board papers march 2015

Surrey and Sussex Healthcare NHS Trust

Board Papers

March 2015

Trust Board Meeting – IN PUBLIC

Thursday 26th March 2015 - 10:00 to 12:30

PGEC Room 7/8, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA

1

10:00

GENERAL BUSINESS 1.1 Welcome and apologies for absence 1.2 Declarations of Interests 1.3 Minutes of the last meeting held on 26th February 2015 - For approval 1.4 Action tracker 1.5 Chairman’s Report

For assurance

1.6 Chief Executive’s Report For assurance

1.7 Board Assurance Framework, & Significant Risk Register - For approval and assurance

A McCarthy A McCarthy A McCarthy A McCarthy A McCarthy M Wilson G Francis-Musanu

Verbal

Verbal

1.3_Minutes in Publi 26 2 15.pdf

Verbal

Verbal

1.6_CEO Report - March 2015 - Fnal.p

1.6a_2015-03-20 SASH letter of referr

1.7_BAF & SRR Report - Summary.p

1.7a_BAF Full Repor - March 2015.pdf

1.7b_SRR Full Report - March 2015

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10:30

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1 Clinical Presentation – Acute Oncology Service

For discussion

2.2 Chief Nurse & Medical Director’s Report For assurance

2.3 15 Step Challenge – Update Report For assurance

2.3 Safety & Quality Committee Update For assurance

D Holden D Holden/ F Allsop F Allsop R Shaw

2.1_Clinical Presentation- Patie

2.3_Fifteen Step Programme Update

2.4_ SQC Update Trust Board -Marc

2.2_CN MD Repo 26 March 2015.pd

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11:15

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M11)

For assurance

3.2.1 Operational & Quality Key Performance Indicators

3.2.2 Workforce Key Performance Indicators 3.2.3 Finance Key Performance Indicators

3.2 2015/16 Capital & Revenue Budget For Approval 3.3 Finance & Workforce Committee Update

For assurance

3.4 Audit & Assurance Committee Update For Assurance

P Bostock D Holden/ F Allsop F Allsop P Simpson P Simpson R Durban P Biddle

3.1_Integrated Performance Report

3.2_ 205-16 Revenue and Capita

3.3_FWC Chair Update.pdf

3.4_ AAC briefing BOARD 26th March 2

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11:55

RISK, REGULATORY AND STRATEGY ITEMS 4.1 Care Quality Commission Action Plan Update For assurance 4.2 Remuneration Committee Annual Report For assurance

F Allsop A McCarthy M Wilson

4.1_ CQC Improvement Plan Up

4.1a_CQC Improvement Plan

4.1b_CQC Improvement Plan

4.2_Nomination an Remuneration Ann

4.3 Mutual Pathfinder Programme - Feasibility Study For approval 4.4 National Staff Survey Report For assurance

Y Parker

4.3_Mutual Feasibility Study 2

4.3a_Feasibility Study revised form

4.4a_Summary o Results - Staff Sur

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12:25

OTHER ITEMS 5.1 Minutes from Board Committees

to receive & note 5.1.1 Finance and Workforce Committee

5.1.2 Safety & Quality Committee 5.1.3 Audit & Assurance Committee

5.2 ANY OTHER BUSINESS 5.3 QUESTIONS FROM THE PUBLIC

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to [email protected]

5.4 DATE OF NEXT MEETING

30th April 2015 at 10.00am

All A McCarthy A McCarthy

5.1.1_Minutes of t Finance and Workf

5.1.2_SQC Minutes 5-2-15 final.pdf

5.1.3_ AAC Minutes January 2015 - Fina

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Minutes of Trust Board meeting held in Public Thursday 26th February 2015 from 10:00 to 12:30

Room 7/8, PGEC East Surrey Hospital

Present

(AM) Alan McCarthy Chairman (YR) Yvette Robbins Deputy Chair (MW) Michael Wilson Chief Executive (PS) Paul Simpson Chief Finance Officer / Deputy Chief Executive (PBo) Paul Bostock Chief Operating Officer (DH) Des Holden Medical Director (SB) Sally Britain Deputy Chief Nurse (PBi) Paul Biddle Non-Executive Director (PL) Pauline Lambert Non-Executive Director (RS) Richard Shaw Non-Executive Director (AH) Alan Hall Non-Executive Director In Attendance

(GFM) Gillian Francis-Musanu Director of Corporate Affairs (SJ) Sue Jenkins Director of Strategy (SMB) Sacha Beeby Notes

1. General Business

1.1 Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, staff and members of the public. Apologies for absence were noted from Fiona Allsop (Chief Nurse) and Richard Durban (Non-Executive Director).

1.2 Declarations of Interest The Chairman asked if the Board members had any declarations of interest, none were recorded.

1.3 Minutes of the last meeting – 29th January 2015 The minutes of the meeting held on the 29th January 2015 were approved as a true and accurate record, with the following amendments made; Item 1.6 – Chief Executives Report (4th para)

Safeguarding Adults will be on a legal footing, meaning that there will be a duty on all local authorities to undertake safeguarding enquiries.

Item 1.7 – Board Assurance Framework & Significant Risk Register (6th para) AH challenged the current status of risk 4E in relation to Recruitment &

Retention strategy Item 3.1 – Integrated Performance Report (finance)

The Trust Board noted the adjustment of the year end position Item 4.1 – CQC Action Plan Update

Action: SJ to chart the progress to show what ‘good’ looks like.

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1.4 Action Tracker

The outstanding actions were completed and are now closed.

1.5 Chairman’s Report for Assurance Following a period of absence due to annual leave, the Chairman had nothing further to report to the Board.

1.6 Chief Executives report for Assurance The board received and noted the Chief Executive’s report in advance of the meeting. MW presented the report and highlighted the following; A report by Sir Robert Francis on the ‘Freedom to Speak Up’ review was published in February. This report identifies two over-arching recommendations, 20 principles and 36 specific actions that cover local and national organisations. The Trusts plans to address the recommendations will be reviewed by the Executive Committee and the Finance & Workforce Committee and an action plan will be developed and implemented. The House of Commons Health Committee report on Complaints and Raising Concerns was published in January. The report provides a follow-up review of the handling of complaints and concerns in the NHS since the Committee’s initial inquiry in 2011 into Complaints and Litigation. The report examines progress in implementing the relevant recommendations made in the original report and the government’s response. Locally, we will consider the recommendations from this report and undertake to review our complaints and other processes in light of the recommendations and will report back to the Safety & Quality Committee. YR questioned the extent of the challenge to achieve the standards of the recommendations made within the report. MW acknowledged that there was work to be done in improving our complaint handling processes and namely, how we respond to specific concerns and issues raised. It is expected that this improvement will be recognised by September 2015. PS further acknowledged the improvements which had already been made and the embedding of complaint handling within divisions. MW was pleased to report the opening of the Earlswood Centre which will accommodate clinics for the treatment of diabetes and endocrine patients. Feedback from patients and the community has been very positive and staff have acknowledged the additional capacity this has resulted in at East Surrey Hospital. Foundation Trust membership continues to grow and exceed our ambition to achieve a membership of 9,000, with a total of 9,888 members (including staff) now enrolled. This is a great position, considering the history of the Trust and will allow us to now consider the appointment of the Council of Governors. The launch of the appeal for the new Macmillan Cancer Support Centre which will be based at East Surrey Hospital took place on 27th January at Reigate Grammar School. The FWC have approved the business case for the build and the Board will remain informed of progress.

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In response to a question on membership engagement, MW confirmed that there were several mechanisms for communication and feedback from members, including social media and weekly reports from the Chief Executive to all Trust staff. MW highlighted that the National Staff Survey results were currently embargoed however, initial reports show the Trust positioned within the top 20 Trusts for ‘response rate’, ‘recommended places to work’ and ‘motivation in the workplace’. Areas which will need to be addressed include staff feeling harassed and bullied by the public and experiencing violence from members of the public. Security incidents and Datix reports have been reviewed and there appear to be no correlation – further investigation will be needed. A meeting scheduled with Surrey Police will help clarify the support they provide to the Trust in terms of mental health patients. SB acknowledged better systems in place to respond to the escalation of concerns raised by staff in relation to pressures in the workplace.

ACTION: National Staff Survey to be circulated to the Board for information and further discussion by the Board to be scheduled. GFM The report was duly noted by the board.

1.7 Board Assurance Framework and Significant Risk Register for Approval and Assurance GFM introduced the BAF and SRR for discussion and approval by the Board. GFM highlighted that the BAF continues to present 19 risks, 5 of which are recorded as key strategic risks and red rated. There are no new key issues to raise since the last Trust Board meeting in January. The Board was asked to approve the recommendation of one new risk which has been added to the Significant Risk Register, which currently records a total of 10 significant risks. The new risk relates to the continuing risk to the delivery of effective services and Trust strategic objectives caused by the resources required to actively manage the Trust’s rising sickness absence rate (1672). GFM further highlighted that the Annual Governance Statement must report all red-rated risks identified by the Trust on the Significant Risk Register. The Executive Committee recommends that the Finance and Workforce Committee review and downgrade risk 1605 in relation to the Trust not fully realizing the benefits available from well embedded I.T. systems. YR accepted PB’s methodology for calculating the risk against ED Performance and that no change was required, acknowledging that an increase in the likelihood of the risk would describe the Trust as being unable to deliver performance on a daily basis. This was not the case and the Safety & Quality Committee have accepted this. PBi recommended that the Trust undertake a review of existing, new and old risks relevant for 2015/16 and consider those risks which are now out of date. AM agreed that the Board should use the appropriate process to formally review and remove risks from the Significant Risk Register. AH raised concerns that the BAF was not truly reflecting the worsening position

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of the risks relating to staffing KPI’s and staff sickness absence as reflected on the Significant Risk Register. AH further challenged whether the Trust was putting sufficient emphasis on staffing risks and noted that the Finance & Workforce Committee had not provided assurance on this matter. PS acknowledged an increase in agency usage, in recognition of activity levels within the Trust. PS further agreed that the Finance & Workforce Committee should receive the relevant information it needs to better inform its membership and the Board and to convey the level of concern attributed to the Trust’s key strategic risks. The board approved the report.

2. Safety, Quality and Patient Experience 2.1 A Patient’s Story

This item will be carried forward to the Trust Board meeting on 26th March 2015.

2.2 2.2.2

Chief Nurse and Medical Director’s Report for Assurance The board received and noted the report in advance of the meeting. SB presented the first half of the joint report focusing on the safer staffing report for January 2015 and invited the Board to further discuss the current position against the Right Staffing Review for Nursing and Midwifery. SB noted an error within the report against Safer Staffing compliance data for Godstone Ward (Medicine) during January. With a total of 17 ward entries and an expected range between 92% and 95%, there are no significant concerns in relation to current ward staffing levels. SB highlighted that the Trust score for total staffing compliance during January was 95.09%, with registered nursing compliance at 94.76% during the day and 92.63% at night which indicates a reduction in compliance against last month and is reflective of activity levels across the Trust during January. With the use of escalation beds and the opening of Capel Anex, shifts have been difficult to fill. During the day, wards were supported by the senior nursing teams and by the enhanced site and outreach teams at night. It was acknowledged that the clinical site teams were managing staff levels across the Trust in a very different way and this was helping the wider position. 20 nurses from the Philippines will commence on 23rd March as part of the International Recruitment initiative and this will further enhance our registered nursing pool and support the safer staffing initiative. The provision of agency nursing staff has been of high clinical quality during the Bank Holiday Christmas period. Agency staff were offered enhanced pay to cover the increased activity and escalation during that period, which was funded by the Agency itself and not by the Trust. Appendix paper – Right Staffing Review – current position. SB highlighted that in April 2014, the Board agreed a staffing profile for general wards of 1 registered nurse to 7 patients during the day and 1 registered nurse to 10 patients at night. The agreed registered to unregistered split was 65:35 and was planned to be enacted over an 18 month period from November 2014.

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Progress has been made in delivery against this plan but the Trust has been unable to recruit sufficient registered nurses to deliver the 1:10 ratio at night. It is anticipated that this will be delivered through the Summer of 2015. Despite the Trust successfully meeting the challenge presented by nursing turnover, significant challenges remain in meeting the uplift required to meet the revised staffing ratios by October 2015. However, the Trust will be back on track to deliver the agreed timescale with the international recruitment of Philippine nurses. AH challenged the need for clarity around planned establishment against the 1:7 and 1:10 ratio and highlighted that the Board should be informed of what it is planning for and to better understand where the Trust is against the aspiration. Action: Additional column to describe the gap between the aspiration and the current position. FA/SB MW noted that the position will change as a result of two additional wards occupying 40 additional beds. DH continued to report that the Patient Safety Executive meetings have been very successful, with clinical and non-clinical managers discussing patient safety issues to ensure learning is disseminated throughout the organization. Non-Executive Directors are invited to attend where possible. The Board duly noted and took assurance from the report.

2.3 Safety & Quality Committee Update for Assurance The board received and noted the report in advance of the meeting. The report summarised some of the key discussion points of the last committee meeting held on 5th February 2015. RS highlighted that the Committee had noted and discussed some of the key issues of winter pressures during December and January. It was apparent that a combination of A&E pressures and the ability to discharge patients has impacted adversely on services such as fractured neck of femur, stroke and paediatrics, as well as on cancellation of elective operations. A review of pressures was undertaken by the Executive Committee and is presented to the Board at Item 3.1. The committee received a half-yearly report on infection control and noted that there had been no MRSA blood stream infections over more than 365 days. Since the committee meeting, DH noted that there has been one reportable case of MRSA however, it is not thought to be blood stream. RS further highlighted that the committee had sought assurance about adverse patient experience comments posted on the Patient Opinion website relating to care in the maternity unit. Comments and subsequent actions are being managed by the Medical Director and relevant Chiefs. MW provided a verbal update in respect of the national initiative to reduce Medically Fit for Discharge lists amongst Trusts. The Trust is agreeing a plan for 50% reduction with CCG and community provider collaboration. The board duly noted the report for assurance.

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3. Operational Performance

3.1. Winter Debrief Presentation

PB presented a summary of performance during the Christmas and New Year period, a period of extreme operational pressures and opportunity for learning. A succession of events saw high volumes of admissions from early December and caused extended recovery backlog with extreme levels of breeches. In summary, the pattern of ED attendances and resulting admissions was a key driver of the poor performance against the ED standard. With the hospital at maximum occupancy, there was minimal room to absorb consecutive ‘abnormal’ levels of activity. There is a clear time lag between abnormal admission levels and growth in the number of medically fit for discharge (MFFD)’s in the hospital. This can be forecast to allow pro-active rather than re-active planning by local partners. Following a review and reflection by the Executive Committee and divisional leads, a number of actions were agreed to ensure future planning and preparation for expected increases in activity levels during peak times of the year (Including Christmas and New Year and Easter Bank Holiday). Some of those actions include;

Improved escalation plans within divisions with ED consultant cover at weekends and advance reduction in elective commitments

Working group to move to a daily consultant face to face review of all patients 7 days a week

Cabinet Office support to reduce the number of MFFD patients. The divisions have commenced planning for staffing Easter Bank Holiday – with Bank Holiday Monday (6th April) operating ‘business as usual’. The Easter Plan will be presented and approved by the Executive Committee in March. The Board recognised how versatile the clinical teams have been in response to the operational pressures faced. Extreme activity levels have been experienced by Trusts and community organisations across the national health system. Councils have heavily invested in the services of the hospital and integrated care remains a primary issue. AM noted the importance of balancing the risk across the health system and ensuring those risks are shared outside of the Trust. The option to close the hospital, divert patients to an alternative Trust or declare Major Incident is greatly discouraged or has no mechanism to enact. MW added that the flu vaccination was not attributed to the peak in emergency admissions. The Board duly noted and took assurance from the report.

3.2. Operational and Quality Key Performance Indicators The board received the Integrated Performance report in advance of the meeting.

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PBo summarised the Trust’s operational performance during January 2015. In January, 92% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches. Delivery of the 4 hour standard remains a challenge across the country and despite the under-performance at the Trust, we remain one of the best performing Trusts in the country. In light of on-going operational pressures in the Trust, two additional risks have been added to the Significant Risk Register recognising capacity to manage winter pressures and ability to place patients into the right bed, first time. Admitted and incomplete pathways RTT standards were achieved at aggregate level while the non-admitted standard was not achieved. There were a number of specialty failures of the admitted and non-admitted standards as work is undertaken to reduce the number of patients waiting over 18 weeks for treatment. PBo noted that every Trust must have an 18-week backlog; an element of this will be attributed to patient choice and those on complex pathways. The Trust continues to monitor ward nursing on a daily basis and is assured that adequate staffing is in place. The Trust reported two new cases of C.Diff, taking the total to 17 YTD against a total of 24 YTD. In light of recent outbreaks of viral gastroenteritis, a risk has been added to the Significant Risk Register to acknowledge the impact on patient safety and experience. Staff turnover increased marginally to 15.7% in January, with actions to improve recruitment and retention being supported by HR Business Partners. SB confirmed that the Trust’s ambition was to reduce the current level of turnover, and accepted that further work was needed on retention strategies. However, this was an acceptable level and should eventually inform the Trust’s recruitment strategy. PS accepted that better understanding was needed in relation to the methodology for calculating staff turnover. SB further added that long-term sickness absence was currently being managed by Matrons. With extreme levels of activity across the Trust, stress-related absence was expected to be high. The Workforce Committee will undertake to review reasons for absence and levels of stress reported amongst the workforce. The new achievement review process will be rolled out across the Trust and will replace the current appraisal processes. The new process should result in an improvement in performance relating to the number of staff appraisals undertaken. MW further added that the quality of staff appraisals appears to be perceived positively, according to the most recent national staff survey. PS reported that the Trust remains on plan at Month 10 with a £1.9m surplus year to date. Divisions continue to spend higher than budget, however, as expected this is offset by income and the Trust is still within forecast despite levels of emergency activity within the Trust peaking in December, and remaining high in January. The year to date income continues to include an accrual in respect of challenge

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to CCGs over the level of emergency activity and the withheld marginal rate, as well as 2 tranches of winter resilience funding. The forecast year end position remains a £2.3m surplus. The risks to this position have been estimated at £5.5m. The downside is a risk of a £2.5m deficit. The output from discussions over East Surrey CCG disputes and the marginal rate tariff are the key factors. The board noted that Crawley, Horsham and Mid Sussex CCG have not made any challenges of their own in respect of those raised by East Surrey CCG. The cost improvement plan year to date target is £8.6m and at M10 this has been achieved. The underlying position at the end of January is £2.5m deficit, reflecting the non-recurrent funding in the year to date position setting off costs from emergency activity and reduced elective income. The forecast year end underlying position is £5.2m, as reported last month. The cash balance at the end of January 2014 was £3.8m, below the planned position due to the delay in receiving contract payments from CCGs. The cash position is becoming more challenging as there are delays in agreeing income figures and significant financial challenges from CCGs and as a result, an application for temporary borrowing is being made. The capital forecast spend has been adjusted to £19.3m (reduction of £100k in respect of Salix funding & expenditure as agreed with TDA). The Board duly noted and took assurance from the report.

3.3 Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting AH highlighted some of the key points of discussion from the FWC meeting held on 24th February 2015. The committee received and approved a full business case regarding the Macmillan Cancer Information Centre which will be developed on the East Surrey Hospital site. The total capital cost is expected to be £1.95m and includes a 10% contingency. Of this, £1.50m is being funded by Macmillan and £0.45m by the Trust. Building is due to start in March 2015 and finish in October 2015. The committee received the month 10 reports for finance, workforce and development, capital and I.T. The Trusts financial position was noted as described above. AH further highlighted concerns of the committee in relation to workforce and the growing levels of sickness absence and vacancies across the Trust. The committee will seek further assurances from divisional reporting at the next committee meeting in March. The Board duly noted the report.

4. Risk, Regulatory and Strategy Items

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4.1 CQC Improvement Action Plan for Assurance The Board received and noted the report and action plan in advance of the meeting. Sue Jenkins, Director of Strategy presented the CQC Action Plan which was developed following a visit by the Chief Inspector of Hospitals in May 2014 and in response to their findings in relation to service improvement. The board receives a monthly update on progress against the action plan. The Trust has formally responded to the CCGs letter of response in respect of the system wide issues identified at the quality summit, requesting greater clarity. This report now includes an update on the actions agreed by other parties that were recommended at the quality summit. Action 2.4 – Implementation of the outpatient partial booking system has been postponed due to lock down of Cerner until June 2015. SJ noted the action from the previous Trust Board meeting to include KPI’s describing the expectation. The Board duly noted and took assurance from the report.

