Relative position July 2019: 3rd quartile at trust level

% patients waiting < 18 weeks from request to diagnostic test


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DM01 – Royal Free Diagnosis and Actions



1. Non-obstetric US

2. Colonoscopy

3. MRI

4. Cystoscopies

• We are due to report ~1,400 breaches for non-obstetric ultrasound in August. This is due to the new pension rules which have resulted in lack of willingness to undertake WLI lists and limited outsourcing availability.

• Radiology are mitigating this by using sonographers as much as possible and discussing redirection of referrals with the CCGs whilst they develop a long-term strategy.

• We now have the ability to book directly into Hadley Wood slots and will be increasing utilisation of this resource.

• Ongoing downtime and lack of resilience is contributing to capacity shortages at short notice resulting in breaches. We have additional outsourced capacity to assist and are requesting ongoing financial support to continue with this until we replace the equipment and have 4 operational scanners. This will resolve in April 2020 once these are installed.

• Breaches are mainly within gynaecology. They have the staffing for an additional outpatient list per week but are finding clinic 9 space challenging.

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1 X:\ Chair and CEO report 25 September 2019

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





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 RECRUIT DEVELOP AND RETAIN THE BEST TALENT

RFL OSCARS 2018/19

The RFL Oscars ceremony took place on 11 September 2019, hosted by actor and comedian Hugh Dennis. More than 300 members of staff, including nurses, cleaners, doctors, midwives, porters, and clinical support staff, attended the ceremony, which was funded by the Royal Free Charity. More than 30 awards were made to staff who had made a significant contribution to patient care and the life of the RFL in 2018/19.

Among the winners was senior clinical operations manager at Chase Farm Hospital, Amanda Sparkes, who won the chair’s leadership award for her work which enabled her teams to grow in confidence and skills, which resulted in a successful opening of the new hospital, improved performance and innovation.

Royal Free London group clinical team of the year was won by the Barnet Hospital Pharmacy team for their outstanding and dedicated work in rolling out the new electronic patient prescribing and drug administration system.

The Royal Free London group clinician of the year award went to Dr Anant Patel, a respiratory consultant based at the Royal Free Hospital and Chase Farm Hospital.

Dr Patel won this award for his dedication to his job, the quality of his lung cancer service which leads to excellent clinical results and a much improved patient experience. Dr Patel was described as a fantastic teacher, incredible clinician and an inspirational leader.

The winners are listed below:

Volunteer of the year award: • Mary Cooper and her dog Mistral, Royal Free Hospital • Royal Free Radio, Chase Farm Hospital • Rashmi Malde, Barnet Hospital

Young volunteer of the year award: Syed Muqtadir

Outstanding contribution to patient safety award: Anita Malana, theatre team leader, Royal Free Hospital

Celebrating diversity award: Stephen Downer, support services team leader

Outstanding contribution to education award: Dr Mahmood Ahmad, senior cardiology registrar

Group clinical team of the year award • Pharmacy, Barnet Hospital • Urgent care centre, Chase Farm Hospital • Inpatient therapy clinical leadership team, Royal Free Hospital • Overall winner: Pharmacy

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Group clinician of the year award • Bernadette Henderson, therapy services paediatric and governance lead, Barnet

Hospital: • Zoe Endemi, urgent care centre clinical lead, Chase Farm Hospital • Dr Anant Patel, respiratory consultant, Royal Free Hospital • Overall winner: Dr Anant Patel

Quality improvement and innovation award: Carol Menashy, theatre sister, Chase Farm Hospital

Non-clinical employee of the year award: Ashick Jahangeer, housekeeper, Barnet Hospital

Non-clinical team of the year award: Catering team

Chair’s leadership award Winner: Amanda Sparkes, senior clinical operations manager, Chase Farm Hospital

BLACK HISTORY MONTH – OCTOBER 2019

The trust will be marking black history month with thought provoking discussions from inspirational speakers, a wide variety of breakfast sessions, guess the flag competition and a lunch from different nationalities. Events will take place on the three main hospital sites and at Enfield Civic Centre between 9 -24 October 2019.

HEALTH AND WELLBEING EVENTS – OCTOBER 2019

Events to promote health and wellbeing will take place on the three main hospital sites and at Enfield Civic Centre between 1 - 21 October 2019. These include information about physical and mental health, a free head, shoulder and back massage and free fruit.

ROYAL FREE HOSPITAL NURSES TRAVEL TO CENTRAL AFRICA TO HELP TREAT EBOLA PATIENTS

Two nurses at the Royal Free Hospital (RFH) are travelling to the Democratic Republic of Congo (DRC) to help treat Ebola patients. They will be based in the large city of Goma, located in the eastern part of the DRC, for six weeks and are taking unpaid leave to travel to the DRC.

The Royal Free London has an education and training partnership with Medecins Sans Frontieres (MSF) but this is the first time staff from the RFH have been deployed to work alongside MSF and local staff. On their’ return to work they will not be allowed patient contact for 21 days.

INTERIM LEADERSHIP ARRANGEMENTS AND CHANGES IN THE TRANSFORMATION TEAM

The trust is currently recruiting a new chief transformation officer, following Libby McManus leaving the role to become chief nurse at Queen Elizabeth Hospital, King’s Lynn. While recruitment is underway an interim director of transformation role has been created to lead the transformation team for six months.

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At the same time, North London Partners in Health and Care – North Central London’s sustainability and transformation partnership (STP) – have asked for the support of a programme director to address gaps in their structure and to support development of a sector-wide, medium-term financial strategy (MTFS).

As a result, the transformation programme directors within the RFL transformation team, Simal Patel and Tendai Wileman, will each be covering one of these roles on an interim basis. Ms Patel will take on the role of interim director of transformation for the RFL and Ms Wileman will be seconded to the STP as director of programme delivery from 1 September.

Some further temporary adjustments will be needed to ensure the transformation team can support services and business units with their programmes; these are being worked through.

B REDUCE UNWARRANTED VARIATION IN PATIENT CARE AND ACADEMIC EXCELLENCE

INFORMATION COMMISSIONER’S OFFICE AND DEEPMIND/STREAMS UPDATE

Three significant milestones were achieved during the summer.

At the end of July, the Information Commissioners Office (ICO) issued a statement on their website which confirmed that the trust had met all the requirements of the undertakings and the audit recommendations. This included the following statement:

“The ICO can now report that the Trust has completed the actions required, both in response to the requirements set out in the undertaking, and to meet the concerns to addressed in the audit. It has also taken steps to complete a data protection impact assessment (DPIA) as required by the new legal regime, and improve privacy information to its patients. We are therefore satisfied that the trust is complying with its data protection requirements and we have no further outstanding concerns regarding the current processing of personal data within Streams.”

The University College London (UCL) evaluation of Streams was published in Nature Digital Medicine and the Journal of Medical Internet Research at the end of July. The Streams clinical application delivers a continuous, secure and real-time flow of clinical data to the appropriate clinician on a mobile device. Results such as blood tests may be viewed instantaneously, as soon as they pass through lab analysers. For particularly high-risk clinical scenarios alerts may be generated and used to notify not only the ward team but senior clinicians and experts. In this way acute kidney injury (AKI) can be more quickly diagnosed and treated.

The service evaluation and qualitative study compared data from four months after implementation of Streams to data from an eight month period prior to the implementation of Streams. Data was also included from a comparator site at RFL that did not implement Streams. Over the cumulative 12 months, the study evaluated 11,840 AKI alerts.

The key findings were :-

• Recognition of AKI improved from 87.6% to 96.7 % for emergency cases

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• The average time from blood test results being available suggesting AKI to an in-application case review by a specialist was 11.5 minutes for emergency patients with AKI and 14 minutes for admitted patients. Previously it was not possible for specialists to review AKI cases arising across the hospital in real time and it could have taken several hours to identify

• Key treatment was delivered faster

• Healthcare costs reduced by just over £2,000 for AKI patients treated (from £11,772 to £9,761)

• For emergency patients there were significant improvements in the outcome trend of renal recovery and admissions to critical care and the kidney unit after AKI

• There was also a significant reduction in the global hospital cardiac arrest rate

The announcement attracted significant media attention including national and international print and broadcast media.

Finally, the trust was announced as the winner of the Health Service Journal (HSJ) patient safety award for deteriorating patients and rapid response teams.

The feedback from the judging panel was that “The judges state that this project is incredibly exciting. The forethought and preparation was impressive with robust quality improvement methods and research underpinning the work. The responsiveness and adaptability to making change was evident.”