4.2 Cost Improvement Plan Review 14/15 for Approval The board received and noted the report in advance of the meeting. PS presented the report which outlines the current position on Quality Impact Assessments of the schemes making the Trusts 2014-15 CIP programme. The QIA process in the Trust has a clear policy with governance structure and is owned by the Medical Director and Chief Nurse. The CQC and QGAF assessment identified that the Trust had not embedded the in-year review element of the process; this has now been completed and identified the need for more regular feedback to the Medical Director and Chief Nurse to ensure that the full benefit of savings is identified in a timely way to allow intervention and to review why schemes had not been started. The Finance & Workforce committee discussed the QIA process in December and the Medical Director has since recommended changes to the process to allow greater real-time detail. In summary, the process is considered adequate, the operation of the process requires attention but there is no significant assurance or controls gap. DH further added that he was very happy with the process of divisions identifying risk assessments for approval by the Medical Director and Chief Nurse. DH further acknowledged that the review process operated less well. PBi suggested that it would be helpful for the Board to receive examples of schemes which have been rejected on quality grounds. DH added that the number of schemes rejected on quality grounds was very low.

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The report did not clearly demonstrate management of implementation plans to reflect the assessment given at the beginning of the year and any amendments made during the review process. The board resolved to approve the report.

4.3 Annual Plan Quarterly Progress Update for Assurance The board received and noted the report in advance of the meeting. SJ presented the report which provides an update on progress against each of the actions from the annual operating plan for quarter 3. Overall, delivery of the plan was on track. The Board duly noted and took assurance from the report.

5. Other Items

5.1 Minutes of Board Committees to receive and note 5.1.1 Finance and Workforce

The minutes of the committee were noted with no questions raised.

5.1.2 Safety & Quality Committees to receive and note The minutes of the committee were noted with no questions raised.

5.2 Any Other Business PL asked the board to acknowledge personal thanks on behalf of her family to the nursing team and staff involved in the care of a family member who was recently admitted onto Tandridge Ward via E.D. with complex needs. No further business was discussed by the Board.

5.3 Questions from the Public There were no questions raised from members of the public.

5.4 Date of the next meeting Thursday 26th March 2015 at 10.00am in Room 7/8, Post Graduate Education Centre, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman: Date:

TRUST BOARD IN PUBLIC

Date: 26th March 2015 Agenda Item: 1.6

REPORT TITLE: CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

REPORT AUTHOR (s): Gillian Francis-Musanu Director of Corporate Affairs

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) N/A

Action Required:

Approval ( ) Discussion (√) Assurance (√)

Purpose of Report:

To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction.

Summary of key issues

National Issues: Independent investigation published into maternity and neonatal services at Morecambe Bay Care Quality Commission Requirement to Display Ratings Local Issues: Trust Development Authority Recommendation to move Trust to the Monitor Assessment Phase NHS England National “Breaking the Cycle” Initiative - Local Implementation

Recommendation:

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Relationship to Trust Strategic Objectives & Assurance Framework:

SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Corporate Impact Assessment:

Legal and regulatory impact Ensures the Board are aware of current and new requirements.

Financial impact N/A

Patient Experience/Engagement Highlights national requirements in place to improve patient experience.

Risk & Performance Management Identifies possible future strategic risks which the Board should consider

NHS Constitution/Equality & Diversity/Communication

Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: 1.6a TDA Letter

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TRUST BOARD REPORT – 26th March 2015 CHIEF EXECUTIVE’S REPORT 1. National Issues 1.1 Independent investigation published into maternity and neonatal services at

Morecambe Bay The Morecambe Bay Investigation was established by the Secretary of State for Health to examine concerns raised by the occurrence of serious incidents in maternity services provided by what became the University Hospitals of Morecambe Bay NHS Foundation Trust which included the deaths of mothers and babies. Relatives of those harmed, and others, expressed concern over the incidents themselves and why they happened, and over the responses to them by the Trust and by the wider National Health Service (NHS), including regulatory and other bodies.

A thorough and independent investigation of these events took place, covering the period from 1 January 2004 to 30 June 2013. The Investigation Panel included expert advisors in midwifery, obstetrics, paediatrics, nursing, management, governance and ethics. A total of 15,280 documents from 22 organisations were reviewed and 118 individuals were also interviewed between May 2014 and February 2015. Family members of those harmed were invited to attend interviews and Panel meetings as observers.

The report details a distressing chain of events that began with serious failures of clinical care in the maternity unit at Furness General Hospital, part of what became the University Hospitals of Morecambe Bay NHS Foundation Trust. The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS. Had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been broken. As it is, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious.

Also included in the report are detailed and damning criticisms of the maternity unit, the Trust and the regulatory and supervisory system. In view of the progress that is now undoubtedly being made in all these areas, the necessity for this Investigation to lay bare all of this may perhaps be questioned, both by Trust staff (who undoubtedly feel beleaguered) and by others. There are two reasons to resist this view. First, although the signs of improvement are welcome, they are still at an early stage and there have been previous false dawns in the Trust; this emphasises the importance of understanding fully the extent and depth of the changes necessary. Second, there is a clear sense that neither the Trust nor the wider NHS has yet formally accepted the degree to which things went wrong in the past and admitted it to affected families; until this happens, there is little prospect of those families accepting that progress can be made.

The report makes 44 recommendations of which 18 are for the Trust to address directly, and 26 for the wider system. The government has confirmed that they will examine the recommendations in detail before providing a full response. At SaSH we are very proud of the high quality of care provided in our maternity and neonatal services. However, as part of the wider NHS we will review the report and take stock of the recommendations and ensure that all relevant lessons are learnt from this report. Full details of the report can be found at: https://www.gov.uk/government/news/investigation-report-into-morecambe-bay-published

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1.2 Care Quality Commission Requirement to Display Ratings

The public has a right to know how care services are performing. To help them to do this, the Government has introduced a requirement for providers to display CQC ratings. The ratings are designed to improve transparency by providing people who use services, and the public, with a clear statement about the quality and safety of care provided. The ratings tell the public whether a service is outstanding, good, requires improvement or inadequate.

The guidance details the following points:

If organisations have been awarded a CQC rating (outstanding, good, requires improvement or inadequate) there is now a requirement to display it in each and every premises where a regulated activity is being delivered, in your main place of business and on your website, where people will be sure to see it. This is a legal requirement from 1 April 2015.

Ratings must be displayed at the premises where your service is being provided unless you are delivering care to someone in their own home.

The CQC will assess whether or not your ratings are displayed legibly and conspicuously – not doing so may result in a fine and may impact on future inspection ratings.

The CQC will make posters for physical display of ratings available to download from their website. Using the CQC posters will ensure organisations include all the information as set out in the Regulation.

Ratings must also be displayed online if organisations have a website Services regulated by the CQC, but which are not awarded a rating (for example

dentists), are exempt from this requirement. Organisations will have a maximum of 21 calendar days to display ratings from the

date your inspection report is published on the CQC website.

Organisations are ultimately responsible for meeting the Regulation.

The Trust currently displays the appropriate rating on our website and once the posters are available from the CQC will ensure that these are displayed in compliance with the requirements. Full guidance is available: http://www.cqc.org.uk/content/display-ratings

2. Local Issues 2.1 Trust Development Authority to Recommend Trust to move to the Monitor

Assessment Phase The Trust Development Authority at its Board meeting on 19th March 2015 has given formal confirmation of referral of Surrey & Sussex Healthcare NHS Trust to the Monitor assessment phase. The formal letter from is attached. This is a very positive outcome for the Trust in our journey toward Foundation Trust status. 2.2 NHS England National Breaking the Cycle Initiative - Local Implementation The aim of “Breaking the Cycle initiative” is to rapidly improve patient flow to produce a step-change in performance, safety and patient experience. The initiative is typically run over one week during which the whole organisation and its health and social care partners focus on improving the emergency care pathway.

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Our implementation of this initiative takes place from Tuesday 7th – Friday 10th April with the objective of micromanaging each inpatient journey with the aim of improving patient care and improving patient flow. All patients will be reviewed twice daily by a Consultant (full Ward round in the morning / Board Round review in the afternoon) and all wards will have a dedicated team of juniors to carry out tasks arising from the ward round in a timely manner. All wards will have the Nurse in Charge attending the Ward round and a liaison officer to help teams chase and resolve any delays. A focused management structure will be in place during the week that ensures any delays which cannot be resolved at ward level are escalated to nominated leaders with a view to rapid resolution.

3. Recommendation

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Michael Wilson Chief Executive March 2015

Ref: PC/JL/MC 20 March 2015 Alan McCarthy Chairman Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH Dear Alan Application for NHS Foundation Trust status I am writing following the meeting of the NHS TDA Board on 19 March 2015 when we considered the application for NHS Foundation Trust status from Surrey and Sussex Healthcare NHS Trust. I am pleased to confirm that the Board approved the referral of your application to Monitor for assessment. The paper and presentation received by the Board set out the assurance process that has been followed by the NHS TDA and a summary of the key issues considered in relation to quality, delivery and sustainability. In considering the application, the TDA recognised the strong progress on delivery and quality during the previous three months. Clearly, it will be vital that this momentum is maintained in order to meet fully the key quality standards in the TDA Accountability Framework and to ensure continued compliance with the Monitor terms of authorisation. The NHS TDA will continue to work closely with you to ensure that your progress is sustained and to maintain oversight of your broader performance on quality, delivery and sustainability as you move through the assessment process. I am copying this letter to Monitor and the Department of Health. Monitor will contact you shortly to formally begin the assessment process and you will then need to progress your application in accordance with the Guide for Applicants.

I want to finish by congratulating you on the progress achieved to date and wishing you every success for the future. Yours sincerely

Sir Peter Carr Chairman NHS Trust Development Authority Copy: Michael Wilson, Chief Executive, Surrey and Sussex Healthcare NHS Trust David Flory, Chief Executive, NHS TDA Jim Lusby, Director of Delivery and Development, NHS TDA David Bennett, Chief Executive, Monitor Richard Douglas, Director General, Strategy, Finance and NHS, Department of Health

1 An Associated University Hospital of

Brighton and Sussex Medical School



REPORT TITLE: Board Assurance Framework & Significant Risk Register

EXECUTIVE SPONSOR: Gillian Francis-Musanu Director of Corporate Affairs

REPORT AUTHOR (s): Colin Pink Corporate Governance Manager

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Team 11th March 2015, AAC 17Th March 2015, FWC 24th March 2015

Action Required:

Approval (√) Discussion (√) Assurance (√)

Purpose of Report:

The BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions, and the implementation of its programme of objectives for year one of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework.


The BAF details 19 risks to the trusts strategic objectives (with a proposal to close 1), subject to Board approval 3 of which are recorded as key strategic risks and red rated (Section 4). The Board is asked to consider the proposals to reduce the risks relating to divisional overspend and strategic information risks and close the strategic clinical leadership risk. There are 8 significant risks recorded on the Trust risk register as the operational risk related to divisional overspend and IT implementation has reduced and no longer meets the threshold.

Recommendation:

The Board is asked to discuss and approve the report and consider the following: Review the BAF and its alignment to strategic objectives Does the Board agree with the recorded controls and assurances Approve the proposals to reduce the two BAF risks Approve the proposal to close and remove the BAF strategic risk relating to

clinical leadership


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model




Legal and regulatory impact The report is a requirement for all NHS organisations.

Financial impact As discussed in sections 5 (Income generation linked to activity referred to throughout the document)

Patient Experience/Engagement Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management These are highlighted throughout the report.


Discussed throughout the report but with the greatest detail in objective 3.

Attachment:

March 2015 BAF and the current SRR



TRUST BOARD REPORT – 26th March 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1. Board Assurance Framework The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2014/15: 1) Safe: Deliver safe services and be in the top 20% against our peers

2) Effective: Deliver effective and sustainable clinical services within the local health economy

3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2. Current status The Executive Team, Audit and Assurance Committee and Finance and Workforce Committee reviewed the existing BAF throughout March 2015 and have made updates accordingly. The changes made reflect conversations at the February public Board, updates on financial position and changes identified through reports reviews of assurances and actions considered by the Finance and Workforce Committee. There are 3 main proposals for the Board to Consider; the reduction of the financial risk relating to divisional overspend to a risk rating of 12 (5.A.2, discussed at AAC), the reduction of the strategic risk for IT to 12 (5.F, discussed at FWC) and the closure of the strategic risk relating to clinical leadership (5.B, reduced to target risk).



Should the proposals be accepted the BAF (attached) would detail a total of 18 risks to the 5 Trust strategic objectives which are scored as follows:

Objective Red (15-25)

Amber (8-12)

Green (1-6)

1.Deliver safe services and be in the top 20% against our peers 0 2 0

2.Deliver effective and sustainable clinical services within the local health economy 0 1 1

3.Ensure patients are cared for and feel cared about 0 2 1

4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

1 3 0

5. Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

2 5 0

Total 3 13 2

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood).The tables below highlight the predicted swing in risk rating. Table 1: Current BAF Risk Profile



Table 2: Target BAF Risk Profile

3.1 Headline information by objective (BAF)

Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.A.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties, supported by robust monitoring mechanisms (Page 2)

S4 x L3 = 12 S4 x L3 = 12 S3 x L2 = 6

1.A.1 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care (Page 4)

S4 x L3 = 12 S4 x L3 = 12 S5 x L2 = 10

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy



Target Risk Score

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties (Page 5)

S3 x L3 = 9 S3 x L2 = 6 S2 x L2 = 4

2.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities (Page 6)

S4 x L3 = 12 S4 x L3 = 12 S4 x L1 = 4



Objective 3 - Caring – Ensure patients are cared for and feel cared about



Target Risk Score

3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients (Page 8)

S3 x L3 = 9 S3 x L4 = 12 S3 x L2 = 6

3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients (Page 10)

S3 x L4 = 12 S3 x L3 = 9 S3 x L1 = 3

3.D.1 There is a Risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff (Page 12)

S2 x L4 = 8 S2 x L3 =6 S2 x L1 = 2

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population



Target Risk Score

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care (Page 13)

S3 x L4 = 12 S4 x L4 = 16 S3 x L3 = 9

4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective (Page 14)

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6

4.D There is a risk that the Trust may not realise the benefits of service development opportunities which are fully appropriate for the local community unless partnership working and links between strategic partners are improved (Page 15)

S4 x L3 = 12 S4 x L3 = 12 S4 x L2 = 8

4.E There is a risk that if That recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services (Page 16)

S3 x L4 = 12 S3 x L4 = 12 S3 x L2 = 6

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Target Risk Score

5.A.1 Failure to deliver income plan (Page 17) S5 x L3 = 15 S4 x L4 = 16 S4 x L2 = 85.A.2 Failure to stop divisional overspending against budget (Page 18) S5 x L3 = 15 Proposed Risk

S5 x L2 = 10 S3 x L2 = 6

5.A.3 Unable to provide realistic medium term financial plan (Page 19) S5 x L3 = 15 S4 x L3 = 12 S4 x L2 = 8

5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position (Page 20)

S5 x L3 = 15 S5 x L3 = 15 S4 x L3 = 12

5.B There is a risk that Clinical leadership efforts will not be embedded if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates (Page 21)

S4 x L2 = 8 Proposed to

close S4 x L1 = 4

S4 x L1 = 4



Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Target Risk Score

5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care (Page 22)

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6

5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision (Page 23)

S4 x L2 = 8 S4 x L2 = 8 S4 x L1 = 4

5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems (Page 24)

S5 x L3 = 15 Proposed Risk S4 x L3 = 12 S5 x L2 = 10

4. Key risks Strategic risks Identified Subject to the Boards approval the BAF would highlight the following 3 key red risks to the Trust objectives that have been identified at time of updating the framework. These are:

Risk description Current rating

Target risk score

Page

4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care

S4 x L4 = 16 S3 x L3 = 9 P13

5.A.1 Failure to deliver income plan

S4 x L4 = 16 S4 x L2 = 8 P17

5.A.2 Failure to stop divisional overspending against budget

Proposed Risk S5 x L2 = 10 S3 x L2 = 6 P17

5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position S5 x L3 = 15 S4 x L3 = 12 P20

5.F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

Proposed Risk S4 x L3 = 12

S5 x L2 = 10 P24

5. Significant Risk Register On the 11th March the Executive Committee reviewed and agreed the content of the significant risk register. There are 8 risks on the Trust significant risk register. Each is in date and has mitigating actions to reduce the level of risk to an acceptable level. The Executive Committee and agreed the proposal to reduce the operational risks relating to divisional overspend and IT implementation. There are 8 significant risks on the risk register. The risk relating to the outbreak of viral gastroenteritis was considered and agreed that it would remain on the SRR as the operational risk is still considerable.



5.1 SRR Breakdown

ID Title Initial Rating

Current Rating

Residual Rating

Next Review

1401 Risk of outbreak of viral gastroenteritis 16 15 9 31/03/2015

1480 Risk that non elective does not reduce and no payment in respect of marginal tariff

16 16 6 31/03/2015

1491 Failure to maintain Emergency Department performance 20 16 6 31/03/2015

1501 Patient admitted to the right bed first time 9 15 6 31/03/2015

1601 Risk that demand growth activity does not deliver the plan

16 16 8 31/03/2015

1604

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

15 15 12 31/03/2015

1652

The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to

16 16 8 31/03/2015

1672

Increasing Sickness Absence Levels with impact on day to day management and expenditure

15 15 9 01/04/2015

6. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following:

Review the BAF and its alignment to strategic objectives. Does the Board agree with the recorded controls and assurances. Does the Board agree with the proposed reductions to the BAF Risks 5.A.2

and 5.F. Does the Board agree with the closure of the BAF risk 5.B.

Colin Pink Corporate Governance Manager, March 2015



Appendix 1: Risk Appetite for 2014/15 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives.

The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well.

The key following principles further define this stance with an opinion from the Board:

Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green

Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice. Target: Amber

Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will endeavour to meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. Target: Green

Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber

Reputation: The board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green

Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. Target: Amber/Green

1

Board Assurance Framework

March 2015

Presented by: Gillian Francis-Musanu (Director of Corporate Affairs)Author: Colin Pink (Corporate Governance Manager ) and the Executive Team

An Associated University Hospital of


Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Chief Nurse

Initial Risk S4 x L3 = 12Key Action for 2014/15 objectives and description of any potential significant risk to this priority

1.A.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties, supported by robust monitoring mechanisms. (Falls management is a specific focus and therefore highlighted)

Current rating S4 x L3 = 12

Target risk score

S3 x L2 = 6

Linked to Risk 1055 and 1545

Controls in place (to manage the risk) Gaps in Control 1) Clinical teams to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2) Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3) Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance. 4) Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5) Matron on site 7 days a week 6) Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7) Nursing and Maternity Strategy and Nursing staffing levels with daily real-time escalation 8) Incident reporting policy to be reviewed to include recent structural changes 9) Ward safety boards 10) Serious incident review group established to monitor and evaluate investigation progress and progress against actions Specific Falls management controls 1) Falls management policy in place 2) Training undertaken for clinical staff in the assessment and management of

patients at risk of falls 3) Falls pathway developed and operational for assessment of patient fall risk and

those at risk of falling line in with NICE guidance June 2013 4) Patient falls strategic group meet monthly and report KPIs to the patient safety

and clinical risk committee. 5) Falls Operational Board meet weekly to share investigation and learning from all

complex, major and moderate falls. 6) Audit of falls policy and falls process undertaken and results and actions

escalated to the appropriate operational and governance groups 7) Monthly reporting at Executive committee for Quality enabling improved

understanding of falls and any gaps in falls management strategies 8) Divisional reporting, oversight and ownership of falls 9) Equipment audit and review undertaken 10) Falls and patient safety consultant nurse appointed, start date 1 December 11) Datix incident reporting in place and all serious falls investigated using SI

methodology 12) Lead trust in south area falls network

1) Lack of system to differentiate between Trust and community acquired cases of VTE Specific gaps in Falls management controls 1) ED Falls pathway – under development 2) Consistency of joint working with community falls teams

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) Patient safety related KPI agreed and monitored at Board and Divisional Level 2)Meeting minutes and action plans, evidence of presentations and board discussion 3) External reports and visits both scheduled and unscheduled (including new CCG quality visits) 4) CQC intelligent monitoring rating 5) Patient tracking and analysis (Whiteboard project) 6) 15 Steps quality program Specific Falls management sources of assurance

1) Datix incident reporting and analysis 2) Monthly trust wide reporting using national benchmarking 3) Training data 4) Annual Falls Report 13/14 5) Clinical Nurse Consultant for Falls and Patient Safety commenced 4

December 2014

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends Negative (-) Never events incidence low (1 in last 12 Months, low harm) (-) NRLS reporting Specific assurances regarding Falls management Positive (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Established links with falls team within community

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time National Safety Dashboard to be implemented once produced

Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Develop Emergency Department falls pathway

1) May2015

Update by FA 20/03/15

Date discussed at board To be discussed at March Board

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A.1 Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Medical Director