PEARS BUILDING

Invitations for a “topping out” ceremony in mid-October will be issued shortly as the building, which is on schedule to be completed by September 2020, will soon reach its full seven floors in height. Visitors will be invited to place some of the first bricks into the structure.

With the concrete frame nearing completion, emphasis is now being focused on the external façade and internal fit-out. A mock-up of the façade has been produced to illustrate how the windows, brickwork and other external features will look, and the off-site production of pre-cast units which are to be incorporated into the external façade continues.

The basement plant room is making progress: the walls are finished and mechanical and electrical plant is being installed. Construction of the internal walls which will enclose the laboratories is due to start soon.

Patients who use our existing accommodation are currently being asked for their views on the finish in the new patient areas and what that part of the building should be called. And significant progress has been made over the final IT specification and infrastructure, together with details of the security and access control arrangements.

The charity has established a working group to manage the move into its new home and is considering ways to optimise the available space.

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C DELIVER WORLD CLASS SUPPORT SERVICES AND NEW SOURCES OF INCOME

NEW DECONTAMINATION UNIT

The trust successfully opened its new decontamination facility at Chalkmill Drive, Enfield on 17 June 2019 starting with the re-processing of flexible endoscopes for the Barnet Hospital and Chase Farm Hospital sites. This was followed by the sterile services team moving from the Barnet Hospital site on 1 July and ensures world class decontamination for both of the hospitals. The final move was the transfer of the Royal Free Hospital sterile services department on 9 September which completed the relocation.

Over 80 members of staff work in the unit. The unit is open 365 days a year (22 hours a day, Monday to Friday and 14 hours at weekends and bank holidays). Each year it will clean approximately four million instruments and 35,000 flexible endoscopes. However the unit has the ability to do over five times this amount and has the potential to bring in revenue by providing the service to other trusts and private enterprises.

PATIENT TRANSPORT SERVICE UPDATE

DHL provides our non-emergency patient transport services and after a tender process across North Central London, from 1 September, they will begin providing services for RFL plus three other trusts.

DHL has been appointed to provide two contracts: the patient transport service and the eligibility booking service.

D POPULATION HEALTH AND COLLABORATION

As part of the development of integrated care systems the trust needs to work closely with its partners in health and care services, which includes the public health teams based in local councils. At the September population health committee we heard presentations from the London Boroughs of Camden, Barnet and Enfield public health teams on their population health priorities. These included:

• Reducing inequalities in health between the most and the least deprived communities (there can be a 12 year difference in life expectancy between the two)

• Tackling smoking, obesity and reduced physical activity which are key risk factors for many long term conditions and cancers.

We also welcomed Dr Tamara Djuretc, director of public health for the London Borough of Barnet as our new director of public health for the Royal Free. This will help us to further develop how we shape our health system from a treatment to a more preventative one.

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E EXCELLENT OPERATIONAL AND FINANCIAL PERFORMANCE

EU EXIT PREPAREDNESS

At its March 2019 board meeting the board received an update on preparations being made by RFL to manage the potential impacts that would be caused by the UK leaving the EU in the event of no deal – this covered medicines and vaccines, medical devices and clinical consumables, non clinical consumables and services, workforce, blood and transplant, data, reciprocal health care and clinical trials. The board was assured that robust arrangements were in place.

The trust’s EU exit working group was stood down after Article 50 was extended to the 31st October on 10 April 2019. This was in line with the regional preparations and daily reporting, which were also stood down. At that point, it was felt that the trust was as prepared as possible based on the operational readiness guidance issued. In July, the new Prime Minister made a commitment to leave the EU by the October deadline either with or without a deal being in place.

The Trust EU exit working group has now been re-established. All areas are continuing to prepare and monitor for any potential impact. The trust has taken steps to reassure EU staff, making it clear to them how much they are valued and how they can obtain settled status.

EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE (EPPR) ASSURANCE – 2018 OUTCOME AND PREPARATION FOR 2019

The annual EPRR assurance is carried out by NHS England (London) to be assured that NHS organisations in London are prepared to respond to an emergency, and have resilience in place to continue to provide safe patient care during a major incident or business continuity event.