Initial Risk S4 x L3 = 12

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

1.A.1 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care


Target risk score S5 x L2 = 10 Linked to Risk 1049 and 1050

Controls in place (to manage the risk) Gaps in Control 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA). This presentation is done in departmental meetings with IC doctor and Nurse attendance. This increases learning in the clinical team when compared to consultant attendance at IC meeting. 7) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 8) 3 ICE-POD units in place – ED, HDU and Hazelwood. 9) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 10)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 11)Antibiotic Stewardship group revitalized 12)Decontamination group informing development of strategy for IPCAS

1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)



1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes

Positive (+)No C. diff outbreaks declared in year 2013/14 (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (+) Recent CQC inspection highlighted improvements in MRSA screening (+)TDA visit inspecting controls and procedures (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Data quality indicated in Internal Audit of Quality Account (2013/14) (+)First seasonal outbreak of Norovirus 2014/15 was contained to one area (+)Incidence of CDI 2014/15 Negative (-)3xMRSA BSI case during 2013/14, 0 to date 2014/15 (-)Period of increased incidence of CDI Godstone ward, typing suggests cross infection (-)Period of increased incidence of CDI Meadvale ward, typing suggests cross infection

Gaps in assurance Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known


1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated

1) Embedding 2) 2014/15 3) Ongoing

Update by DH 23/03/15

Date discussed at Board To be discussed at March Board

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.A Achieve the best possible

clinical outcomes for our patients Director responsible Chief Nurse / Clinical Leads

Initial Risk S3 x L3 = 9 Key Action for 2014/15 objectives and description of any potential significant risk to this priority

2.A.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking outcomes are not utilised and implemented appropriately across divisions and specialties


Target risk score

S2 x L2 = 4

Linked to Risk 844

Controls in place (to manage the risk) Gaps in Control 1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads

1) Evidence of learning from incidents/outcomes



1. Regular data collection 2. PROMS 3. Minutes of divisional meetings including M & M 4. Minutes of Clinical Effectiveness and Patient Safety and Risk

subcommittees 5. Patient tracking and analysis (whiteboard project) 6. Datix reporting and analysis 7. Clinical Nurse Consultant for Patient Safety and Falls commenced

02/12/14 8. Results from National Clinical Audit Programme 9. Benchmarked reports from Academic Health Science Network

Enhancing Quality and Recovery Programme

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+)The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence low (1 in last 12 Months, low harm) (-) NRLS reporting

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time National Safety Dashboard to be implemented when available


1) Development of ward based performance dashboards 1) Start date 12/01/2015



Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.B Deliver services differently to

meet need of patients, the local health economy and the Trust

Director responsible Chief Operating Officer


2.B.1 There is a risk of a loss of elective business to outside provider if we do not align our activity to local commissioning priorities


Target risk score

S4 x L1 = 4

Linked to Risk No specific risk recorded on the operational risk register

Controls in place (to manage the risk) Gaps in Control 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Still to agree 15/16 contract with BICS



1)Letters of intent 2)Contracts 3)Meeting minutes

Positive (+) Commitment from all parties, initial plans and agreements good (+) Consultant engagement in pathway redesign (+) Recent experiences and management of Dermatology services (+) Current referral flows likely to remain until Q1 2015/16 (+) Contract 14/15 signed with BICS Negative (-) Other services provided could be effected by the outcome of this model (-) Cancellation rates and effect on elective case management

Gaps in assurance Assurance Level gained: RAG Contract to be agreed with BICS, undefined staff model (TUPE) and activity undefined


1)Appropriate pathways to be determined and developed 2)Currently Negotiating 15/16 contract with BICS

1)Q4 2014/15 2)Q4 2014/15

Update by PB 20/03/15


Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3.B Deliver high quality care around

the individual needs of each patient Director responsible Chief Nurse and Medical Director


3.B.1 Failure to recruit and retain clinical staff may result in excessive usage of agency and may impact negatively on Trust’s quality of care provided to patients.


Target risk score S3 x L2 = 6 Linked to Risk 1416, 1652

Controls in place (to manage the risk) Gaps in Control 1. Workforce KPIs including vacancy rates, turnover and temporary

staffing monitored by Workforce subcommittee, Exec Committee and the Board

2. Nursing Recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored through Agency PMO, Workforce subcommittee and divisional team meetings

3. Recruitment process reviewed, KPIs under development to provide assurance

4. Bank workstream developed and bank recruitment in progress to reduce use of agency nursing staff

5. Review of MAST and induction processes to be undertaken to ensure they meet operational requirements

6. Marketing plan in development 7. Weekly PMO focusing on agency usage 8. SASH funded by HEKSS to develop and lead on physician associate

training and recruitment for SEC 9. SNCT data presented and approved at November Board 10. Foundation doctors workloads re-modelled such that 95% of time is

spent with no more than 14 patients.

1) E-Roster system is not updated out of hours 2) Unfilled agency shifts 3) Staffing Ratios in some areas of the Trust at night are under review 4) The Trust still carries a volume of vacancies specifically within ITU and theatres 5) Imperfect induction for short notice, short term medical locums 6) Aiming for full recruitment (influenced by HEKSS)



1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs.

2. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. Daily Nursing review “planned vs actual” 7. References from other local employers 8. Revalidation (GMC) for locums 9. SOP developed for the management of nursing staffing

Positive (+)SNCT data (+)Further recruitment planned has been undertaken Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates (-) Temporary staffing Internal Audit

Gaps in assurance Assurance Level gained: RAG Trust position known - no identified gaps in assurance

Mitigating actions underway Progress against mitigation (including dates, notes

on slippage or controls/ assurance failing. 1)Continue to monitor recruitment drives 2)Implement latest version of E-Roster (better utilisation of bank staff) 3)7 day working plans for medical staff under development across the Trust

1) Underway and ongoing 2) Being implemented 3) Embedding and under review

Update by FA 20/03/15 and DH 23/03/15


Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3.B Deliver high quality care around

the individual needs of each patient Director responsible Chief Nurse


3.B.2 If the Trust does not put into place systems to assess, monitor and evaluate nursing staffing levels there may be negative impact on Trust’s quality of care provided to patients.


Target risk score S3 x L1 = 3 Linked to Risk 1447

Controls in place (to manage the risk) Gaps in Control 1. Ward staffing templates monitored daily by Matrons and escalated to

the Divisional Chief Nurses to ensure safe levels to meet patient needs.

2. Planned versus actual staffing levels on a shift by shift basis and evidence actions taken

3. Procurement of updated e roster system. 4. SNCT tool 5. Agency staff sourced from agencies known to and contracted by Trust.

Issues regarding agency staff practice are subject to formal arrangements between the agency and the Trust any unresolved concerns are escalated and managed by Deputy Chief Nurse.

6. Robust recruitment process to both substantive and bank staff posts including overseas recruitment

7. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level

8. Matron for workforce recruited

1. E-Roster system is not updated out of hours 2. Trust does not currently have the latest version of E-Roster that is more effective

at accessing and utilizing Bank Staff 3. Unfilled agency shifts 4. Staffing Ratios in some areas of the Trust at night are under review 5. The Trust still carries a volume of vacancies specifically within ITU and theatres



1. Daily ward staffing review and reporting 2. Incident reporting via Datix demonstrating patient or staff harm 3. Staff absence reports 4. % of vacant shifts filled by Trust and agency staff 5. Number /severity of issues escalated to relevant agency 6. SNCT data presented at November Board 7. Increased reporting of positive patient experience in relation to

staffing/high quality care and compassion reported 8. Gap analysis against ‘Right Staffing’ report and current ward staffing

levels undertaken 9. Gaps filled by using staff flexibly across the Divisions with bank staff

used in priority to agency. 10. Review of maternity staff ratio undertaken 11. Monthly reporting of nursing staffing levels with actions taken to

mitigate to Trust Board

Positive (+) CQC Chief Inspector of Hospitals Report (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-)Vacancy rates and turnover rates

Gaps in assurance Assurance Level gained: RAG Trust position known no identified gaps in assurance


1. Implement e-roster upgrade and utilize core functionality (bank and messaging) 2. Implement plans to manage staffing issues in ITU and Theatres

1) March 2015 2) April 2015



Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3.D Treat patients and their families

with dignity, respect and compassion

Director responsible Chief Nurse / Director of HR



3.D.1 There is a risk that the Trust may not deliver continuous improvement to patient experience if the wider care and compassion strategy, vision and values are not embedded and sustained with all members of staff.


Target risk score

S2 x L1 = 2

Linked to Risk No specific risk recorded on the operational risk register, 20 risk monitored by the Executive patient experience committee

Controls in place (to manage the risk) Gaps in Control 1) Trust values embedded and disseminated across organization 2) Nursing and Midwifery Strategy implemented including 6 C’s 3) Values based recruitment integral to nursing and midwifery recruitment and performance management/appraisal 4) Customer care training undertaken with OPD and ED front line staff 5) YCM and F&FT feedback shared with clinical and non-clinical staff. Actions plans developed in response 6) Work underway to ensure staff are treated with respect by patients & other staff

1) Evidence of shared learning across divisions and clinical units 2) Standarised appraisal and performance management process 3) Ability to roll out customer care training across organisation



1) Work in progress to develop and roll out GE leadership development including values and organisational development (SASH Plus) 2) YCM and FFT 3) Datix and patient compliments and complaints 4) Local clinical audits which have made positive improvements the patient experience of services

Positive (+) CQC Chief Inspector of Hospitals Report (+) Staff survey (+) YCM and FFT score (above average for inpatients) (+)The August FFT score for ED was +81, the highest score to date. Since December 2013, the (+)ED FFT score has been between +75 and +81, well above the National average. (+) The Inpatient score has risen by 2 points this month to +84, the inpatient FFT scores have been between +80 and +84 since March2014. (+) Incident reporting (+) pilot of 8a and above appraisal process incorporating assessment against behaviours (+) Regular contact with healthwatch Surrey and Sussex (+) Advocacy group – SEAP have been working with PALS Negative (-) Complaints received relating to patient experience (-) FFT response rates variable (-) Appraisal rates recorded (-) Temporary Staffing Internal Audit



on slippage or controls/ assurance failing. 1)Customer care training pilot 2)Evaluate effect of pilot and consider wider role out 3)Role out Behavioural Anchors developed through SASH Plus and embed values in staff appraisal

1)Complete 2)Underway 3)Apr 2015

Update by FA 20/03/15 and YP 20/03/15


4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.A.1 Deliver access standards Director responsible Chief Operating Officer



4.A Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care


Target risk score S3 x L3 = 9

Linked to Risk 1220 and 1491

Controls in place (to manage the risk) Gaps in Control 1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Extra 10 surgical beds for 3 months (Dec –Feb) to support elective flow and reduced cancellations 10) Capel Annex opened 1/12 (20 beds) 11) AMU Annex opened 29/12 (12 beds until 28/2)

1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed



1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations 9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.

Positive (+) ED Standard delivered Q1 and Q2 narrowly missed Q3 and Q4 (+) Maintaining top 20% performance (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings Negative (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity (-) Increase in no of medically fit for discharge patients Christmas New Year period

Gaps in assurance Assurance Level gained: RAG Winter plans and local health economy position going into winter months Mitigating actions underway Progress against mitigation (including dates, notes

on slippage or controls/ assurance failing. 1) Rolling bed capacity plans being reviewed

1)Ongoing

Update by PB 20/03/15 Date discussed at Board To be discussed at March Board

Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.A.2 Deliver access standards Director responsible Medical Director


4.A.2 As readmission rates are an indicator of high quality care, failure to improve the Trust’s rate poses a risk to this objective


Target risk score

S3 x L2 = 6


Controls in place (to manage the risk) Gaps in Control 1) Discharge processes in place, Medical and MDT fit 2) Dr Foster report re-admission monthly (monitored by clinical effectiveness and ECQR) 3) Data review for pathway specific re-admissions 4) Change of some patient episodes to reflect out-patient contact rather than readmission 5) Establish Frailty Service in community staffed with HCE Consultants to reduce need for readmission 6) White board project facilitates agreement and work towards agreed date of discharge.

1) Temporary notes makes clinical coding more difficult , but are reducing in numbers 2) Not all elements of pathway under central oversight



1) KPIs 2) Dr Foster alerts 3) Regular audit review of readmissions at service level 4) Joint Audit with Clinical Commissioning Groups 5) Triangulation with other data sets (e.g. VTE) 6) Clinical audit of clinical pathways which impact on reducing emergency re-admissions. 7) Clinical audit of Enhanced Recovery Programme

Positive (+) Re-admission data no longer flags on “Dr Foster” reports (+) Re-admission data work by local physicians (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) RCA on areas highlighted by Dr Foster (+) Activity data not seeing significant readmissions Negative (-) Readmission data quality

Gaps in assurance Assurance Level gained: RAG 1)Exact definition of re-admission required Mitigating actions underway Progress against mitigation (including dates, notes

on slippage or controls/ assurance failing. 1) Safer discharge practices agreed by local healthcare providers, discharge to access pilot 2) Data quality coding 3) OPAL Service linked to GP 4) Review storage of medical records to reduce need for temporary notes 5) Work to improve coding at ward level on clear signaling of planned readmission (TWOC) 6) Work to identify issues surrounding readmission rates for non-elective patients

1) Under review 2) Underway 3) Underway 4) Tendering at present 5) Underway 6) To commence



Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.D Develop local services as

appropriate at East Surrey Hospital, other Trust sites and in the community

Director responsible Chief Operating Officer



4.D There is a risk that the Trust may not realise the benefits of service development opportunities which are fully appropriate for the local community unless partnership working and links between strategic partners are improved


Target risk score

S4 x L2 = 8

Linked to Risk 1501, 1270, 1491, 1164, 1332

Controls in place (to manage the risk) Gaps in Control 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards

1)Length of stay needs to reduce 2)Repatriation of tertiary services effected and influenced by external factors



1)Letters of intent 2)Contracts 3)Meeting minutes

Positive (+) Joint working with Royal Surrey County ( Chemeo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Initial work on repatriating Cardiology Lab (8 wk pause to support winter pressures) (+) Winter beds initiative 2013/14 (+) Business case new surgical ward and additional theatre



on slippage or controls/ assurance failing. 1)Decant ward established and operational

1)Q4 2014/15

Update by PB 20/03/15


Objective 4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.E Develop local services as

appropriate at East Surrey Hospital, other Trust sites and in the community

Director responsible Director of Human Resources



4.E There is a risk that recruitment and retention strategies are not effective in attracting and retaining staff which will impact on our ability to develop and maintain services.


Target risk score

S3 x L2 = 6

Linked to Risk 1580,1652

Controls in place (to manage the risk) Gaps in Control 1) Workforce & OD Strategy with vision to be “Employer of Choice” 2) Key Theme of W&OD Strategy is Recruitment and Retention with key objectives for short, medium and long term 3) Finance and Workforce Committee receives monthly updates on key themes 4)Executive Committee for Quality & Risk through Workforce Sub-group considers workforce metrics and risks. 5)Workforce metrics – turnover and vacancy rate reported at Divisional and Trust level. 6)Specific Nursing Recruitment & Retention workstream Chaired by Chief Nurse reports into Workforce Committee via Deputy Chief Nurse

1) Nature of workforce skills means that “Employer of Choice” must not be restricted to catchment populations of Surrey & Sussex. The Trust must be free to recruit for the skills required as these may not be present in the locality. The benefits of employment on population health and life expectancy mean that the Trust should where appropriate recruit from the locality.



1) Performance reports and minutes of committee meetings 2) Progress on Workforce Strategy

Positive (+) Trust vacancy rate (+) Hospital Intelligent Monitoring report for July 2014 – no elevated risks flagged for workforce Negative (-) Specific issues relating to the current local and national availability of qualified nurses (-) Trust Turnover rate (-) Draft Hospital Intelligent Monitoring report for Oct 2014 – indicates low risk relating to nursing turnover benchmark

Gaps in assurance Assurance Level gained: RAG 1) Subjective factors in employee motivation and long lead in time mean it is difficult to monitor ‘cause and effect” for R&R

initiatives 2) Performance reporting is not currently configured to report at Service Line level


1) Monthly reporting of metrics 2) Task & finish group with key deliverables

1) Ongoing

Update by YP 20/03/15


Objective 5 – Well Led Priority ID and reference 5.A Live within our means to remain

financially sustainable

Director responsible Chief Finance Officer


5.A.1 Failure to deliver income plan Current rating S4 x L4 = 16

Target risk score S4 x L2 = 8 Linked to Risk 1479,1480,1601,1648,1649

Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Signed contracts with both main sets of commissioners (NHSE and CCGs). 3) Contract management process in place - clearer and better structure than last year. 4) Financial reporting, including forecast scenarios presented to Board Please note that the linked SRR risks refer to shortfall in elective income (1601), maternity pathway risk (1645) and (a non –finance risk) the level of emergency demand (1491)

1) A Chief Officer meeting has replaced the LTB but it is still establishing its structures – these are anticipated to be in place soon, but there is a question over the effectiveness of health system forums to manage emergency activity actions. This remains the case at the end of the year and is reinforced by the approach to QIPP plans. 2) No agreement over repayment of withheld marginal rate emergency tariff or completion of activity query process (action in train) 3) CCG plans made significant assumptions on activity reductions that are not being adjusted by them in response to actual outturn and there is a widening gap between their plan and actuals – this is impacting elective activity as well as driving cost and providing the “wrong” income. (Activity Query Notice in train).



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience group) 5) Output of Contract Management Process - including the output from Activity Query Notice process.

Positive (+) 2013/14 activity and income met the Plan (+) Reconciliation process working with CCGs at the moment (avoiding delay to disputes) - that continues to be the case at M07 (+) settlement of 13/14 Surrey income dispute, also settlement of first 2014/15 dispute with NHS England. (+) forecast activity volumes are sound as the Trust completes M11,and the forecast deficit now reported takes into account anticipated outturn… but please note dispute issue below; Negative (-) East Surrey CCG have raised a material dispute that includes a retrospective financial challenge. This provides risk. No other CCg has raised any such challenge. (-) Too much non elective activity, not enough elective.

Gaps in assurance Assurance Level gained: Green Turned green as at M11. The dispute with East Surrey does not constitute a gap in assurance.

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Dispute with East Surrey is subject to a process and legal advice is supporting the Trust action; 2) Trust is bringing action to a conclusion in respect of the 30% marginal rate tariff payment.

Actions proceeding to timetable – M11 shows additional income but also additional over spending.

Update by PS 17/03/15 Date discussed at Board To be discussed at March Board





5.A.2 Failure to stop divisional overspending against budget

Current rating Proposed score S5 x L2 = 10 Target risk score S3 x L2 = 6 Linked to Risk 1602, 1663

Controls in place (to manage the risk) Gaps in Control 1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans agreed & signed off 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board 5) M06 forecast process sees all Divisions working to clear targets

1) There are some areas in the Trust where variance from budget is significant and reduction of spend is not appropriate – these budgets need to be reviewed (and that will form part of 2015/16 budget setting)



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Management Board and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Positive (+) Corporate budgets within tolerance. (+) budgets corrected for undeliverable savings and contingency found. (+) forecasts have been reviewed and nominal permission to overspend given where appropriate, with action in other areas. (+) Overspending at m11 is within forecast tolerance Negative (-) Emergency activity pressures are greater than expected (-) Overall agency cost remains high. Overall risk for BAF “amber” – assurance rating also “amber” noting that overspend is within tolerance

Gaps in assurance Assurance Level gained: Amber

Please note comments above – budgets are overspent, but overspending levels have been agreed (nb: not as final control totals yet) and action is being linked to that work. The assurance level is amber because overspend is within tolerance.


1) PMO/Performance structure continues - M11 PMOs is progress 2) Controls are being exercised in divisions and centrally 3) Contingency action around emergency and elective activity has been implemented with the opening of additional capacity.

Actions proceeding to timetable






5.A.3 Unable to provide realistic medium term financial plan


Target risk score S4 x L2 = 8 Linked to Risk 1603

Controls in place (to manage the risk) Gaps in Control 1) Items referred to in 5.A.1 and 5.A.2 above 2) V5.0 long term financial model and integrated business plan

completed (submitted to TDA in September 2014) 3) TDA Plan submitted in January 2015 4) Board to Board held with the TDA in November 2014.

1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Elements of 2014/15 planning cannot yet be incorporated in Trust financial

planning (e.g.: Better Care Fund implications) because of lack of detail. 3) Lack of alignment between CCG activity plans and actual performance. 4) Reliance on centrally determined rules for PbR, Better Care Fund and the

wider NHS finance regime.



1) Delivery of current year financial plans 2) Delivery of long term financial model and integrated business plan documentation, and delivery against them

Positive (+) Delivery of performance in 2013/14 (+) 5 versions of LTFM submitted – each has passed muster with TDA high level review although it has not been subject to full challenge and scrutiny. (+) LTFM submitted describes viable position (+) TDA have provided positive feedback following Board to Board. Likely next stage is a Monitor “pre-assessment” review (+) Performance in 2014/15 will be within tolerance and is reflected in LTFM Negative (-) alignment with CCG plans is not clear. There are significant differences between actual performance on activity and CCG plans. (-) Contracting process delayed with financial gap with CCG plans Overall, on basis of current assumptions and delivery of LTFM, RAG remains amber. Assurance RAG amber.

Gaps in assurance Assurance Level gained: Amber Revised LTFM (long term financial model) and IBP (Integrated Business Plan) currently being prepared but not yet complete


on slippage or controls/ assurance failing. 1) Monitor “pre-assessment” review has been undertaken, and, a full assessment will now

take place - a revised LTFM is being prepared. Progress is on timetable






5.A.4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position



Linked to Risk 1604

Controls in place (to manage the risk) Gaps in Control 1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

1) Problems with Commissioners delivering to agreed cash flow dates.



1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance 2) Monthly finance reporting to Executive Committee and Trust Board

Positive (+) Positive cash flow reported for 2013/14 - temporary borrowing needed in 2013/14, but reasons for that were delays in agreements (CCG and TDA) – temporary borrowing repaid in full by 31 March 2013 (+) Liquid ratio has followed expectations (+) Cash remains on plan in M11 2014/15 Negative (-) no confirmed additional cash to resolve underlying liquidity problem – likely to be resolved in FT application process – potentially through a working capital loan (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. (-) remedial action has had to be taken to secure cash from Commissioners. Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved.

Gaps in assurance Assurance Level gained: Amber In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness.


1) Day to day cash control is main action currently, coupled with actions to maintain service income and manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses.

Actions proceeding to timetable


Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.B We are an organisation that is

clinically led and managerially enabled

Director responsible Medical Director


5.B There is a risk that Clinical leadership efforts will not embed if staff do not feel empowered and supported in order to make positive changes regarding care pathways within specialties and directorates

Current rating S4 x L1 = 4 Propose to close

Target risk score

S4 x L1 = 4


Controls in place (to manage the risk) Gaps in Control 1)JD and appointments to reflect importance of Chiefs and clinical leads 2)Joint work with Clinical leads and Exec Team undertaking the opportunity to work with GE 3)Work of Clinical leaders in many significant projects draws on and underlines the value of clinicians as leaders 4)Implementation of Trial appraisal using “talent mapping” methodology to promote succession planning 5)Clinical Leads meeting frequency increased to twice monthly

1)Variation in priorities of clinical leads 2) Some departments are small with no appropriate interest in clinical management.



1) 1:1 training 2) Board presentations SQC, Prescribing committee 3) HEKSS established dentistry school 4) GMC survey highlights no safety concerns (for the first time) 5) Talent review and achievement review at appraisal 6) Increased interest in clinicians wanting to lead and manage 7) Clinical audit projects which deliver improvements to the care of patients

Positive (+) CQC report and feedback (+) GE updates (+) Increasing buy in from clinical leads to leadership agenda (+) Overall staff survey (+) Deanery reports Negative (-) GMC survey training results , some areas report undermining



on slippage or controls/ assurance failing. 1)Ongoing work to embed Clinical Leads in activities to support strategic objectives 2)Delivery of outputs of SASH Plus (Appraisals)

1)Next phase commenced August 2014 2)April 2015



Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.E Have appropriately qualified and

competent staff always working to the highest standards of professionalism and ethics

Director responsible Director of Human Resources



5.E.1 There is a risk that staff do not take up opportunities to participate in developmental programmes which could further impact upon staff development and missed opportunities to improve quality of care


Target risk score

S3 x L2 = 6

Linked to Risk 1170, 1672

Controls in place (to manage the risk) Gaps in Control 1) Personal Development Plans as part of Appraisal identify development needs 2) Training Need’s Analysis at Divisional level extrapolated to Trust level inform strategic planning of development priorities. 3) Analysis of education and training activity 4) Make available e learning packages as an alternate to face to face training implement new delivery model on yearly cycle (elearning one year face to face the next) 5) Pilot elearning and roll out across Trust 6) OLM configured to capture locally delivered MAST programmes

1) Reporting of development that is undertaken within Divisions



1) PDP’s 2) Training needs analysis update to August 2014 Finance Investment and Workforce Committee 3) Monthly reporting against 10 Core Mandatory Training subjects at Divisional and Trust level at Finance Investment and Workforce Committee through ECQR&CC – Workforce Committee.

Positive (+)Trust utilises HEKSS central funding (+)TNA update to August 2014 Finance Investment and Workforce Committee Negative (-) Bursary funding being restructured under national ‘costings’ exercise (-) Compliance rates for MAST programme (-) Sickness absence rates effect availability of staff to attend training

Gaps in assurance Assurance Level gained: RAG Reporting of development that is undertaken within Divisions


1) Reporting structure in ESR being reconfigured 1) Ongoing

Update by YP 20/03/15


Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.G.2 We are a well governed

organisation Director responsible Director of Corporate Affairs



5.G.2 If the Trust does not progress and deliver its Foundation Trust plans it is unlikely to be able to successfully authorised. This could leave the Trust without local autonomy and could lead to an alternative organisational form being imposed on the Trust. Which could reduce choice and focus on local health provision



Linked to Risk 1531

Controls in place (to manage the risk) Gaps in Control 1)BGAF assessment carried out and action plan in place 2)Corporate governance framework in place 3)Foundation Trust project board meeting 6 weekly 4) FT Task & Finish Group meeting monthly 5)Timeline agreed with TDA 6)QGAF assessment carried out and action plan in place

No significant gaps in control identified



1)BGAF action plan and self-assessment completed 2)LTFM agreed by the Board 3)FT Project board 4)FT Project plan 5)Integrated Business Plan 6)Public Consultation completed with positive outcome 7)QGAF External assessment completed with implementation of action plan 8)Speciality deep dives to inform Trust on readiness for assessments 9) TDA Readiness Review completed 10) Chief Inspector of Hospitals Inspection 11) Elections to Shadow Council of Governors due following TDA approval 12) TDA Board to Board completed 13) Implementation of Board Development Programme 14) HDD to be completed as part of Monitor phase

Positive (+) Active FT Project Board (+) Draft IBP submitted to TDA 20.6.04 - updated & submitted 20.10.14 (+) LTFM submitted to TDA – 20.06.14 - updated & submitted 20.10.14 (+) FT membership strategy revised and being implemented (+) External review of BGAF & QGAF undertaken (+) BGAF action plan being implemented - Amber/Green (+) Refresh of QGAF by Deloitte’s – complete – score 3.5 action plan in place (+) Readiness Review held with TDA – March 14 (+) FT Timeline agreed with TDA (+) Mock board to board undertaken – Sept 14 (+) Board to Board with TDA took place on 20.11.14 – positive formal outcome (+) Positive outcome of public and staff consultation (+) Patient & Public membership increasing with engagement of MES – 100% target achieved (+) Governor Awareness Sessions completed with +90 expressions of interest (+) Engagement of ERS for Governor Election Services – Draft election timetable agreed (+) Monitor pre-assessment currently in progress (+) TDA Recommendation to Monitor 19.3.15

Gaps in assurance Assurance Level gained: RAG Historical Due Diligence to be confirmed by TDA & Monitor Mitigating actions underway Progress against mitigation (including dates, notes

on slippage or controls/ assurance failing. 1) Membership Strategy implementation with positive increase in membership 2) Re-fresh of QGAF external assessment - score of 3.5. Action plan being implemented

1) Ongoing 2) Plans are on track

Update by GFM 17/03/15 Date discussed at Board To be discussed at March Board

Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.F. Ensure IT support/optimise

patient experience by improving patient interface, sharing and capture of patient information and patient communication

Director responsible Director of Information and Facilities



5. F. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

Current rating Proposed score S4 x L3 = 12


Linked to Risk 1605

Controls in place (to manage the risk) Gaps in Control 1) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 2) Clinical Informatics Group 3) Clinical IT leads 4) EPR User Group now well established 5) Various project group (EPMA etc.) 6) Internal Audit 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) EPR Contract now signed and implementation underway with datacenter transfer scheduled for Mid-June 2015 10) Cerner Optimisation Group no win place

1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits



Efficiencies being delivered through IT enabled change

Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA) (+) EPR Contract signed and implementation commenced (+) Business Continuity System now in place (7/24) Negative (-) Major IT transition approaching – 2015

Gaps in assurance Assurance Level gained: RAG Trust position known, no identified gaps in assurance


1. Procurement of replacement EPR as national contract ending November 2015 - contract signed and implementation commenced

2. Establishment of Chief clinical Information Officer role 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2014/15 and future years

EPR Contract to be awarded October 2014 – preferred supplier now selected. EPMA go-live November 2014. 724 Go-live November 2014. PC Upgrade plan in-place, funded and commenced. Network review first draft now complete and action plan being prepared.

Update by IM 26/02/15 Date discussed at Board To be discussed at March Board

ID Mon

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Specialty

Risk Owne

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Risk Type

Title Description Existing controls Initial Rating

Curren

t Con

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Curren

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Curren

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Treatment Plan Due date Done date Resid

ual Rating

Next R

eview

1401

Saf

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23/0

1/20

13

CO

RP

Med

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Dire

ctor

's O

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Des

Hol

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Pat

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Saf

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Risk of outbreak of viral gastroenteritis Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures.

D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning

Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit

Outbreak control Group Surveillance of diarrhoea and vomiting

Red aprons system

Stat and mandatory training Policy

Communications messages to staff, visitors and patients Norovirus leaflets

Hand hygiene facilities Restricted visiting

Use of signs at entrance to wards and bays, and red aprons to facilitate communication that an outbreak is taking place.

16 3 5 15 Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&VMeeting with stakeholders regarding norovirus preparedness Audit of post-outbreak cleaning Pilot Patient Hand Hygiene Champions in Elderly CareStakeholders meeting to discuss health system norovius planningMonitor use of ED risk assessment for patients admitted with diarrhoea and/or vomitingMonitor ward refurbishment programme Stakeholder norovirus study day Prepare options appraisal for emptying bays to facilitate terminal cleaning following outbreak

31/03/201330/06/201301/04/201302/09/201331/03/201431/03/201320/03/201501/03/201522/09/201431/03/201430/03/201325/09/201331/01/2013

06/12/201326/07/201326/07/201302/09/201311/02/201406/12/2013

22/09/201421/05/201426/07/201325/09/201326/07/2013

9

31/0

3/20

15

1480

Exe

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23/0

7/20

13

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imps

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ent Risk that non elective does not reduce and no payment in

respect of marginal tariffRisk that the Trust may not achieve its breakeven plan as a result of non elective activity no reducing as planned and no payment recieved in

respect of the marginal tariff.Subset of BAF 5.A.1

i) Follow up notification to CCGs and agree payment from the 70% (ongoing)

16 4 4 16 Robust plan required to manage elective activityAs describded on the BAF

30/05/201431/03/2015

18/11/2014 6

31/0

3/20

15

1491

Res

pons

iven

ess

29/0

8/20

13

CO

RP

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Failure to maintain Emergency Department performance Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care.

1) EDD Patient Pathway 2) Discharge management

3) Plans for escalation areas agreed and management tools in place4) Reviewing all breaches on weekly to implement lessons learnt

20 4 4 16 As decribded on the board assurance framework 31/03/2014 6

31/0

3/20

15

1501

Res

pons

iven

ess

19/0

9/20

13

CO

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Ope

ratio

ns

Pau

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Invo

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Patient admitted to the right bed first time If the Trust does not maintain and improve ability to allocate the right bed first time there is an increased risk of receiving poor quality of our care (effectiveness, experience and safety)

1) Operational meeting three times a day chaired by Chief / Deputy Chief Operating Officer with clinical involvement from Matrons, Nurse Specialists

and therapists 2) Daily Board rounds by clinical site team

3) Live 'To come In' lists available to view in all specialty wards to encourage active pull of patients from AMU to the correct specialty bed

4)Matrons walk round5) Additional screens arriving to reduce chance of mixed sex

accommodation breaches during winter pressures 6) Matron on site 7 days a week

9 3 5 15 As describded on BAF 27/06/2014 31/03/2014 6

31/0

3/20

15

1601

Exe

cutiv

e C

omm

ittee

18/0

6/20

14

CO

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Fina

nce

- Fin

. M

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emen

tP

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imps

on

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ent Risk that demand growth activity does not deliver the plan If non elective activity does not reduce there will be constraints on

capacity to deliver the demand plan. Subset of BAF 5.A.1

i) Ring fence elective beds after new capacity has opened and monitor delivery.

16 4 4 16 As described on BAF 31/03/2015 20/11/2014 8

31/0

3/20

15

1604

Exe

cutiv

e C

omm

ittee

18/0

6/20

14

CO

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Fina

nce

- Fin

. M

ana g

emen

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imps

on

Fina

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ent Liquidity: Inability to pay creditors/staff resulting from

insufficient cash due to poor liquid positionRisk of not being able to pay suppliers from in sufficient cash due to poor liquidity problem

1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy

3) Annual cash plan linked to business plan and capital plan

15 5 3 15 As described on the BAF 01/09/2014 12

31/0

3/20

15

1652

Wor

kfor

ce

23/1

0/20

14

CO

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Ope

ratio

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Fion

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The current local availability of qualified nurses and pressures on temporary staffing costs is effecting the Trust's ability to

The Trusts current vacancy rates, turnover and reliance on agency is leading to increased resource time being spent on ensuring existing clinical areas are safely staffed. The acute presentation of these issues is felt in the management of escalation areas and plans to staff the decant ward.

As decribeded on the BAF 16 4 4 16 As describded on the BAF 24/10/2012 8

31/0

3/20

15

1672

Wor

kfor

ce

01/0

2/20

15

CO

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HR

- W

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Increasing Sickness Absence Levels with impact on day to day management and expenditure

Continuing risk to the delivery of effective services and Trust Strategic Objectives caused by the resources required to actively manage the Trusts rising Sickness Absence rate and ensure safe services. This is also having a significant effect on the ability to control the Trusts temporary staffing costs.

Firstcare real time sickness absence monitoring reports and daily updates to managers inbox.

Daily sit reps at ward level used to ensure shift by shift safe levels of service.

eRostering software to manage rota's prospectively.Agency PMO.

15 3 5 15 Actions described in the Agency PMOFocused interventions to support the Trust's Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)

31/03/201531/08/2015

9

01/0

4/20

15

Presentation Title 36pt Arial BoldSub heading 24pt Arial

Acute Oncology Service

An Associated University Hospital ofBrighton and Sussex Medical School

1 hour to antibiotics audit: Improving door-to-needle time for

neutropenic sepsis.

Changes to Neutropenic Sepsis Protocol.

Dr Eirini Thanopoulou; AOS Lead

Dr Emma O’Donovan; Haematology Consultant

Lisa Jaccques; Lead AOS CNS

Background‘Acute Oncology Service’ concept

National Confidentiality Enquiry into Patient Outcome & Death

(NCEPOD) 2008

35% hospitals care judged as good49% hospitals room for improvement8% hospitals less than good

Recommendation:Systematic approach to dealing with cancer related emergencies

2009 – AOS service was conceived

Slide 2

Acute Oncology Service core principles

• Promote education

• Increase awareness of oncological diagnoses

• Early access to specialist oncology input

• Integrated way of working amongst acute specialties within NHS Trusts

• Reduce fragmentation of care of unwell cancer patients

Slide 3

Key documents

Slide 4

Audit Progress so far:

Slide 6

Audit Period Mean door-to-needle time

Median door-to-needle time

% of patients getting antibioticswithin 1 hour

2011April-October

4 hours 35 mins 2 hours 49 mins 0%

2013July-October

2 hours 3 mins I hour 34 mins 23%

2013-2014November-April

1 hour 50 mins 1 hour 15 mins 10%

2014July-December

1 hour 51 mins 1 hour 19 mins 26%

Audit – Door-to-Needle Time

Slide 7

Audit – Patients receiving antibiotics within 1 hour

Slide 8

Education

• AOS Nurse lead in ED appointed 2012

• AOS Consultant lead appointed 2014- Giving regular teaching to ED, FY1,

FY2, SHO

• 4th Haematology Consultant appointed 2013

Slide 9

Next Step:

Updating the Neutropenic Sepsis Pathway

• Switch to monotherapy

• Easy to follow pathway

• Education, Education, Education

Slide 10

Key changes to guideline

1. There was no formal written trust wide guideline

2. Re-definition of neutropenia; neutrophils ≤0.5 (previously 1.0)

3. Change to Piperacillin/Tazobactam monotherapy

- Less toxicity (gentamycin) and less complications

4. Easy to follow flow-sheet for 1st hour, first 24 hours

5. Introduction of MASCC score and sepsis 6 scoring

6. Flowcharts for 96 hours and 5 days with formulaic changes to therapy suggested

7. Antifungal and prophylaxis guidelines

Slide 13

Future PlansNeutropenic sepsis remains priority for AOS in 2015

• Pilot new pathway in ED

• Introducing Patient Group Direction (nurse led treatment)

• Process mapping in ED

• Prospective audit of suspected neutropenic sepsis

Slide 14

Presentation Title 36pt Arial BoldSub heading 24pt Arial

Thank you!

Early detection and intervention frequently make the difference between living and dying in oncological emergency



Date: 26 March 2015 Agenda Item: 2.2

REPORT TITLE: Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse Des Holden, Medical Director

REPORT AUTHOR (s): Fiona Allsop, Chief Nurse Des Holden, Medical Director


Action Required:

Approval () Discussion (√) Assurance (√)

Purpose of Report:

To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports.


Chief Nurse Report Safer Staffing report (February 2015 data) indicates that the Trust has delivered the

planned versus actual staffing levels in the inpatient areas and maternity unit. The Board will note that there has been some variation in the availability of nursing assistants during the day which has been managed by the matrons but overall the actual number of nurses on duty has matched in planned demand.

Update on Friends and Family Test changes Information on the Care Certificate Medical Director Report Medical appointments made since the last trust Board PVL-MRSA Electronic Early Warning Score

Recommendation:

To note the report


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact Yes

2

Financial impact Yes

Patient Experience/Engagement Yes

Risk & Performance Management Yes


Yes

Attachment:

N/A

3

Chief Nurse/ Medical Director Trust Board Report – 26 March 2015 1. Introduction To provide an update to the Board ion nursing staffing in relation to planned versus actual staffing, a brief summary of further changes to FFT and an overview of education support to be provided for nursing assistants in the Trust. 2. Chief Nurse Report Staffing Planned versus Actual – February 2015

4

Ward Ward Specialty Entries RN Day RN Night NA Day NA Night Total Day Total Night Overall

Abinger Ward 430 ‐ GERIATRIC MEDICINE 28 95.49% 100% 91.89% 100% 93.62% 100% 96.07%

Acute Medical Unit 300 ‐ GENERAL MEDICINE 28 95.09% 97.96% 84.51% 88.39% 92.06% 94.48% 93.13%

Birthing Centre 501 ‐ OBSTETRICS 28 100% 100% N/A N/A 100% 100% 100%

Bletchingley Ward 300 ‐ GENERAL MEDICINE 28 96.44% 100% 98.35% 97.62% 97.18% 98.87% 97.89%

Brockham Ward 502 ‐ GYNAECOLOGY 28 96.4% 100% 92.86% 92.59% 95.21% 96.36% 95.67%

Brook Ward 100 ‐ GENERAL SURGERY 28 98.24% 100% 96.38% 92.86% 97.64% 98.57% 98.06%

Buckland Ward 101 ‐ UROLOGY 28 97.14% 100% 87.72% 100% 93.5% 100% 95.92%

Burstow Ward 501 ‐ OBSTETRICS 28 88.98% 100% 96.55% 96.3% 90.53% 98.18% 93.89%

Capel Annex l Ward 28 99.11% 100% 96.79% 100% 98.11% 100% 98.8%

Capel Ward 430 ‐ GERIATRIC MEDICINE 28 92.63% 97.62% 95.73% 100% 93.59% 98.57% 95.76%

Chaldon Ward 300 ‐ GENERAL MEDICINE 28 94.16% 96.3% 93.32% 94.7% 93.8% 95.42% 94.42%

Charlwood Ward 301 ‐ GASTROENTEROLOGY 28 96.34% 98.21% 92.61% 94.44% 94.98% 96.36% 95.52%

Copthorne Ward 301 ‐ GASTROENTEROLOGY 28 97.19% 100% 99.48% 100% 98% 100% 98.79%

Coronary Care Unit 320 ‐ CARDIOLOGY 28 88% 100% 500% 96.3% 92.88% 98.77% 95.77%

Delivery Suite 501 ‐ OBSTETRICS 28 99.4% 99.4% 87.5% 96.43% 96.43% 98.66% 97.54%

Discharge Lounge 300 ‐ GENERAL MEDICINE 28 87.18% 100% 95.83% 100% 91.27% 100% 94.37%

Godstone Ward (Haem) 303 ‐ CLINICAL HAEMATOLOGY 28 96.43% 98.21% 1700% N/A 123.94% 100% 112.21%

Godstone Ward (Med) 300 ‐ GENERAL MEDICINE 28 100% 96.67% 100% 98.28% 100% 97.46% 98.87%