The outcome of the 2018 assurance process was that NHS E (London) felt the trust had a good level of preparedness and resilience and demonstrated its commitment to EPRR, in the way the trust continues to identify improvements. Aspects of the internal incident plan were identified as good practice. The trust has been assessed as being ‘substantial’ in its level of compliance. Out of the 64 core standards the trust is assessed against, NHS England agreed with the trust’s self-assessment that three areas are amber. Despite progress being made these included evacuation and lockdown, which were amber in the previous year. The final one related to having adequate numbers of staff trained to ensure there is the capability to provide decontamination 24 /7.

Since the assurance outcomes were received from NHS England, the emergency planning team have continued to work with colleagues in security to improve the lockdown arrangements, with tests either having taken place or planned.. In relation to the evacuation arrangements, the emergency planning team are working closely with site colleagues on improved procedures. Theatres at the Royal Free site have undertaken two evacuation exercises this year and they have assisted the team to identify some learning that can be incorporated into the current arrangements.

In relation to the decontamination training, additional internal trainers have been identified and trained by the London Ambulance Service to support the ongoing delivery of this

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training. All three sites have a programme in place for delivering this training on an ongoing basis.

The trust has recently received the details of the 2019 assurance process. There are no significant changes to the core standards this year. This year’s deep dive is based on severe weather and climate adaption.

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 August results are below.

Royal Free London combined data

% likely/extremely likely to recommend August 2019

(range: 0 – 100%)

Number of patient responses

In-patient 87% 1,537

A&E 85% 5,782

Barnet Hospital % likely/extremely likely to recommend August 2019

(range: 0 – 100%)


In-patient 86% 538

A&E 82% 2,784

Antenatal care N/A 0

Labour and birth 99% 168

Postnatal hospital ward 99% 166

Postnatal community care 97% 66

Out-patients 88% 825

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

(range: 0 – 100%)


In-patient 98% 134


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

(range: 0 – 100%)


In-patient 87% 865

A&E 88% 2,298

Antenatal care 67% 3

Labour and birth 100% 2

Postnatal hospital ward 100% 2

Postnatal community care 97% 66


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

F STAKEHOLDERS

COUNCIL OF GOVERNORS AND MEMBERS

Annual members’ meeting - 24 July 2019

Members were invited to attend the 2019 Royal Free London NHS Foundation Trust annual members’ meeting which took place on Wednesday 24 July at the Royal Free Hospital. There was an excellent turnout of members who were able to hear about some of the trust’s pioneering research projects. Professor Alison Rodger, who led a study which showed that anti-HIV drugs could stop the virus being passed, and Professor Anthony Schapira, who carried out world-leading research into Parkinson’s disease, were two of the speakers at the event held in the atrium at the RFH.

RFL group chief executive Caroline Clarke spoke about some highlights from the past year, including the opening of the new CFH, while Professor Derralynn Hughes spoke about how patients are helping to shape newly-redesigned cancer pathways.

Members were also invited to find out more about some of the trust’s leading projects, including the Pears Building, the UCL Institute of Immunity and Transplantation and the new decontamination unit in Enfield at display stands that were put up around the atrium.

Governor elections

Governor elections are currently taking place. To encourage members to stand for the council we have a short video with short clips from governors to help inform potential candidates of what the role entails, to inform the electorate on what the council does and what attributes a successful governor should have. The trust held drop-in sessions at the Royal Free, Barnet and Chase Farm hospitals for those considering standing, to provide more information about the role. The number of places and candidates is below.

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Category Places CandidatesPublic governor 3 36 Patient governor 3 24 Staff governor 1 13

The election company advise that this was the highest number of any London trusts that they deal with and is also amongst the highest nationally.

Polling closes on 26 September 2019 and the results will be announced shortly afterwards.

NHS IMPROVEMENT (NHSI) OVERSIGHT

The group executive leadership team continue to meet monthly with a team from NHSI to discuss operational and financial performance.

G OTHER UPDATES

COMMUNICATIONS BOARD REPORT: JULY AND AUGUST 2019

Media coverage

Positive stories: Widespread coverage about new form of medicine called “gene-silencing” approved for use on the NHS and featured on the BBC. Professor Julian Gillmore quoted. The Royal Free Hospital’s efforts to help patients quit smoking were highlighted in The Ham & High and there was also coverage in the paper for the 2,000 liver transplant event held at the Emirates. There was also widespread coverage of our partnership with DeepMind following the evaluation of the Streams app, including on the BBC’s website.