Holmwood Ward 320 ‐ CARDIOLOGY 28 97.14% 100% 82.14% 100% 92.86% 100% 95.45%

ITU/HDU 192 ‐ CRITICAL CARE MEDICINE 28 96.25% 94.04% 73.06% 89.29% 92.84% 93.7% 93.25%

Leigh Ward 110 ‐ TRAUMA & ORTHOPAEDICS 28 96.34% 94.64% 94.06% 89.29% 95.51% 91.96% 94.28%

Meadvale Ward 430 ‐ GERIATRIC MEDICINE 28 92.23% 100% 94.59% 100% 93.49% 100% 95.78%

Neonatal Unit 420 ‐ PAEDIATRICS 28 92.61% 93.46% 101.75% 92.98% 95.77% 93.29% 94.54%

Newdigate Ward 110 ‐ TRAUMA & ORTHOPAEDICS 28 95.38% 101.79% 93.77% 72.73% 94.71% 87.39% 92.19%

Nutfield Ward 430 ‐ GERIATRIC MEDICINE 28 100% 98.21% 92.43% 98.28% 97.09% 98.25% 97.48%

Outwood Ward 420 ‐ PAEDIATRICS 28 92.89% 101.88% 93.25% 82.14% 92.93% 98.94% 95.43%

Rusper Ward 501 ‐ OBSTETRICS 28 100% 100% N/A N/A 100% 100% 100%

Surgical Assessment Unit 100 ‐ GENERAL SURGERY 28 99.11% 94.64% 78.57% 98.21% 95% 96.43% 95.63%

Tandridge Ward 300 ‐ GENERAL MEDICINE 28 98.23% 103.7% 95.62% 98.15% 97.17% 100.93% 98.39%

Tilgate Ward 300 ‐ GENERAL MEDICINE 28 100% 100% 98.9% 100% 99.55% 100% 99.7%

Woodland Ward 100 ‐ GENERAL SURGERY 28 97.33% 100% 98.4% 92.59% 97.73% 96.3% 97.26%

Total 95.98% 98.26% 94.17%

5

Patient Experience Update As will be seen from the Performance Update the response rate and scores for inpatients and ED Friends and Family Test (FFT) were very good for February. The FFT is now mandated in outpatients and for day case procedures. For some time it has been the first question on the Your Care Matters (YCM) survey and work has been done to raise the profile of Your Care Matters in these particular areas. Volunteers have been recruited to support staff in promoting the importance of the survey to colleagues, patients and visitors. The YCM team are working on a combination of letters (to a sub group of inpatients and ED patients) and text reminders to others, including outpatients and day cases, to boost the number of responses. The Guidance also emphasises the need to be as inclusive as possible and have appropriate versions for vulnerable/hard to reach groups and also children. Four further versions of the YCM cards have been designed in collaboration with relevant staff and disseminated for:

Patients with dementia Patients with learning disabilities Children aged 5-10 Children aged 11-16

Care Certificate The introduction of the Care Certificate is the first step towards regulation of supportive staff following the Cavendish Review. It will provide clear evidence to employers and patients that Nursing Assistants (NA) have been assessed against a specific set of standards and has demonstrated they have the skills, knowledge and behaviours to ensure that they provide compassionate and high quality care and support. These standards cover the areas that are common to both health and social care. It meets the legal requirement for providers of regulated activities to ensure that their staff are suitably trained. It is applicable to all staff on Bands 1-4. The Care Certificate Standards:

1. Understand Your Role 2. Your Personal Development 3. Duty of Care 4. Equality and Diversity 5. Work in a Person Centred Way 6. Communication 7. Privacy and Dignity 8. Fluids and Nutrition 9. Awareness of Mental Health, Dementia and Learning Disability 10. Safeguarding Adults 11. Safeguarding Children 12. Basic Life Support 13. Health and Safety 14. Handling Information 15. Infection Prevention and Control

6

Each NA starting in a new role within the scope of this certificate is already expected to have learning and development/ training/ education and assessment as part of their induction. This will usually take place over the first 12 weeks of employment. The Care Certificate is a key component of the overall induction which an employer must provide, legally and in order to meet the essential standards set out by the Care Quality Commission. The Care Certificate is only one element of the training and education that will make them ready to practice within their specific workplace. The Care Certificate does not replace employer induction specific to the workplace in which practice will take place, nor will it focus on the specific skills and knowledge needed for a specific setting. Attendance on a study day is not proof of competence; the NA is expected to return to their workplace and demonstrate their new knowledge / skill to their assessor who is responsible for making the decision on whether the NA has met the Standard set out in the Care Certificate. Medical appointments made since the last trust Board. Dr Ben Upton has been appointed as the Trusts first Clinical Chief Information Officer and a deputy has been appointed to assist him in the role out of our Health Informatics strategy (Dr Ivor Lewis). Dr Julian Webb has been appointed as the Chief of Safety and will lead on several projects designed to improve safety and learning for safety across the organisation. He will remain clinical lead for ED although we expect talent spotting and succession planning to occur in the next year. PVL-MRSA The trust identified two members of staff with skin infection related to this multi-resistant organism. As a consequence all staff and patients were screened for this bacterium. No patient was found to be colonised and over the weekend of 21-22nd March the site and ward team not only managed normal patient non-elective flow but were also able to conduct a deep clean of the affected ward which has re-opened to patient care. The two members of staff will be de-colonised and then be able to return to work. Electronic Early Warning Score After an introduction through the AHSN we have been working with Ground Vision, an SME with a web based Early warning Score calculator. The pilot which has run for 10 months saw roll out from a single bay on Newdigate ward to three surgical division wards and has allowed staff to help with the design of the product. This interaction between a health tech start up and a trust has been written up in the KSS AHSN magazine Innovate as a successful example of new collaboration to promote patient safety. 3. Recommendation To note the report Fiona Allsop Dr Des Holden Chief Nurse Medical Director March 2015

1



REPORT TITLE: 15 Steps Challenge Quarterly Update

EXECUTIVE SPONSOR: Fiona Allsop Chief Nurse

REPORT AUTHOR: Lynn Sanders Corporate Matron


Action Required:


Summary of Key Issues

Report outlining the15 steps challenge activity to date including completed improvement actions. Themes around the recommended improvements from the 15 Steps activities include:

Signage Storage of equipment Information for patients for medical conditions Information for patients and visitors about feedback Minor maintenance and cleaning issues General decorations of areas

Actions carried out to date in response to the feedback given following the 15 steps visits are included in the paper. The 15 steps challenge has to date visited 11 areas (9 included in paper) and has bought about many improvements at ward level. General awareness of first impressions of visitors to the ward has been raised, and engagement in the activity is evident when verbal feedback is given to the ward teams on the day of the visit.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO5: Well - led


Legal and regulatory implications Compliant

Financial implications Compliant

Patient Experience/Engagement Compliant

Risk & Performance Management Compliant


Compliant

2

Attachments:

3

Fifteen Steps Programme – Quarterly Update for Trust Board – March 2015

The monthly 15 steps programme has been in place for 6 months, with 11 separate wards and department areas visited to date (9 included in table).

The team is made up of a Non‐Executive lead, a clinical staff member, a non‐clinical staff member and a patient representative or volunteers, and the combination of this team has provided a selection of viewpoints on how the ward feels from a patient or visitors perspective.

Through the visits from the 15 steps team a “fresh eyes” approach has enabled feedback to the ward teams and recommendations for improvements made. It has also provided an opportunity for a structured visit for the non‐executive directors to visit the clinical areas with clear objectives. The improvements to dates are outlined below.

Ward/Department

Date Overall comments Main Recommendations/ areas for improvement

Feedback of Actions

SAU Sept 2014 Clean, good decoration, calm, well managed. Confidence giving, very professional.

Small improvements could be made to enhance further.

Some signs could be larger/or removed Staff photos not visible from behind desk Staffing board not clearly explained No directions to patients toilets from

waiting area Encouragement for patients to ask about

treatment/investigations and delays

Review of patient information displayed completed.

Funding obtained from charitable funds to redecorate lounge area including the purchase of comfortable chairs and patient information boards.

Location of staffing board with photos to be moved to a more visible position.

Staffing board is the same on each ward. To review design and information at NEG.

Abinger Sept 2014 Staff care seemed really good‐ very welcoming at all levels

Staff have worked well with old

Ask me anything badge for ALL staff Equipment away from entrance and doors All doors open; think about closing some

Decision not to do this as badge overload. Keep it to a few individuals. Consider giving to staff who have been seen to

4

tired ward environment‐ has potential to give negative impression to visitors

doors e.g. store room provide exemplar customer service Ensure refurbishment is on WIG list Discuss equipment storage with teams at

ward managers meeting/NMPC Staff to be reminded to close doors at

ward meeting Newdigate Oct 2014 Welcoming and professional ward

visit, staff and patients appeared relaxed and organized.

Challenging environment with restricted space for storage and information, however felt clean and tidy.

Bay 1‐ fire escape blocked by equipment Shower room being used for storage but

remains signposted as a shower Consultant in charge not apparent for

visitors Pt information leaflets could be displayed

in a better way, and patient information board could be added to.

Pt reports difference felt between substantive and agency staff attitude.

On‐going challenges continue relating to the lack of storage for the many items required close to patients to undertake nursing care. It is anticipated this will be resolved through the ward upgrade and refurbishment programme planned for 2015.

Patient boards displaying name of consultant and nurse above each bed are being sourced and selected.

Patient information leaflets reviewed, will be addressed in ward upgrade as lack of available space to display more effectively.

The division has prioritised Newdigate ward for recruitment to reduce the need to employ temporary workers.

Burstow Oct 2014 Calm, well managed. Confidence giving, very

professional.

No alternative languages displayed on signs

Signage for ward only visible from branch corridor

This is a Trust /Estates action as it needs to be Trust wide.

We can ensure leaflets are available for the women on Burstow in different

5

Some environmental maintenance required with paintwork and ceiling tiles

Notes area awaiting work from Capital bid to increase storage space of notes due to additional requirement for separate notes for babies.

languages Place signage at end of Burstow corridor

therefore visible form the main corridor. Estates contacted

Estates to visit ward to refurbish To a high standard to improve environment

To write a business case to increase the storage space within Burstow

Outwood Nov 2014 Calm and clean environment Well equipped Info and notices need reviewing and

reorganization Very happy to have a child treated

on the ward Positive patient comments heard.

Board out of date on arrival Uniform guidance missing Consultant details should be by surname Visiting times inside ward Access by other parents‐ voice/common

areas Trailing cables Buggy park/space needed Feedback forms, YCM needs to be near

boxes You said/we did needs to be more

prominent Reception area and corridor cluttered‐?

Need more storage Workstation wires, looked messy Emails open on office. Patient data on

workstation visible

Information for board to be discussed with Ward manager and Matron and reviewed on weekly basis.

There are no fixed visiting times in paediatrics. However relatives other than parents are encouraged to leave by 8pm

There is a sign on both sides of the main entrance door reminding all those entering or leaving to ensure the door is closed behind them. Staff and parents to be reminded not to let others through the door with them without checking they are entitled to be in the area.

Immediate action to move cable out of the way

H&S to be asked to review in conjunction with estates for a longer term plan for storage of buggies. Parents to be

6

encouraged to take buggies home YCM forms are in fixed Perspex holders

around the ward. You said, we did is fixed on entry board. Responses to be printed to stand out

more, bolder, larger print Reception area and environment on Risk

Register. Daily check to keep corridor clear. Possible trunking to house cables

H&S to be asked to review in conjunction with estates for a longer term plan

Ensure staff are aware of responsibilities to maintain confidentiality

Woodland Dec 2014 Patients spoken to were extremely positive about staff on the ward and their treatment

Staff were all professional and pleasant, pro‐actively dealing with patients.

There is obvious frustration with the cramped conditions, particularly in relation to storage and staff facilities, which must be considered as part of future maintenance plans

De‐clutter entrance, utilise rear of ward Visiting times just numbers No TVs on wards‐ no plans? Corridors could do with more lighting No staff toilet‐ share with patients Staff room shared with 4 wards Speak more softly at night Bleeps quite loud‐ cannot be lowered.

Possible earplugs? Disabled Toilet/Discharge lounge/ A4

occupied sign Door numbers confusing

A review of storage available between within clinical areas located in the Princess Alexandra wing is underway which is hoped will provide additional storage for the ward.

All single and double bays have TV’s in place. Rooms 4 and 5 (4 bedded bays) require a solution. TV’s provided at each bed would be the preferred choice and the ward sister is working with Val Pyke to review this option.

The ward sister has identified noise at night as an issue and approaches to reduce noise levels on the ward have been

7

shared with all team members. The ward keeps a stock of ear plugs and

all bins have been changed to soft closing. Tandridge Dec 2014 Staff visibility at patient’s bedside

was evident; focus around personalized care was seen.

The attitude of the staff was very positive and they interacted with the patients throughout the visit.

Storage of equipment was challenging.

Lights not working in 3 of bays‐ 1,4 &7 Can alternative storage be considered In need of decoration Only hoist should be in front of fire exit Room AA35‐ chipped toilet and not very

clean Information about PALS or complaints not

easily seen Privacy curtains in toilet out of date, toilet

brush not in holder

Inform estates – log call

Nil – surgery to refurbish ward April 2015

Inform cleaning staff Ensure visible for patients and relatives

and correct info

AMU Jan 2015 Staff visibility at patient’s bedside was evident; focus around personalized care was seen.

Very impressed with the calmness, cleanliness of the ward. It appeared very well organized and caring despite the high turnaround of patients.

Signage to direct visitors to go to the left side reception would be useful

Less staff visible on right side Corridor obstruction from bed and chair Bay 1‐ TV cable trailing, walking frame trip

hazard Old nurse on duty board visible‐ looks

unfilled Consultant posters not on wall Some equipment storage less than ideal Different visiting times between main

AMU and annexe

Place signage as patient/relative enters area

Ward porter to be asked to check and clear daily

Immediate action to move cable out of the way

H&S asked to review in conjunction with estates for a longer term plan

To be removed New area to be found for this equipment Review of signage with dementia nurse

8

Charlwood Feb 2015 Patients spoken to were extremely positive about staff on the ward and their treatment.

A number of issues identified through the visit are as a result of a recent deep clean, and will be resolved as the ward replacing information and posters.

During a fire alarm the visitors in the corridor were unclear as to whether they should enter the ward which was concerning for some.

Generally very positive visit, and feedback received well by nurse in charge.

Information board on staff on duty needs tidying, paper curled

Slightly confusing signposting to ward Equipment left in corridor at narrowest

point. No poster visible to encourage or signpost

feedback One oxygen cylinder on floor Out of date infection control charts

outside the ward Member of cleaning staff not wearing ID Info on protected mealtimes not complete

Review and update of all patient information boards has been completed.

Way finding review needs to be undertaken by estates teams.

Infection control posters are distributed centrally – issue fed back to the infection control teams.



REPORT TITLE: Safety & Quality Committee Update

NON EXECUTIVE SPONSOR: Richard Shaw, Chair Safety & Quality Committee

REPORT AUTHOR (s): Katharine Horner Patient Safety & Risk Lead

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) n/a

Action Required:

Approval () Discussion ( ) Assurance ()

Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in March 2015.

Recommendation:

The Board is asked to note the report.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about Corporate Impact Assessment:

Legal and regulatory impact Compliance with CQC, MHRA and Audit Commission

Financial impact Serious incidents often become claims


Risk & Performance Management Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication Compliant

Attachment: N/A

Trust Board Report – 26th March 2015 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 5th March 2015. It considered its standing agenda items; the report from January’s ECQRM and CQRM meeting and the SQC Dashboard and Quality Report. The committee noted that the Trust has responded to East Surrey CCG’s proposed intention to stop commissioning community beds which facilitate early supported discharge for patients requiring rehabilitation. Children’s Safeguarding The Committee was updated on recent work within the Children’s safeguarding team. The committee welcomed the positive feedback the team had received following the February CQC inspection of Surrey Safeguarding. The committee heard that the change to filing ED records on the main hospital patient record for children has had a significant impact on ability of the team to identify children who may be at risk. The committee heard that the team has addressed a number of child sexual exploitation issues over recent weeks. The committee Chairman will write to the Chairman of Surrey Safeguarding Board to raise concerns that there appears to be increasing incidence of child sexual exploitation within the local area. The Chairman will request assurance from the Safeguarding Board that SASH is doing all it can to support the Safeguarding systems in Surrey and Sussex and that they are satisfied that collectively we are working together as effectively as possible. Adult Safeguarding The Committee welcomed the good progress being made in adult safeguarding this year and the increasing awareness of safeguarding issues across the Trust. The committee heard that training remains a challenge but that bespoke and ad hoc training on the wards for teams is helping. Fractured Neck of Femur pathway The Committee received an interesting presentation on the fractured neck of femur pathway. This showed an improving trajectory, especially in prompt undertaking of assessments. The Trust was shown to be performing consistently above the regional and national averages in most key performance areas. The presentation highlighted the importance of patients being admitted to the NOF ward within 4 hours for their comfort and access to specialist rehabilitation physiotherapy seven days a week. The presentation showed a significant reduction in the number of falls in hospital resulting in a fractured neck of femur. The committee heard that the top issue is discharge with an average length of stay slightly higher than average. Audit The Committee received an update on the Divisional audit plans. The team from the Women and Children Division attended the meeting to talk through their plan and recent outcomes from audits. It was noted that it had not been possible to pull the Divisional audit information together into a single report. It was acknowledged that the process of registering and reporting audits is not smooth. The committee requested that a single report be presented at the next meeting which should summarise how many audits give positive assurance and the steps that have been taken where the results have been negative. The committee also asked for an indication of why audits are commissioned; clinical practice, quality or safety.

The next meeting of the Committee is on 2nd April 2015


1

Integrated Performance ReportM11 – February 2015

Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Fiona Alsop (Chief Nurse) Paul Simpson (Chief Financial Officer)



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Care Quality Commission• The Trust is not subject to any CQC enforcement action and continues to progress the improvement plans which followed the CQC

Inspection in May 2014.

Patient Safety

• Patient safety indicators continued to show expected levels of performance.

• The Trust had no MRSA bloodstream infections and six Trust acquired C-Diff cases in February 2015.

• Adult bed occupancy remains higher than plan due to increased activity and is one of the items covered within the collaborativeCQC action plan.

Clinical Effectiveness

• The latest HSMR data shows overall Trust mortality is lower than expected for our patient group.

• Maternity indicators continue to show expected performance.

Access and Responsiveness

• In February 2015, 91% of patients were admitted or discharged within the ED standard of 4 hours with no 12 hour trolley waitbreaches.

• In February 2015, the incomplete pathways RTT standard was achieved at aggregate level while the admitted and non-admittedstandards were not achieved.

• All Cancer Access Standards were achieved.

Patient Experience

• In February 2015, ED and Inpatients both achieved an FFT score of 97%.

Performance – February 2015


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Action: The Board are asked to note and accept this report

Legal: What are the legalconsiderations & implicationslinked to this item? Please namerelevant Act

Patient safety: Legal actions from unintentional harm to patients would normally be covered by negligence, an area of English tort(civil) law, providing the remedy of compensation. Case law is extensive. Criminal action could be pursued if investigation judgedintentional harm and remedies will vary according to severity.Staff safety: The Health and Safety at Work Act etc 1974 may apply in respect of employee health and safety or non clinical riskto patients (usually reported under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995)

Regulation: What aspect ofregulation applies and what arethe outcome implications? Thisapplies to any regulatory body.

The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore licensecare services under the Health and Social Care Act 2009 and associated regulations. The health and safety executive regulatescompliance with health and safety law. A raft of other regulators deal with safety of medicines, medical devices and otheraspects.

Workforce

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place.Ward staffing levels are now published on the Trust’s external website at ward level. The Trust is also continuing to monitor temporarystaffing usage on a weekly basis

Finance• The Trust is reporting a £2.9m deficit at month 11. The previous accrual in respect of the marginal rate dispute has been removed as

the arbitration process will not complete in this financial year.

Key Risks

• Finance – The risk to the forecast outturn is recorded as £0.7m potential adverse change. That risk is from income - emergency vselective case mix

• Quality – The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Accessstandards, Outbreak of viral gastroenteritis, Local availability of qualified nurses and Increasing sickness absence levels.

Performance – February 2015


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Patient Safety

• Patient safety indicators continue to show expected levels of performance.

• There were no Never Events or medication errors causing severe harm or death in February 2015.

• Safety Thermometer – achievement of both the “All Harm” and “New Harm” measures was sustained in February 2015.

• VTE assessment performance was achieved in February 2015.