Main negative story: The Camden New Journal reported on the RFL’s financial position. The table below shows the sentiment of press mentions in July and August.

July and August

Royal Free Hospital

Barnet Hospital Chase Farm Hospital

Total

Positive 315 5 3 323Neutral 153 21 16 190Negative 56 0 2 58 Total 524 26 21 571

Digital Communications

Total number of Facebook followers: 7,555 (+18) Number of Posts: 45, reaching 57,032 people

Total number of Twitter followers: 18,523 (+373) Number of Tweets: 164, reaching 429,911 people

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Our top Twitter post for July was about a temporary closure of Belsize Park underground station. The post received 17,391 impressions and 63 total engagements.

Our top Tweet for August was about the Google Doodle on 15 August featuring a former RFL employee, Louisa Aldrich-Blake (1865-1925). This received 8,525 impressions and 158 engagements.

Internal communications

Freenet 2 – Communications plan is in place with weekly updates across all channels on training, what it means for staff and the importance of completing staff profile details.

Take 5 – We rolled out the new look chief executives' briefings, which feature three key RFL messages and two site messages for colleagues to share and discuss at team meetings.

Focus on finance sessions – Staff were invited to attend a series of staff briefing sessions to find out what the financial challenges mean and what individuals and teams can do to help. We communicated widely, with key financial messages, across all communications channels and supported with slides and updates.

Oscars – We received 473 nominations across the 10 categories in this year’s Oscars awards. This followed an intensive communications effort using Freenet banners, Freemail, mentions in chief executive’s briefings, managers’ briefing and on social media. We continued with preparations to organise and promote the awards ceremony on 11 September.

‘What matters to you?’ presentations – Presentations took place at each of the chief executive briefings on 'What matters to you’ day, with staff discussing their experiences.

Values week – We executed a trust wide campaign highlighting our RFL values and celebrating how our staff live those values. We created and shared on social media a series of video blogs (viewed nearly 6,000 times on social media) from staff on how they demonstrate the trust's values and how this benefits patients and staff.

Imaging department redevelopment programme – a communications plan was developed for the imaging department upgrade at the Royal Free Hospital to inform internal and external stakeholders of the redevelopment, including the benefits it will bring to our patients and staff once completed.

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Final

Report from the people committee meeting

Executive summary

To follow is a report from the people committee held on 18 July 2019 on key discussion items and agreed actions.

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






From from James Tugendhat, non-executive director and chair of the people committee Author Veronica Jackson, group committee administrator Date 11 September 2019



Paper 13

Final

Current goals and Board Assurance Framework risks A process to refresh the group goals was underway. The committee agreed that its aligned goals would need to be key levers for driving and accelerating patient and staff experience and engagement.

People strategy The committee received a high level overview of the people strategy. The aim was to have RFL as the best place to work by 2028, the trust’s 200th birthday. The report also reflected on the trust’s proposed revised group goals, highlighting five against which the strategy would be tracked.

Workforce Race Equality Standards (WRES)The committee recevied its routine WRES report; a specific update was given on the steps taken by workforce to address the committee’s previous comments in respect of diverse interview panels and recruitment and selection training. The committee also recevied the draft WRES annual report; it recommended the report be signed off by the trust board at its July meeting.

Workforce Disability Equality Standards (WDES) The committee recevied the draft WDES report and agreed that that should also be signed off by the trust board at is July meeting.

Organisational development The committee received a presentation on creating a talent pool for the role of clinical director.

Bullying and harassment (B&H) The committee requested a deep dive on the trust’s interventions in respect of B&H to see whether they were making a tangible difference. It was agreed that the committee would receive a report on that later in the year.

Reports from the site patient and staff experience and workforce committees The committee received its routine updates from the Barnet Hospital, Chase Farm Hospital and Royal Free Hospital’s PSE&WCs. Of particular note was staff wellbeing and resilience, bringing the digital and workforce agendas together and staff retention.

Inpatient survey 2018 The committee recevied the survey feedback; the key message was that the trust was the same as other trusts across 11 domains. However, the trust had an aspiration to improve its scores and be a Top 10 organisation on patient experience. It was agreed that in the next round of the survey, the trust would need to see if its interventions had hit those areas that patients felt strongly about.