Patient Safety

Indicator Description Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15 Trend

No of Never Events in month 0 0 0 0 0 1 0 0 0 0 0 0 0

No of medication errors causing Severe Harm or Death 0 0 1 0 1 0 0 0 0 0 0 0 0

Safety Thermometer ‐ % of patients with harm free care (all harm) 92.7% 94.2% 90.5% 92.8% 92.3% 90.8% 92.5% 92.0% 95.0% 93.0% 93.0% 93.0% 92.0%

Safety Thermometer ‐ % of patients with harm free care (new harm) 96.5% 97.7% 95.4% 97.0% 97.3% 95.3% 96.1% 94.5% 98.0% 96.0% 97.0% 96.0% 95.0%

Percentage of patients who have a VTE risk assessment 96% 95% 95% 96% 95% 95% 95% 95% 95% 95% 95% 95% 95%

WHO Checklist Usage ‐ % Compliance 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 100% 96%

Number of Sis 2 6 4 7 1 11 3 3 3 2 2 5 6

Serious Incidents ‐ No per 1000 Bed Days 0.13 0.35 0.24 0.40 0.06 0.63 0.17 0.17 0.17 0.12 0.11 0.28 0.38

Number of overdue CAS and NPSA alerts 0 0 0 0 0 0 0 0 0 1 0 1 1


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• Six SIs were declared in February 2015.

• Delayed Diagnosis – Patient referred under Cancer 2 week rule who was seen promptly but biopsy was not received by Pathology. Repeat biopsy was arranged which confirmed cancer.

• Delayed Diagnosis - intracranial haemorrhage missed on CT scan.

• Closure of Maternity unit in January 2015.

• Antenatal Screening Service - number of issues were identified relating to practice and process within the service with one - one serious near miss identified as part of case review.

• Unexpected Death in Medicine.

• Patient Fall following a physiotherapy assessment.

Infection Control

• There were no cases of MRSA in February 2014, and six cases of trust acquired C.diff taking the total to 23 YTD against a trajectoryof 27 YTD and 23 cases for the same period last year.

• The trust continues to enforce good antimicrobial practice with on-going audit and reporting of results to clinical teams.

• In light of the recent outbreaks of viral gastroenteritis, the following risk has been added to the Trust's significant risk register:

• Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact onpatient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3)

Patient Safety


MRSA (incidences in month) 0 0 0 0 0 0 0 0 0 0 0 0 0

CDiff Incidences (in month) 0 0 3 0 2 2 3 0 1 4 0 2 6

MSSA 1 0 0 0 2 2 2 3 0 1 1 0 2

E‐Coli 16 15 23 25 23 18 17 22 18 15 16 14 18


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Mortality and Readmissions

• Mortality – The latest HSMR data shows overall Trust mortality is lower than expected for our patient group when benchmarked against national comparators.

• Readmissions within 30 days continues to remain at expected levels.

Maternity

• Maternity continues to show positive performance overall and quality measures remain under monitoring at the Clinical Effectiveness committee.

Clinical Effectiveness


HSMR (56 Monitored diagnoses ‐ 12 Months) 98.3 94.9 95.3 95.6 93.7 92.9 91.5 90.2 88.6 88.2

Emergency readmissions within 30 days (PBR Rules) 6.3% 7.4% 6.7% 6.6% 6.6% 7.2% 6.8% 6.8% 7.1% 7.0% 7.0% 6.7%


C Section Rate ‐ Emergency 20% 16% 18% 15% 14% 17% 14% 17% 12% 14% 17% 19% 16%

C Section Rate ‐ Elective 8% 11% 10% 10% 11% 10% 13% 9% 12% 13% 11% 7% 11%

Maternal Deaths 0 0 0 0 0 0 0 0 0 0 0 0 0

Admissions of full term babies to neo‐natal care 6.0% 6.2% 7.6% 6.7% 7.5% 8.5% 6.1% 8.0% 5.4% 3.8% 6.3% 6.0% 6.0%


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Emergency Department

• In February 2015, 91% of patients were admitted or discharged within 4 hours with no 12 hour trolley wait breaches

• The delivery of the ED 4hr standard remains a challenge across the country and despite the under-performance at the Trust, we remainone of the best performing Trusts in the country.

• Ambulance Turnaround data is still subject to review with SECAmb.

• In light of the on-going operational pressures in the Trust, the following two risks are on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system tomanage winter pressures – Risk score 16 (Likelihood of 4 and consequence of 4)

• Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed firsttime, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5and consequence of 3)

• Following discussion at the Access and Responsiveness Committee, the Executive Committee will discuss the inclusion on the SRR ofa risk in relation to cancelled operations. The outcome will be reflected in the March report.



ED 95% in 4 hours 94.7% 97.5% 96.8% 96.1% 96.6% 97.6% 95.9% 95.4% 94.3% 95.7% 93.3% 92.0% 91.3%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0

Ambulance Turnaround ‐ Number Over 30 mins 96 72 83 105 77 41 72 97 151 183 344

Ambulance Turnaround ‐ Number Over 60 mins 6 0 9 19 0 0 3 2 6 4 10


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Cancer

• All Cancer Access Standards were achieved in February 2015.



Cancer ‐ TWR 95.9% 96.1% 93.1% 93.1% 93.6% 93.1% 93.0% 93.2% 93.8% 93.1% 93.1% 93.1% 93.1%

Cancer ‐ TWR Breast Symptomatic 99.2% 98.6% 93.7% 93.5% 93.7% 93.2% 94.4% 93.2% 93.3% 93.6% 93.5% 93.4% 96.3%

Cancer ‐ 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer ‐ 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer ‐ 31 Day Diagnosis to Treatment 99.0% 99.0% 100.0% 100.0% 98.1% 99.2% 97.1% 99.2% 100.0% 99.1% 98.4% 97.1% 100.0%

Cancer ‐ 62 Day Referral to Treatment Standard 85.0% 95.2% 89.7% 87.0% 86.9% 90.8% 87.9% 78.8% 87.1% 86.3% 86.1% 85.4% 88.0%

Cancer ‐ 62 Day Referral to Treatment Screening 50.0% 100.0% 100.0% 100.0% 100.0% 50.0% 100.0% 83.3% 83.3% 100.0% 100.0% 92.3% 100.0%


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Referral to Treatment (RTT) and Diagnostics

• In February 2015, the incomplete pathways RTT standard was achieved at aggregate level while the admitted and non-admittedstandards were not achieved.

• The non-achievement of the standards was part of the national drive to reduce long waiters. The Trust achieved the nationally set targetfor the end of February (to have less than 1,140 patients waiting over 18 weeks for treatment) and is continuing to try to drive this downfurther.

• The outcome can be seen in the improvement in the RTT Incomplete standard from 92% in January 2015 to 94% in February 2015.

• There were a number of speciality failures of the admitted and non-admitted standards as work is undertaken to reduce the number ofpatients waiting over 18 weeks for treatment. Several specialities also failed the incompletes standard.

• Within Diagnostics, the quality standard for waits over 6 weeks was achieved and there were no urgent operations cancelled twice.



RTT Admitted ‐ 90% in 18 weeks 92.0% 91.4% 92.9% 94.4% 94.7% 92.8% 90.4% 90.7% 88.1% 81.4% 91.1% 90.2% 82.1%

RTT Non Admitted ‐ 95% in 18 weeks 98.1% 97.6% 97.4% 97.2% 96.5% 95.2% 95.8% 93.2% 93.9% 92.8% 95.0% 91.7% 91.0%

RTT Incomplete Pathways ‐ % under 18 weeks 95.9% 96.2% 96.4% 96.0% 95.2% 94.9% 93.9% 93.8% 93.5% 93.3% 92.2% 92.1% 94.0%

RTT Patients over 52 weeks on incomplete pathways 0 0 0 0 0 0 0 0 0 0 0 0 0

Percentage of patients waiting 6 weeks or more for diagnostic 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% 0.1% 0.0% 0.0% 0.4% 0.1% 0.9% 0.7%

% of operations cancelled on the day not treated within 28 days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.0% 1.6% 0.0% 0.0% 0.0% 0.0%


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Patient Voice

February FFT Scores• ED achieved an FFT score of 97.1%, an increase of 1.3% compared to January. The response rate was 24%.

• At 96.9% the inpatient score increased to nearer that seen in October and November 2014. The response rate increased to 40%,the highest for 9 months

• In maternity, FFT scores remained stable for both Antenatal and the Postnatal Community Care (97% and 100% respectively), andincreased for both the Delivery and Postnatal Ward touchpoints (97% and 91% respectively)

• For the postnatal community touchpoint the FFT response rate remains a challenge with just 1% of mothers responding.

• There were no Mixed Sex Breaches in February 2015.

Patient Experience


Inpatient FFT ‐ % positive responses 98.0% 98.0% 96.0% 97.0% 97.0% 95.0% 95.7% 96.9%

Emergency Department FFT ‐ % positive responses 99.0% 98.0% 98.0% 95.0% 96.0% 93.0% 95.8% 97.1%

Maternity FFT ‐ Antenatal ‐ % positive responses 97.0% 99.0% 96.0% 97.0% 95.0% 90.0% 97.6% 97.1%

Maternity FFT ‐ Delivery ‐ % positive responses 100.0% 98.0% 95.0% 95.0% 93.0% 100.0% 95.5% 97.2%

Maternity FFT ‐ Postnatal Ward ‐ % positive responses 92.0% 93.0% 93.0% 90.0% 92.0% 96.0% 85.9% 91.0%

Maternity FFT ‐ Postnatal Community Care ‐ % positive responses 93.0% 100.0% 100.0% 94.0% 100.0% 85.0% 100.0% 100.0%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints (rate per 10,000 occupied bed days) 27 25 17 27 22 19 23 18 31 17 18 15 25


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Workforce

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is inplace.

• Staff Turnover remained static at 15.7% in February 2015. HR Business Partners within the divisions continue to support actionsto improve recruitment and retention with a significant focus on nursing.

• Sickness absence increased marginally to 4.4% in February 2015.

• The following workforce related risks sit on the Trust’s significant risk register:

• Current local availability of qualified nurses and pressures on temporary staffing is leading to increased resource timebeing spent on ensuring existing clinical areas are safely staffed – Risk score 16 (Likelihood of 4 and consequence of 4)

• Increasing Sickness Absence Levels with impact on day to day management and expenditure – Risk score 15 (Likelihoodof 5 and consequence of 3)

Workforce


Average fi l l rate – registered nurses/midwives (%) ‐ Day 97.3% 97.7% 97.5% 95.7% 95.4% 96.4% 97.1% 95.1% 94.8% 95.9%

Average fi l l rate – care staff (%) ‐ Day 95.6% 97.3% 95.1% 97.5% 96.4% 95.3% 95.0% 93.1% 92.6% 93.8%

Average fi l l rate – registered nurses/midwives (%) ‐ Night 97.5% 97.9% 98.2% 97.2% 98.1% 99.2% 99.4% 97.3% 97.2% 97.7%

Average fi l l rate – care staff (%) ‐ Night 96.7% 97.5% 97.2% 97.5% 96.7% 97.4% 95.3% 93.7% 93.3% 94.9%

Overall Sickness Rate 3.9% 3.2% 3.0% 3.3% 3.6% 3.8% 3.2% 4.0% 4.4% 4.0% 4.5% 4.3% 4.4%

%age of staff who have had appraisal in last 12 months 76% 87% 80% 82% 80% 80% 75% 74% 72% 69% 72% 67% 68%

Staff Turnover rate 14.8% 14.3% 14.6% 14.5% 15.0% 15.0% 15.8% 15.6% 15.3% 15.3% 15.6% 15.7% 15.7%


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Finance

• The Trust is reporting a £2.9m deficit at month 11. The previous accrual in respect of the marginal rate dispute has been removed asthe arbitration process will not complete in this financial year.

• As a consequence the forecast year end position is now a £2.5m deficit (M11 is a short month and income improves at M12). The riskto this position has been estimated at £0.7m (a reduction against M10 due to the removal of the income accrual). A dispute with EastSurrey CCG is also a risk.

• The year to date income continues however to include the two tranches of winter resilience funding (11/12ths has been included foreach).

• Divisional spend remains above budget due to the levels of emergency activity within the Trust but it is within expected tolerance.

Indicator Description Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Sep‐14 Oct‐14 Nov‐14 Dec‐14 Jan‐15 Feb‐15

Outturn £m Surplus / (Deficit) ‐ Plan 0.0 0.0 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3

Outturn £m Surplus / (Deficit) ‐ Forecast 0.3 0.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 (2.5)

YTD £m Surplus / (Deficit) ‐ Plan 0.0 0.0 (0.9) (1.7) (2.8) (2.1) (1.5) (1.3) 0.1 0.4 1.0 1.9 1.4

YTD £m Surplus / (Deficit) ‐ Actual 0.3 0.3 (0.9) (1.7) (2.8) (2.1) (1.5) (1.3) 0.1 0.5 1.0 1.9 (2.9)

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Plan (3.5) (3.5) 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4 3.4

Outturn UNDERLYING £m Surplus / (Deficit) ‐ Actual (4.3) (4.3) 3.4 3.4 3.4 3.4 3.4 1.0 1.0 (0.7) (5.2) (5.2) (5.2)

YTD Savings £m ‐ Actual 9.9 11.1 0.4 0.6 1.1 1.9 2.8 3.8 5.0 6.2 7.4 8.6 9.8

OT Risk £m Surplus / (Deficit) ‐ Assessment (4.3) 0.0 (8.5) (8.0) (8.0) (8.5) (8.5) (8.5) (8.5) (6.3) (6.3) (5.5) (0.7)

Outturn Cash position £m Fav / (Adv) ‐ Forecast 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6

YTD Cash position £m Fav / (Adv) ‐ Actual 8.3 2.6 2.9 2.6 2.4 2.7 3.1 3.0 3.8 2.8 4.8 3.8 3.8

YTD Liquid ratio ‐ days (1.0) (13.0) (16.0) (15.0) (18.0) (18.0) (17.0) (10.0) (7.0) (4.0) (8.0) (8.0) (18.0)

YTD BPPC (overall) volume £m 84% 85% 94% 94% 94% 94% 94% 94% 90% 85% 88% 87% 86%

YTD BPPC (overall) value £m 84% 85% 87% 89% 90% 87% 88% 87% 92% 78% 84% 83% 83%

Outturn Capital spend Fav / (Adv) ‐ forecast 16.4 16.4 19.3 19.3 19.3 19.3 19.4 19.4 19.4 19.4 19.3 19.3 19.3


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Finance

• The cost improvement plan year to date target is £9.8m and at M11 this has been achieved.

• The underlying position at the end of February is £5.6m deficit, reflecting the non-recurrent elements in the year to date position.The forecast year end underlying position remains £5.2m.

• The cash balance at the end of February 2015 was £3.8m, below the planned position due to the delay in receiving contractpayments from CCGs. The cash position is becoming more challenging as there are delays in agreeing income figures andsignificant financial challenges from CCGs and as a result, an application for temporary borrowing was made.

• The capital forecast spend remains £19.3m.

• The liquidity position has corrected to its underlying position with the timing of capital expenditure, the removal of the incomeaccrual and other balance sheet movements.

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REPORT TITLE: 2015/16 Revenue and Capital Budgets

EXECUTIVE SPONSOR: Paul Simpson – Chief Finance Officer

REPORT AUTHOR (s): Lorraine Clegg – Deputy Chief Finance Officer

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) FWC 24th March 2015

Action Required:

Approval (√ ) Discussion () Assurance ()

Purpose of Report:

This paper sets out the interim revenue budget for 2015/16 and the final capital budget for 2015/16 for approval.


This budget has been discussed at the Finance and Workforce Committee prior to the Board. As in past years, the revenue budget is an interim budget. There are two reasons for this:

1) slippage to the national timetable for contract negotiations - contract signatures are not expected for some weeks. Boards are, however, expected to have signed off plans by 31 March;

2) the prices for the “enhanced tariff option” (ETO) are not yet published (the Trust selected this option on 4 March after the national rejection of the original tariff).

The revenue and capital budgets proposed here are entirely consistent with year 1 of the current Long Term Financial Model being submitted to Monitor. The revenue budget proposes a surplus of £1.6m and includes a cost improvement plan of £8.2m. The budget is interim because it includes a Trust estimate of the anticipated income from the contract. The capital budget proposes investment of £17.0m

Recommendation:

The Board is asked to note and approve the interim revenue budget and the final capital budget for 2015/16.

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Legal and regulatory impact

No legal breach is reported, or forecast. NHS Trust financial performance is subject to Schedule 5 of the NHS Act 2006 (the “breakeven duty”). This was breached in 2007/08 and the Auditor has notified the Secretary of State in several letters as required by Section 19 of the Audit Commission Act. The Trust continues to have permission to spend through agreement of its 2014/15 plan and its compliance with the conditions of its working capital loan. Legal aspects impact on individual parts of spend and income according to the nature of the spend & source of income but no other material disclosures are appropriate.

Financial impact Direct – sets the interim revenue budget and final capital budget for 2015/16

Patient Experience/Engagement No adverse impact

Risk & Performance Management

No compliance issues. Risk and financial performance are a core part of the monthly internal performance management process in the Trust that holds Divisions to account and, as this is a forward looking process, identifies mitigating actions to deal with risk..


No compliance issues. In respect of communication, Trust financial performance is reported through an on-line financial system in some detail to operational areas and is supported by a hierarchy of Divisional and Board reporting that pulls together activity, HR, finance, performance and quality.

Attachment:

Appendix A – Revised national timetable

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TRUST BOARD REPORT –26th March 2015 2015/16 Revenue and Capital Budgets 1. Introduction This paper outlines the proposed interim revenue budget for 2015/16 and the final capital budget. The revenue budget remains interim as the national timetable for contract agreement with CCG’s has been delayed – and the detailed enhanced tariff option (ETO) tariff [prices] has not yet been published. This budget is consistent with year 1 of the LTFM v6, and delivers a £1.6m surplus. 2. National timetable for contract signature As this budget is presented, the Trust has not signed any contracts for 2015/16 with commissioners. The main contracts will be with (respectively) Sussex CCGs, Surrey CCGs, NHS England (for specialist commissioning) and the Sussex Musculoskeletal Partnership (SMSK). The TDA issued a revised national timetable on 3rd March 2015 – attached as appendix A. A 2015/16 plan submission is required on 7th April 2015 - this interim budget will form the basis of that submission to the TDA. A final plan submission based on signed contracts is required by 14th May 2015.

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3. Capital budget/ plan 2015/16

The Capital plan is consistent with the Integrated Business Plan and the Estates Strategy and reflects year 1 of that 5 year plan. Formal approval by the Department of Health of the CRL total of £16,963k is expected in Qtr 1.

Planned CRL & Secured Variance

Funding Funding£000 £000 £000

Depreciation 8,142 8,142 - Theatres Phase 2 DH funded (rolled from 2014-15) 550 - 550 Capital Investment Loan 4,400 - 4,400 Earlwood Lease 1,200 - 1,200 Medical Equipment Leases 1,500 - 1,500 Other internally generated income 1,171 - 1,171 CRL 2014-15 16,963 8,142 8,821

Capital Schemes - Trust Approved Schemes

Planned Programme

£000s FOT @

M1 £000s

Variance / Control

£000 Angio/Cardio Private Patient Unit 1,651 1,651 - Angio/Cardio Private Patient Unit - LOF contribution (200) (200) - Building services infrastructure - eg pipes, gases, electricity 250 250 - Capital Project Management 150 150 - Car park improvements 125 125 - Compactor replacement 55 55 - Earlswood lease 1,200 1,200 - Electronic Prescribing EPMA 572 572 - Email replacement 100 100 - EPR Procurement 2,535 2,535 - Fire Doors 200 200 - Fixed Allocation Endoscopy 150 150 - Fixed Allocation Medical equipment 200 200 - Fixed Allocation Non Ward Works 250 250 - Fixed Allocation Theatre equipment 150 150 - Fixed Allocation Ward Improvement Group 275 275 - GP order communications for radiology requests 175 175 - Haematology outpatients 250 250 - HSDU - reverse osmosis 150 150 - Interventional radiology recovery area 500 500 - IT Hardware / Windows upgrade 300 300 - Kitchen Vetilation & modernisation 260 260 - Leigh & Newdigate 2 x ward upgrade 750 750 - Macmillan 324 324 - Mammography - to be funded by charitable funds 700 700 - Medical Day unit - cost of converting exsisting DSU 100 100 - Medical equipment replacement/contingency 945 945 - Network upgrade 250 250 - Pathology joint venture 1,096 1,096 - Replacement of maple annex with two-storey inc health records 1,000 1,000 - Resus & CT in ED 1,000 1,000 - Self check-in kiosks for outpatients 50 50 - Tandridge ward refurbishment incl Theatre 10 600 600 - Tandridge ward refurbishment incl Theatre 10 - Contribution for LOF (100) (100) - Theatres Phase I I 550 550 - Urology to Crawley - equipment costs 250 250 - Windows replacement programme (estates) 150 150 -

- Capital Resource Limit 2015-16 - Application to DH 16,963 16,963 -

Capital - Forecast Statement of financial position for 2015-16 01 April 2015

Capital Resource Limit is financed by:

The Board is asked to approve the capital budget.

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4. Interim Revenue Budget 2015/16

To date no contract completion timetable has been received from the CCG’s – the proposed budget therefore is based on the Trust’s view of contract income for 2015/16. The proposed revenue budget for 15/16 is as follows:

2014/15 Forecast

2015/16 Budget

Movement

£'000 £'000 £'000Income (excl Divisional income)

NHS Clinical Income 221,914 243,338 21,424Chemo Profit Share (103) (134) (31)High Cost Drugs (10,964) (11,797) (833)Excluded devices (945) (923) 22Donated Assets 252 252 0Other Income 7,488 7,701 213

Total Income & Related Costs 217,642 238,438 20,796

Divisions (inc Divisional income)

Surgical 59,733 60,475 742Medical 46,941 47,035 94WaCH 23,362 23,459 97CSS 31,273 30,962 (311)Cancer Services 3,204 3,375 171Clinical Services (Escalation) 5,313 5,419 106E&F 13,183 13,013 (170)HR 2,929 2,725 (204)CEO 979 989 10Restructuring and PMO 826 1,000 174Finance 3,085 3,085 0Nursing 2,999 3,071 72IT 3,060 3,147 88Corporate Affairs 1,203 1,049 (154)Overheads 8,301 8,161 (140)Movement on Provisions (400) 0 400CQUIN 66 250 184

Reserves 2,202 16,324 14,122 208,259 223,538 15,280

EBITDA 9,383 14,899 5,516

Financing Charges 11,871 13,267 1,3960 0 0

Net Surplus / (Deficit) (2,488) 1,632 4,120

Technical Adjustment (don assets) 49 (32) (81)

Adjusted Net Surplus / (Deficit) (2,439) 1,600 4,039 The Board is asked to approve the interim budget.

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Appendix A

[END]


Date: 26 March 2015 Agenda Item: 3.3

REPORT TITLE: Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR: Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s): Richard Durban (Non-Executive Director and FWC Chair)


No – Board Update

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Purpose of Report:

To update the Board on the discussions and actions from the Finance and Workforce Committee.


The Finance and Workforce Committee met on the 24th

March 2015. The key points from the

meeting were as follows:

Business Case Investment

• The Committee received an update on the proposed Monitor assessment timetable.

Financial, Workforce, Capital and IT M10 performance reports

• M11 reports were received for Finance, Workforce and Organisational Development,

Capital and IT.

• On Finance the Trust has reported a £2.9m deficit at month 11 because the arbitration

over the marginal rate dispute is still ongoing.

• The Trust now forecasts a £2.5m deficit with an improvement in income expected in M12.

• The Committee recommend a reduction in IT BAF Risk to a 4 for likelihood and a 3 for

impact.

Recommendation:


SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


2An Associated University Hospital of



The FWC reviews assurance in respect of workforce, capital

and investment projects, business planning (which includes

financial planning) and cash aspects. Employment law: laws

governing the rights of individuals and terms and conditions

terms include: National Minimum Wage Act 1998; the

Working Time Regulations 1998; Employment Rights Act

1996; Equality Act 2010; Employment Rights Act 1996, and;

the Transfer of Undertakings (Protection of Employment)

Regulations 2006. Other key laws affecting employees

include the Pensions Act 2004 and the Trade Union and

Labour Relations (Consolidation) Act 1992.

Financial performance is subject to Schedule 5 of the NHS

Act 2006 which provides the “breakeven duty”. Legal aspects

related to capital works will depend on the nature of the

works.

The main regulators, are as follows:

- External audit (the Grant Thornton for this Trust)

gives an opinion on the Trust’s compliance with

International Financial Reporting Standards and with

NHS accounting conventions – this is not purely

financial and deals with procurement, fraud,

transparency and legal duties. It also gives a Value

for Money Conclusion on the Trust’s ability to put in

place arrangements to deliver economy, efficiency

and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to

its compliance with regulations concerning the safety and

quality of services

Financial impact The report provides assurance about savings, capital spend

and the structure of the business planning process.

Patient Experience/Engagement Indirect impact through Trust planning and workforce.

Risk & Performance Management The committee, and this report, provides assurance about

workforce and capital management.


Attachment:

Report Paper

3An Associated University Hospital of


TRUST BOARD REPORT – 26 March 2015

Finance & Workforce Committee Chair Update

The Finance and Workforce Committee met on 24 March 2015 and it was quorate. The key

points from Part 1 were as follows:

Business Planning

The Committee received an update on the outline Monitor timetable. Monitor are scheduled to

begin their assessment of the Trust for Foundation Trust (FT) status on the 7th

April.

Financial, Workforce, Capital and IT M11 performance reports

The month 11 Finance, Workforce and Organisational Development, Capital and IT reports were

presented to the Committee:

- The Trust has reported a £2.9 million deficit year to date (YTD) at M11. This movement from a

surplus to deficit is because the arbitration over the marginal rate dispute is now not expected

to be complete before the year end. The Trust has taken the prudent decision not to recognise

income in respect of this. As a consequence the forecast year end position is now a £2.5m

deficit with an improvement in income expected in M12. There remains a dispute with East

Surrey CCG against which no financial risk is currently included in the report. This will be

reviewed as the dispute process continues. The maximum risk is £2.4 million.

- The Capital and IT reports were presented and noted by the Committee. Tilgate Annex opened

on the 4th

March following hand over by the contractors on the 1st

March. The Committee noted

that an IT road map will be presented in May highlighting the implementation of future IT

projects.

- A recommendation to the Board from the Committee for the reduction in the IT BAF risk was

sought and received following discussions around the severity of the risk and the improved

process around IT implementation. The Committee recommends the reduction of the IT BAF to

a 4 likelihood and 3 impact.

- The Workforce and Organisational Development Report was received by the Committee. It was

noted that new style appraisals (Achievement Reviews) will be implemented in the Trust from

the 1st

April. This follows a successful pilot with senior managers. To ensure transparency

between appraisals the original KPI’s will continue to be collected and reported alongside any

new KPI’s.

[END]



REPORT TITLE: Audit & Assurance Committee Chair Update

NON EXECUTIVE SPONSOR: Paul Biddle (Non-Executive Director and AAC Chair)

REPORT AUTHOR (s): Colin Pink Corporate Governance Manager

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Audit & Assurance Committee – 17/03/15

Action Required:

Approval () Discussion () Assurance (√)

Purpose of Report:

This report provides the Board with an executive summary of the January Audit and Assurance Committee.


The reviewed the draft BAF and discussed emerging risks to be considered for addition to the updated BAF focussing on specific risks; to describe the impact of the high usage of agency, issues relating to the agreement of contracts/income plans and the possible impact of current negotiations. Management presented its review of corporate governance controls which had been updated and reviewed by the Executive team. This provided assurance that systems are in place to manage elements of corporate governance. The Head of Internal Audit gave his draft end of year opinion that based on the work undertaken in 2014/15, significant assurance can be given that there is a generally sound system of internal control, highlighting the main issues that had been identified throughout the year. Recommendation:

The Board is asked to note this report.





The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Financial performance is subject to Schedule 5

2An Associated University Hospital of Brighton and Sussex Medical School

of the NHS Act 2006 which provides the “breakeven duty”. The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources. The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services.

Financial impact

No material financial implications. The report provides independent assurance about BAF reporting on financial risk and counter fraud systems

Patient Experience/Engagement No relevant aspects

Risk & Performance Management

The committee provides assurance about internal control and risk management. This report discusses BAF reporting


No relevant aspects

Attachment:

N/A


TRUST BOARD REPORT – 26/03/2014 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 17/03/2015; it was quorate. The key points from this meeting were as follows:

1) The committee discussed the BAF in preparation for public board on 26th March. The committee requested specific updates to financial risks to reflect the end of year position and requested that workforce related risks reflected the risks recorded on the significant risk register.

The committee then went on to discuss emerging risks that should be considered for addition to the updated (15/16) BAF focussing on specific risks; to describe the impact of the high usage of agency, issues relating to the agreement of contracts/income plans and the possible impact of current negotiations.

2) Management presented an updated review of its risk management systems, which provided positive assurance of the controls in place and continuing progress in improving the system and compliance with the policy. This opinion was validated by Internal Audit who confirmed that there where visible improvements in risk management systems over the last two years.

3) Management presented its review of corporate governance controls which

had been updated and reviewed by the Executive team. This provided assurance that systems are in place to manage elements of corporate governance. The Committee noted the positive steps taken to tighten controls relating to Emergency Planning and Business Continuity. The Committee went on to state that, should the Trust achieve its aspiration to attain foundation trust status, the controls map would need to be updated to include elements of how the board would function and the role of the council of governors.

4) The Head of Internal Audit gave his draft end of year opinion that based on the work undertaken in 2014/15, significant assurance can be given that there is a generally sound system of internal control, highlighting the main issues that had been identified throughout the year. Internal Audit confirmed that issues related to NICE Guidance Compliance (One remaining item being clarified) and project management reviews that had now been addressed. As the temporary staffing audit had just been completed the committee requested a briefing at the next meeting and a review of the initial deadlines on the action plan.

5) Internal Audit presented its update report, highlighting good assurance for safeguarding children systems, management of consent and lessons learned (Amber/Green). The report into temporary staffing systems had identified multiple issues and had been graded as (Amber/Red). The committee requested that the Executive team look to review the findings of the audit, monitor the actions identified and that an update report be taken to the May committee. Finally the committee discussed the regular BAF


audit which provided strong assurance (Green) that the assurances relied on are independent, timely and relevant to the risks and controls (Risk 2.A.1 and 3.B.2).

6) Management presented a working draft of the Annual Governance Statement for early review. The committee noted the initial commentary, reflected on the changes in national guidance and highlighted areas of improvement or where greater clarity was required.

[END]


Date: Agenda Item:

REPORT TITLE: CQC Improvement Action Plan Update

EXECUTIVE SPONSOR: Fiona Allsop Chief Nurse

REPORT AUTHOR (s): Sue Jenkins Director of Strategy

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Executive Committee

Action Required:

Approval () Discussion () Assurance (√)

Purpose of Report:

This report provides the Board with assurance that the recommendations made following the CQC visit in May 2014 are being addressed


The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. This report includes a summary of the initial recommendations that were made in the report and how the Trust has responded to them. Progress against the detailed action plan that has previously been reported to the Board is also included. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green or blue. The CQC also made some “should do” recommendations which are also reported against in this report. The system wide updates following the quality summit are also included in this report for completeness

Recommendation:

The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. They are also asked to consider content and frequency of future reporting.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health


economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory implications Compliance with CQC recommendations and delivery of action plan to address areas highlighted is essential

Financial implications Capital and revenue implications will be addressed through separate business cases

Patient Experience/Engagement Feedback from patients regarding their experience in outpatients is a key part of this action plan

Risk & Performance Management A monthly steering group is in place to ensure delivery of the plan


N/A

Attachment:

4.1a - Mouth Care Matters Briefing 4.1b – CCG Update


TRUST BOARD REPORT –26 March 2015 CQC Improvement Plan Update - Outpatients 1. Introduction The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. This report includes a summary of the initial recommendations that were made in the report and how the Trust has responded to them. Progress against the detailed action plan that has previously been reported to the Board is also included. This report provides a summary of progress to date which confirm that all of the four main work streams are rated as green. The CQC also made some “should do” recommendations which are also reported against in this report. 2. Progress against recommendations and concerns raised in original CQC report Ref Issue raised in CQC report Update Safe Medical records not available for all

clinics which results in incompleteness of patient records

Medical records staff extended to cover 24/7 which supports improvement of note availability

Safe Medical records availability not reported on Datix

Trial in place during April 2015 to support reporting of all notes non availability or incompleteness on Datix

Safe Datix could only be accessed by band 6 and above staff to report incidents

Datix now available to all receptionists and band 5s

Safe Datix feedback to staff was not consistent

Audit afternoon has been reviewed and is to be restructured to support formal and informal feedback of concerns raised by staff

Safe Location of medical records in Southampton compromised access to notes on occasions

Off site notes storage facility has been reviewed and re-procured. New contract agreed with supplier a few minutes from ESH

Safe Number of last minute ad hoc clinics compromised access and availability of medical notes

Linked to demand and capacity work underway

Safe Quality of note tracking information was not consistent

2 major upgrades of system completed. Improved communications with users

Safe Medical records working environment is poor

Immediate steps taken to improve minor issues raised and


capital identified to support reprovision of new department

Safe MCA and DoLS awareness of some outpatient staff was limited

Training provided to all relevant outpatient staff

Safe Staffing skill mix required more qualified nurses

Review underway which is linked to demand and capacity review

Caring Environment of main outpatients is poor and overcrowded

Capital identified to support rebuild or reprovision of outpatients accommodation in 16/17

Responsive Clinics cancelled at short notice Linked to demand and capacity review

Responsive Clinics overbooked and overrun Linked to demand and capacity review

Responsive Play areas not available in waiting area Will be included in plans for reprovision of outpatient accommodation

Responsive Patients felt that there is not enough car parking

Additional car parking provided for patients

Responsive Appointments arranged multiple times Report to be developed to confirm number of times appointments are rescheduled

Responsive Clinics cancelled at short notice (< 6 weeks)

Reported to Board each month and process put in place to record all changes with less than 6 weeks notice

Well led Senior leadership problems identified in outpatients

New outpatient manager appointed January 2015

Well led Medical secretary and medical records leadership

Meetings held for these staff groups with senior members of staff and exec team have undertaken back to the floor exercises to raise profile

Well led Staff engagement for outpatient staff to make improvements

Staff focus groups for outpatient staff being established in the spring

Well led No evidence of clear strategies to respond to future outpatient activity

Demand and capacity review looks forward as well as prospectively

Must do Carry out a review of the outpatient service to ensure there is adequate capacity to meet the demands of the service

Updated progress detailed in plan below

Must do Implement a system to monitor quality of outpatient service that includes number of cancelled appointments, waiting times for appointments and number of patients with no medical records available for their appointment

Updated progress detailed in plan below

3. Outpatient review update There are four key work streams that the outpatient action plan covers. They are

Environment


Workforce and leadership skills Communications Systems and processes

The table below details the key actions that are being undertaken for each of the four areas and a RAG status is included:- RAG Definition

B Action complete G Action being delivered to plan A Action delayed or outside of budget but plans in place to bring back on track R Action unlikely to be delivered to plan

Ref Details RAG

status 1.0 Environment G 1.1 Minor redecoration and refurbishment in the existing department have

been completed B

1.2 The Earlswood centre opened on 4 February for their first diabetes and endocrinology clinics. All clinics (except ante natal) have moved from East Surrey hospital to The Earlswood Centre. Initial feedback from staff and patients has been very favourable. Three Chipstead clinic rooms that were released by move to Earlswood are being refurbished and due to commence with new activity on 2 March 2015.

B

1.3 IT solution being explored to support room allocation and monitoring of clinic space. Onsite visit from potential supplier of software system to support room use and allocation has taken place and further meetings to progress a pilot have been planned. A business case has being developed and was considered and supported by CHIG in February. The capability of the new Cerner release is being considered but timing of this could compromise a prompt solution. No capital has been allocated to this scheme at the moment and likely cost is estimated at £24k. A capital bid pro-forma is therefore being developed.

G

1.4 Accommodation for additional ophthalmology clinics was considered at Horsham but unlikely to progress. A meeting with a property developer has also taken place to discuss the opportunity of having additional outpatient capacity built on the Earlswood estate. A specification for the service is currently being developed by the clinical team and this will potentially release space on the ESH site for ophthalmology

G

1.5 Refurbishment of haematology clinic areas included in capital plan for 2015/16 but work planning to start in March 2015. Revised plans are being reviewed with clinical staff.

A

1.6 Chemo outpatient clinics to be accommodated on ESH site following repatriation from Royal Surrey Hospital. Some of these clinics have commenced and the rest will be accommodated when rooms have been identified

G On-going

1.7 Report requested from information team to review allocation of patients waiting for outpatient clinics to nearest location to home address and information now available and to be used to inform appointment bookings.

B

1.8 Outpatients refurbishment and works project group established and B


meeting on a weekly basis 2.0 Systems and processes G 2.1 Trust wide review of demand and capacity underway. Projections

around anticipated growth and improvements in new to follow up ratios and DNAs have also been modelled. The top three specialties which equate to more than 20% of all outpatient activity are being focussed on to test forecast demand against clinic templates and job plans. This work will go beyond the 31.3.15 deadline that was originally proposed.

G

2.2 Service level review of demand and capacity underway and will be matched with trust wide review.

G

2.3 New templates implemented and in place for ad hoc clinics, cancellations and room requests

B

2.4 Separate partial booking project team established and plan to be completed. Original aim was to implement January 2015 using Cardiology and Rheumatology as pilot areas but this has been postponed due to lock down of Cerner. Plans being revised to reflect availability of Cerner support staff who are essential to support go live

A

2.5 Electronic process for referrals being considered and developed with GPs. Trial being developed with two GP practices.

G On-going

2.6 KPIs and metrics agreed for monitoring outpatients by steering group B 2.7 Consultant to consultant process reviewed and referrals reduced to

minimise financial penalties B

2.8 Monitoring of new to follow up ratios in place on a monthly basis to ensure financial penalties are minimised

B

2.9 Weekly monitoring of KPIs commenced and reporting in place at divisional level. Detailed reports for key breaches to be developed and reported at monthly outpatient steering group

G On-going

2.10 Telephone clinics in place for some specialties and tariff being developed to support this more efficient and effective way of working. Rheumatology and gastroenterology are looking at this area in more detail and some software with a years free trial is being explored to support

G On-going

2.11 Bleep system to enable patients to leave the department has been explored with other trusts who have system in place. Not considered viable as patients too concerned that they will lose their appointment slot. Self-check kiosk option being considered as an alternative and pilot being explored with potential supplier and a case to support the trial was considered and supported by CHIG in January 2015. Proof of concept being developed for go live in August. Capital confirmed

G

2.12 Outpatient booking office call answering currently at 98%. Plan in place to improve to 99%

G On-going

3.0 Workforce and leadership B 3.1 Interviews for Outpatient Service Manager completed and offer made

to strong candidate who commenced at beginning of January 2015. Interim management arrangements in place.

B

3.2 Skill mix review of outpatient services continually underway and reviewed each time vacancies arise.

B

3.3 Single line management of all outpatient staff considered and agreed not to progress at this point

B

3.4 Outpatient steering group and weekly operational groups all in place B 3.5 Back to the floor session by Director of Strategy undertaken in

outpatients department B

3.6 Programme to extend skills of nurses being developed and to be G


worked up in more detail following appointment of new service manager

On-going

4.0 Communications G 4.1 Lead clinician and members of outpatient team have met with a

number of GP practices and CCG governance committee to consider views on referrals from GP perspective. This is key to improve working relationships between the Trust and primary care.

G On-going

4.2 Lead clinician meeting with clinicians on a 121 basis to gain views and feedback on outpatient services

G On-going

4.3 Outpatient services to be included on agenda item for all consultants meeting – Mid September

B

4.4 Outpatient nurse lead to meet with patient experience forum G On-going

4.5 Outpatient focus group for patients planned for 2 December and 157 members interested in outpatients have been invited. Focus groups completed with 14 participants and feedback has informed an action plan which is monitored by monthly outpatient steering group.

B

4. Progress against should do recommendations

Requirements Lead Update on progress Outcome Review the training provided to clinical staff on the Mental Capacity Act to ensure all staff understand the relevance of this in relation to their work.

Fiona Allsop Barbara Bray

Nursing: Currently rolling out ward based training for Nurses and now included within MDT MAST training. ELearning main tool for delivery of medical training.

Reviewing general training compliance and monitored by safeguarding functions. Medical compliance reviewed separately

Ensure that a review of mouth care is undertaken so that staff are clear where this should be recorded in the patients care record.

Fiona Allsop Mouth Care Matters is being rolled out and includes a revised documentation process.

Improved oral health for hospitalised patients at SASH. See embedded document

Mouth Care Matters brief Feb 2015 V2.doc

Continue to focus on improving the trusts performance on complaints handling.

Fiona Allsop The Trusts continues to implement the actions recommended by both the CQC inspection and internal audit review of systems (Feb 2014)

The Complaints team are updating the Trust’s policy including updates to systems and monitoring. Complaints review group commenced March 2015. Front line non clinical customer care training rolled out to approximately 300 staff.

Review the action taken to engage with

a. Medical administration review in place to

a. Weekly progress report monitoring delivery of action plan reported at the


a. medical secretaries,

b. ward clerks and

c. medical records staff to ensure these groups feel more included in decisions relating to their role.

Jim Davey Fiona Allsop Ian Mackenzie

support improved engagement of medical secretaries and implementation of Dictate IT. Fortnightly project board includes 2 medical secretaries as members

b. Review of ward clerk establishment and role underway and regular meetings in place to review concerns raised

c. Back to the floor and trust wide article on the role of medical records has helped improve engagement with this key staff group. Regular meetings in place for staff to raise concerns.