Annual complaints report 2018-19 The committee received the annual complaints report. It was noted that the complaints rate was low in terms of the trust’s overall activity but that did not mean that those patients who had not raised a complaint had had a positive experience. There has been no change to what made up the top complaints although patient transport services had featured this time around.

Gender pay gap (GPG) The committee received an update on the current position on the GPG.

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Report from executive finance committee

Executive summary

To follow is an update from the meeting of the executive finance committee held on 27 August 2019. This was the last meeting of this committee as it has been agreed to establish a board finance and compliance committee, in line with the Deloitte well led review recommendations.

The draft terms of reference are attached for the board’s review and approval.

Action required

The board is asked to note the report and to approve the terms of reference.


Meeting Date Decision n/a n/a n/a


GOALS BAF risks






Report from Caroline Clarke, group chief executive and chair – executive finance committee Author Alison Macdonald, board secretary Date 13 September 2019



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1. INTRODUCTION

The executive finance committee was established in April 2019 and its role is to provide

assurance to the trust board on matters of financial performance, including delivery of the

capital programme, financial improvement plan (FIP) and the longer term financial strategy.

As the committee is a specialist sitting of the group executive committee (GEC), it has the same delegated decision making rights as GEC.

The committee is responsible for providing assurance to the trust board on the following goals:

• Top 10% for workforce efficiency • Deliver additional 2% year on year FIP • Review service portfolio to deliver £15m benefit • Release capacity in planned care to achieve £5m benefit • 100% compliance with statutory / regulatory requirements • Deliver regulatory undertakings (NHSI / ICO) • Demonstrable organisation health (group governance

2. EXECUTIVE FINANCE COMMITTEE MEETING AUGUST 2019

2019/20 month 4 finance report and financial improvement programme (FIP) report

The committee reviewed the reports which indicated that the trust delivered an actual deficit of £23.4m at the end of July, which was £3.3m worse than plan and a £0.6m deterioration on the previous month. The position was being mitigated with contingencies and non recurrent measures. However the externally agreed financial plan had been delivered at month 4.

The financial improvement plan (FIP) progress was reviewed; in year delivery was £3.9m and there was forecast in year delivery of £26m. There was steady progression but high in year delivery risk.

Discretionary spend decisions

Controls have been placed on discretionary spend in a number of areas, with a lead identified for each. However the underlying trend was still upward. There was discussion about how to control this expenditure, including the consequences to individuals who committed expenditure despite the controls and whether it would help to put additional controls in place. A performance management framework will shortly be introduced which should help to hold people to account.

Debt report and action plan – Month 4

The committee noted that the debtors position had improved by £7.8m since June.

3. FINANCE AND COMPLIANCE COMMITTEE TERMS OF REFERENCE

Draft terms of reference are attached which have been discussed by the committee and which the board is asked to approve.

FINAL DRAFT – REVISED 16.9.19

FINANCE AND COMPLIANCE COMMITTEE

TERMS OF REFERENCE

1. PURPOSE OF THE COMMITTEE

1.1 The finance and compliance committee’s overall role is to review in greater detail than is possible at the trust board the financial performance of the trust and its operational units including delivery of the integrated recovery plan, the capital plan and cost improvement/savings plan.

1.2 The committee is an assurance committee and not a decision making body and will be responsible for providing assurance to the trust board on the following priorities and goals

• Excellent operational and financial performance

• Delivery of the trust’s financial strategy

• Reference Cost Index<90

2. ESTABLISHMENT

2.1 The committee is established under standing order 6 of the trust’s standing orders (appointment of committees).

2.2 The standing orders of the trust, so far as they are applicable, shall apply to the meetings and proceedings of the committee.

3. REPORTING

3.1 The agenda and minutes of meetings will be agreed by the chair and circulated to all members.

3.2 After each meeting the committee will report to trust board. The chair of the committee shall draw to the attention of the board to any issues that require disclosure to the full board.

3.3 The committee will report to the board annually on its work, specifically progress against the priorities and work plan set by the committee at the beginning of the year.

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4. MEMBERSHIP

4.1 The membership shall comprise:

Non-executive director to chair – not chair of the audit committee Non-executive director x2 Group chief executive Chief finance and compliance officer Chief transformation officer

5. ATTENDANCE AT MEETINGS

5.1 Members of the site teams and wholly owned subsidiaries (WOS) to be invited according to the committee’s work plan and any matters arising. This may include, but is not limited to:

Chief digital officer Financial operations director Assistant director of finance Commercial finance director Deputy director of quality and governance Managing director - RFL property services Ltd Managing director - group corporate shared services Any executive member of the trust board Any member of the site/business unit executive teams Any member of the board of the wholly owned subsidiaries

Other executive directors and senior managers will be invited to attend meetings of the committee when the committee is discussing subjects that are the responsibility of that director. Non-executive directors who are not members of the committee may also be invited to attend.

6. QUORUM

A quorum shall consist of at least one third of the membership and must include one non-executive director and one executive director.

7. SECRETARY

7.1 The group committee administrator will be secretary to the committee and shall attend to take minutes of the meeting and provide appropriate support to the chairman and committee members. This will include:

• agreement of agenda with chairman and collation of papers • taking the minutes and keeping a record of matters arising and issues

to be carried forward • advising the committee on pertinent areas

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8. FREQUENCY OF MEETINGS

8.1 The committee shall meet 11 times per year, on a monthly basis, excluding August.

9. AUTHORITY

9.1 The committee is authorised by the trust to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the committee. This shall include those employed by the wholly owned subsidiaries. The Committee will not be a decision making body, specifically in relation to capital expenditure, but decisions relating to land opportunities will fall within the scope of the committee.

10. DUTIES

10.1 At the beginning of each financial year, the committee will agree its priorities and workplan for the year, against which progress will be tracked and on which an annual report will be made.

10.2 The committee will

Report to the trust board on the trust’s financial, activity, workforce and capital plans over the short, medium and long term horizon. (Usually, but not exclusively a one, three and five year planning horizon).

Review in year performance against the service, financial, workforce and capital plans and that risks to the delivery of the plan are effectively managed or mitigated.

Examine the effectiveness of any in year remedial actions plans.

Commission and receive the results of in-depth reviews of key issues affecting the financial performance of the trust.

Provide assurance to the trust board on the delivery of programmes to reduce costs and/or increase efficiency.

Review and sign of the reference cost submission and give assurance to the board the trust is compliant with guidance.

• Be responsible for oversight of the delivery of agreed land opportunities (decision making formally remains with the group services and investment committee).

• Provide assurance to the trust board that the trust is compliant with the regulatory framework in terms of statutory and regulatory submissions.

• Have oversight of the CQC action plan.

• Consider central guidance relating to the contracting, financial and capital regimes and ensure the trust board is adequately briefed.

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11. REVIEW

The terms of reference of the committee will be reviewed on or before (one year from approval of terms of reference).

Approved by committee: Approved by trust board:

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Draft Forward Work Plan

Month Finance & FIP

Capital report

CQC Update

Divisonal Review

Ref cost submission

ContractUpdate

Planning Update

April x x x Corporate x xMay x x RFH xJune x x x CF

&GCSS x

July x x BHSeptember x x x Corporate x

October x x x CF &GCSS

x

November x x BH x xDecember x x x Corporate x xJanuary x x RFH x xFebruary x x x CF

&GCSS x x

March x x BH x x

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Paper 15

FINAL

Population health committee report

Executive summary

To follow is an update from the population health committee held on 4 September 2019 on key discussion items and agreed actions.

Health inequalities The committee received a presentation on deprivation analysis. The presentation provided a high level summary of associations between socioeconomic inequalities in the trust’s patient population and a variety of outcomes, including prevalence of long-term conditions, readmission rates, treatment and cancer wait times, and non-attendances at outpatient clinics.

Integrated care The committee received updates from the local boroughs of Barnet, Camden and Enfield on their Joint Strategic Needs Assessment and population priorities. It also received a report on the North Central London’s Sustainability and Transformation Partnership on its prevention work in respect of population health.

Prevention Green paper The committee received a review of the Department of Health and Social Care’s Prevention Green Paper - Advancing our health: prevention in the 2020s – and opportunities to strengthen the prevention role of acute trusts.

Partnership developments The committee received an update on Primary Care Networks, Clinical Practice Groups end to end pathways and hospital partnerships.

Future agenda items The committee agreed to receive the following at its next meeting in November:

• Clinical strategy • Presentation: Better births for vulnerable women

Action required


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



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FINAL


GOALS BAF

risks






From from Sir Chris Ham, non-executive director and chair of population health committee Author Veronica Jackson, group committee administrator Date 11 September 2019