Executive team and at Board in November 2014

b. Update received at Exec 10.12.14

c. Weekly progress report monitoring delivery of action plan reported at the Executive team and at Board in November 2014

Review the working environment for the medical records staff.

Ian Mackenzie Capital plan for 2015/16 includes re-provision of Maple House Annexe

Weekly progress report monitoring delivery of action plan reported at the Executive team and Board in November 2014

Update against system wide quality summit actions Clinical Commissioning Groups:

Occupancy rates – Reducing emergency demand – establishing a clear and collaborative programme of action that delivers reduced occupancy in the short and medium term as a key output

Discharge to assess – Full commitment to support the programme going forward Stop undertaking Continuing Health Care assessments and DSTs in hospital –

These should be carried out in the community so that patients get the greatest possible benefits.

On all three of these actions an initial response has been provided by the CCGs but additional detail and clarity has been sought

Move relationships from a transactional basis to a transformational one particularly regarding clinical pathway development through clinically led work

Information sharing – Improve access to and sharing of patient information

Ortho rehabilitation (Including fractured neck of femur) and access to stroke

rehabilitation – Developing improved pathways and access to rehabilitation in community settings


Local Transformation Board developing “Hospital Without Walls” -Using existing

expertise in the system including winter resilience preparation Collaboration on financial challenges

Evidence of how actions are being achieved and success is being measured has been sought from the CCGs and the attached plan has been provided in response to letters

from the Trust. KD update trust

board 130315 v2.doc

Healthwatch

Continue to be a critical friend Encourage Surrey & Sussex to share templates and paperwork (e.g. Continuing

Health Care Assessments) Our Chief Nurse and Deputy Chief Nurse have met with Healthwatch members from both West Sussex and Surrey and have agreed to meet them together on a quarterly basis to discuss soft intelligence they have received about the Trust. They have also agreed to consider how representatives from Healthwatch can contribute to relevant work stream within the organisation to increase the patient voice. In addition the Trust has agreed to promote the face of Healthwatch within the organisation to facilitate better knowledge and understanding by patients. Healthwatch were also updated on the recent PLACE visits.

General Medical Council

Share lessons from the Surrey & Sussex Healthcare NHS Trust locally and nationally

The GMC public relevant reports on their website sharing findings and best practice on a national basis

Health Overview & Scrutiny Committee

Continue to bring organisations together and provide challenge Encourage proactive work with CCGs, GPs & healthcare providers to find solutions

for appropriate use of healthcare services Provide a means of promoting the users and the public to use health services

appropriately Provide an opportunity for planning and dialogue with health and social care on demographic changes and access to health services for children and young people

The Trust has had recent experience of the West Sussex HASC calling all providers to account for how services had been delivered across the winter months. They have been instrumental in facilitating the agreement of plans which have included a commitment to increasing the social service support being provided on the hospital site.


Recommendation The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Sue Jenkins Director of Strategy March 2015

MiliDoshi22/2/15

MouthCareMatters–ImprovingtheOralHealthofHospitalisedPatients

‘Mouth Care Matters’ is part of a Health Education England, Kent, Surrey andSussexinitiativetoimprovetheoralhealthofhospitalisedpatients.East Surrey Hospital had a very good CQC inspection last year but one of thesuggested improvementswas to have a reviewofmouth care. The inspectionfound that patients had drymouths and therewas no evidence of oral healthassessmentsinthenursingnotes.There is evidence to show that poor oral health can lead to a deterioration ingeneralhealthandhencelengthenhospitalstaysforpatients. Currentlynursesandnursingassistantshaveminimalornotraining inprovingmouthcare; thismeansthatvulnerablepatientswhoneedassistanceoftendonotreceiveit.EastSurreyHospitaliscurrentlydevelopingaprogrammethataimstoimprovethe oral health and hence general health of hospitalised patients. This willinvolve:

1. Interactivehandson trainingwithnursingstaff in thedental simulationlab

2. Theintroductionofmandatorymouthcareassessmentforallin‐patients3. Ward based follow on training so nurses can be observed and have

assistanceifrequired4. Trainingfordoctorsindiagnosingandprescribingformouthconditions.5. Trainingofmouthcarechampionsforeachward

Summaryofworktodate

LiteratureSearcho Highlighted the negative effects of hospitalisation stays on oral

healthandthelinksbetweenoralhealthandsystemichealth.

Focusgroupswithhospitalmatrons/seniorstaff/infectioncontrolo Identified thatmouth care isnearlyalways carriedoutbynursing

assistantswhohavenomouthcaretraining.Practiceandknowledgeamongststaffislow,forexampletheuseofpinkfoamswabs,salineafter tooth brushing in critical care, no knowledge ofmouth caregels, aspirating toothbrushes, non‐foaming toothpastes andmouth

MiliDoshi22/2/15

guards.Nursingstaffarenotrecordingmouthcareandwouldreallylikehelpwiththisandthedevelopmentofaneasytouseassessmentform. Nursing staff do not always know how to access help andadvicefromthedentalservices.ITskillamongstnursingstaffvariesandthiswouldbeabarriertoE‐Learning.

Surveyofnurses’mouthcaretrainingandcurrentpractice

o 47respondentsfromacrossarangeofdifferentwardsatEastSurreyHospitalcompletedthissurvey.Themajorityoftherespondentswereeithernursesornursingassistants.

o 95%ofnursingstaffbelievethatassessingandprovidingmouthcareispartoftheirroleasanurse.

o Only53%ofthenursingstaffthatcompletedthesurveyhadreceivedtraininginassessingpatients’mouthsand/orprovidingorassistingwith oral care. Of thosewho had been trained, themajority hadreceiveditaspartoftheirnursing/nursingassistanttraining.

o 89%ofnursingstaffwhoanswered thesurveystated that theydidprovidemouthcaretopatientsonthewards.

o 64%ofnursingstaffsaidthattheywouldliketoreceivetraininginmouth care, the majority (60%) stating that they would likeinteractivehands‐onteaching.

AuditofmouthcarerecordsinHospitalNoteso Only15%ofnotesauditedhadacompletedmouthcareassessment,

allofwhichwerefromintensivecareorhighdependencyunitso Therewerenomouthcareassessmentsinanyofthemedicalwards

Auditofpatienttoothbrushingpractice

Liaisingwith leads for critical care and the elderly to consider auditing

whether hospital acquired pneumonia rates decrease after the MouthCareMattersroll‐out

Linkswithspeechandlanguagetherapylead

o Speechand languagetherapistsstatethattheyhavehadvery littletraining inoralcareandwould like tobe trained so that theyarefollowingup‐to‐dateevidencebasedpractice.

MouthCareMatterspromotiono ‘MouthCareMatters’ stand in theHospital foraweek outside the

hospitalrestaurant(18/2/15).Thisgaveustheopportunitytotalkto staff about the training and show them products that can helpthemdelivergoodmouthcare.

o Article to be published in the Hospital Journal on the trainingprogrammeandwhywearedoingit.

o ‘A patient story’ to be presented to the patient safety executiveboard, 25/2/15. A case of a patient with dementia who had atraumaticulceronherlipthatwaspoorlymanagedbythewardandemphasiseswhymouthcaretrainingissoimportant.

MiliDoshi22/2/15

Establishingthecorrectmouthcaretoolstouseo Meetingswithvariouscompanieslookingatdifferenttoothbrushes,drymouth gels and non‐foaming tooth pastes and alternatives topinkfoamswabs.

o Medicinesmanagement committeemeetings to seek agreement tochangehospitalprocurementandadditionstoformulary.

NextstepsMarch2015

‐ Pilotsessions19thand24thMarch‐ Three Hour interactive sessions for nurses of all grades and speech

languagetherapists‐ 20traineespersession,heldindentalsimulationlab

April

‐ RefinementoftrainingprogrammeMayonwards

‐ RolloutoftrainingacrossEastSurreyHospital.ThiswillinvolvefurthertrainingsessionsandweplantomakethistrainingpartofSASHnurses’mandatorycertifiedtraining.

‐ Trainingonthewards;thiswillinvolvedentalstaffbeingpresentonthewardforaboutaweek,supportingstaffwithmouthcare.

‐ Trainingforhospitaldoctorsprescribingonthewards.‐ MouthCareMatterschampions(MouthCareMatterspart2);trainingfor

wardstaffidentifiedashavinganinterestinmouthcare.FromSeptember2015

‐ RollouttootherhospitalsinKSSEstablishingeffectivenessoftheprogrammeThiswillinvolve:

1. Posttrainingevaluation2. Re‐auditofhospitalnotes3. Re‐auditofpatientquestionnaire4. Hospital acquired pneumonia rates and ventilator assisted pneumonia

rates.

‐ENDS‐

1

Whole System Update for Surrey and Sussex Healthcare NHS Trust Board, March 2015.

Introduction

East Surrey and Crawley Horsham Mid Sussex Clinical Commissioning Groups have been asked by the Deputy Chair of Surrey and Sussex Healthcare NHS Trust (19 February 2015) to provide a progress report on how our plans will achieve the jointly agreed CQC actions:

Reduce emergency demand through a clear and collaborative programme of action that delivers reduced bed occupancy Support the ‘Discharge to assess’ programme Stop undertaking Continuing health Care assessments and DSTs in hospital

The following account gives East Surrey’s position on progress against key milestones and delivery dates. It also outlines the governance and infrastructure that supports this programme of work. East Surrey Clinical Commissioning Group (ESCCG) is committed to supporting Surrey and Sussex Health care NHS Trust (SASH) in achieving its CQC action plan through ‘whole system’ improvements in urgent and emergency care. To ensure a reduction in high bed occupancy ESCCG with partners from the Trust, primary, community and social care are focussed on improving access to rehabilitation services through its ‘Discharge to Assess’ work stream and promoting rapid, safe integrated discharge which includes the new local approach to continuing health care where suitable patients are assessed for on‐going care in the community by a health care professional who knows them best. East Surrey QIPP scheme overview East Surreys 2015 – 2016 QIPP scheme consists of three overarching programmes supported by a number of work streams. This is outlined in the table below:

Signposting and Prevention e.g.

Nursing Home Attendances

Out of Hospital e.g.

Hub Integration and efficiency Reducing Elective admissions

Reducing Admissions and Promoting Discharge

E.g. Sheffield model

Reducing Excess bed Days through D2A, CHC redesign, Integrated Discharge team

Review Rehabilitation in the community

2 This work programme is collectively delivered by the Surrey health and social care system through the following mechanisms:

East Surrey System Resilience and Transformation Board (SRTB). The Board is jointly chaired by clinicians from SASH and ESCCG. Broad multi‐agency membership, established Sept 2014 with remit for ensuring resilience across elective and non‐elective care, as well as ensuring system transformation. Governance for the SRTB is set out below. Terms of reference and membership are available.

The SRTB monitors spend and related activity of operational resilience and capacity planning budget and provides governance for the ‘Better Care Fund` transformation work‐streams:

1. Signposting and prevention

Provides signposting and valid alternatives to care for frequent attenders/ regular users of services Supports Care Homes in preventing unnecessary emergency admissions into hospital Will promote health and well‐being and improve communications for patients and public so that they access the most appropriate care

3

2. Out of hospital transformation

Management of patient care in a controlled and integrated environment with all healthcare professionals able to access personalised care plan information where relevant

Further enhance hub model working by incentivising stakeholders to work together and share information Utilise care pathway redesign to support proactive care and improve health outcomes

3. Reducing admissions, promoting swift integrated discharge (RAPSID).

Improve patient experience by reducing admissions to hospitals when care and treatment can be provided outside of hospital. Improve patient experience by promoting discharge so that patients can return to their normal place of residence as soon as possible Implement changes to the pathway for continuing health care assessments (CHC) for patients in an acute hospital setting Reduce numbers of patients who are medically fit for discharge from SASH through a whole system approach, improving communication, co‐

ordination and development of robust action plans. The table below highlights progress since baseline was set at the beginning of February. Detailed Project Initiation Documents and Plans on a Page are available.

RAPSID update

The East Surrey Reducing Admissions Promoting Swift Integrated Discharge (RAPSID) group is chaired by Jim Davey, Director of Service Development SASH, and jointly led with Tanya Procter, urgent care lead, ESCCG. Membership includes all East Surrey providers and actions that are relevant to the SASH Trust Board update are pasted below. Meetings take place monthly. The actions below represent a selection of the action log that most respond to the questions raised by SASH Deputy Chair Of particular note: 2.2 monitors progress on development of Discharge to assess in the Emergency Department project, jointly led by SASH and ESCCG, fortnightly

project group meetings taking place from 17/3/15. 3.5 monitors progress on changes to assessment pathway for patients who would currently be assessed for CHC in the acute setting. Project

led by ESCCG. New pathway will be implemented from 1/5/15.

4 3.8 monitors progress on Discharge to Assess project. Originally led by Crawley and Horsham CCGs but now jointly led by SASH and ESCCG. 1.1 Scope IDT co‐ordinator role alongside D2A co‐

ordinator function To include strengthened liaison with intermediate care teams in other areas to reduce delayed discharges for out of area patients

March 2015

JaD, PT

Amber IDT/D2A review date set by Crawley for 17/4. Sue Jenkins writing a bid for support for D2A

project to include co‐ordinator costs Crawley have SCOFF role which in part covers

IDT co‐ordinator role; East Surrey CCG/FCHC need to agree IDT co‐ordination role

Update to be completed by Sue Jenkins this week

1.2 Review role of IDT and make recommendations March 2015

LS, JD, CR

Amber

See above

2.2 Establish D2A in ED project Process mapping taking place w/b 10/2 Project meetings fortnightly thereafter Include within scope integrated social care teams

To begin by 30/4/15

TP/SJ Amber Process mapping took place 10/2 D2A in ED PID risk assessed and agreed by ESCCG

clinical exec PID shared with all SRTB members 6/3/15 Project group established and meetings taking

place fortnightly from 4/3/15 (first full group 17/3/15)

3.2 Develop project plan for development and implementation of “Trusted Assessor” role between FCHC, SASH and SCC in order to reduce numbers of assessments and potential conflict around decision making. Sally Dando, Fiona Allsop, Katie Davies to be

involved from SASH, with SD taking the lead for SASH

Jo Poynter now in post at SSC and will lead for SSC

JaD to have overall lead

Project plan to be in place by Jan 2015

JaD and VN/JP

Amber Meeting to agree Trusted Assessor model 11/03/15 with Jo Poynter, Katie Davies involved moving forward to make this happen

5 3.5 Implement changes to CHC assessment pathway

Ensure FCHC staff trained to undertake DSTs by end of April

Develop business case and commission appropriate community bed stock and staffing to support new pathway

1/2/15 TP/JaD/JP

Amber First discharge 1/2/15. Aiming to avoid 12 DSTs in SASH each month

ESCCG PID to support developed and risk assessed

FCHC have completed bed modeling. JP, JaD and TP to meet 6/3/15 to agree

Changes to be introduced gradually and reviewed for learning from May 2015

Assess at next meeting and aim to move to Green

3.8 Develop and implement Discharge to Assess Implementation plan on completion of the pilot to be developed to meet agreed BCF target reduction of at least 200 excess bed days. Minimum of 5 patients per week to be

discharged under D2A by 1/4/15

End March 2015

TP, TC, SJ

Amber 20 patients now discharged. Criteria has been expanded to include patients

with longer LoS, with aim of developing pace to 5 patients/week. Links will also be established to patients who may receive CHC.


Pilot has had positive impact on supported discharge processes

SJ putting together bid for funding for co‐ordinator role to case‐find.

SJ to attend April meeting to update

3.9 SSC and FCHC to work together to implement changes to community bed stock/RCH/ Social care to maintain flow outside hospital

Fed 2015 JP, JaD

Green CQC criteria to be relaxed for Dormers; pathway to be written by CR and PM to enable vacant beds to be used

SC manager to be appointed to support flow out of interim beds

HB to request information on criteria for nursing homes from recent tendering process

1.1 Scope IDT co‐ordinator role alongside D2A co‐ March JaD, Amber IDT/D2A review date set by Crawley for 17/4.

6

ordinator function To include strengthened liaison with intermediate care teams in other areas to reduce delayed discharges for out of area patients

2015 PT Sue Jenkins writing a bid for support for D2A project to include co‐ordinator costs

Crawley have System Capacity Officer role which partially covers IDT co‐ordinator role; East Surrey CCG/FCHC need to agree IDT co‐ordination role

Update to be completed by Sue Jenkins this week

1.2 Review role of IDT and make recommendations March 2015

LS, JD, CR

Amber

See above

2.2 Establish D2A in ED project Process mapping taking place w/b 10/2 Project meetings fortnightly thereafter Include within scope integrated social care teams

To begin by 30/4/15

TP/SJ Amber Process mapping took place 10/2 D2A in ED PID risk assessed and agreed by ESCCG

clinical exec PID shared with all SRTB members 6/3/15 Project group established and meetings taking

place fortnightly from 4/3/15 (first full group 17/3/15)

3.2 Develop project plan for development and implementation of “Trusted Assessor” role between FCHC, SASH and SCC in order to reduce numbers of assessments and potential conflict around decision making. Sally Dando, Fiona Allsop, Katie Davies to be

involved from SASH, with SD taking the lead for SASH

Jo Poynter now in post at SSC and will lead for SSC

JaD to have overall lead

Project plan to be in place by Jan 2015

JaD and VN/JP

Amber Meeting to agree Trusted Assessor model 11/03/15 with Jo Poynter, Katie Davies involved moving forward to make this happen

3.5 Implement changes to CHC assessment pathway Ensure FCHC staff trained to undertake DSTs

by end of April

1/2/15 TP/JaD/JP

Amber First discharge 1/2/15. Aiming to avoid 12 DSTs in SASH each month

ESCCG PID to support developed and risk

7

Develop business case and commission appropriate community bed stock and staffing to support new pathway

assessed FCHC have completed bed modeling. JP, JaD and

TP to meet 6/3/15 to agree Changes to be introduced gradually and

reviewed for learning from May 2015 Assess at next meeting and aim to move to

Green 3.8 Develop and implement Discharge to Assess

Implementation plan on completion of the pilot to be developed to meet agreed BCF target reduction of at least 200 excess bed days. Minimum of 5 patients per week to be

discharged under D2A by 1/4/15

End March 2015

TP, TC, SJ

Amber 20 patients now discharged. Criteria has been expanded to include patients

with longer LoS, with aim of developing pace to 5 patients/week. Links will also be established to patients who may receive CHC.


Pilot has had positive impact on supported discharge processes

SJ putting together bid for funding for co‐ordinator role to case‐find.

SJ to attend April meeting to update

3.9 SSC and FCHC to work together to implement changes to community bed stock/RCH/ Social care to maintain flow outside hospital

Fed 2015 JP, JaD

Green CQC criteria to be relaxed for Dormers; pathway to be written by CR and PM to enable vacant beds to be used

SC manager to be appointed to support flow out of interim beds

HB to request information on criteria for nursing homes from recent tendering process

1



REPORT TITLE: 2014/2015 Annual Report from the Nomination and Remuneration Committee

NON-EXECUTIVE SPONSOR: Alan McCarthy Chairman

REPORT AUTHOR (s): Yvonne Parker Director of Human Resources


Action Required:

Approval (√) Discussion ( ) Assurance (√)

Purpose of Report:

All Board Sub-Committees and required to report to the Board on an annual basis outlining the work of the committee during the year.


The key issues addressed in the report are as follows: Purpose, meetings, business and areas for improvement for the committee including a summary of the work undertaken in 2014/15.

Recommendation:

To approve the report which outlines the work undertaken in 2014/15.


SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model.


Legal and regulatory impact The Committee is a statutory committee of the Trust Board.

Financial impact The committee considers any financial impact of its decisions at each relevant meeting.

Patient Experience/Engagement N/A

Risk & Performance Management This is an essential part of the role of the committee.


The Committee has due regard to equality & diversity legislation in undertaking its work

Attachment: N/A

2

Trust Board Report - 26TH March 2015 2014/2015 Annual Report from the Nomination and Remuneration Committee 1. Purpose of the Committee The Remuneration Committee’s role is to establish and monitor the level and structure of reward for executive directors, ensuring transparency, fairness and consistency. The Committee shall receive reports from the Chairman of the Board of Directors on the annual appraisal of the Chief Executive and from the Chief Executive on the annual appraisals of executive directors, as part of determining their remuneration. The Committee shall develop and implement an effective succession plan to identify and develop internal personnel to fill key senior management posts as part of ensuring the availability of experienced and skilled employees when posts become available. For Executive Directors other than the Chief Executive, the Committee shall take advice from the Chief Executive. The Committee, which will meet at least twice per year, is comprised of the Board Chair and all Non-Executive Directors. A minimum of three members should be present at meetings who are independent of management. The Committee will report in writing to the Board at least once annually. 2. Meetings of the Committee The Committee met on 5 occasions during the period February 2014 – January 2015 and membership at each meeting was in accordance with the Terms of Reference of the Committee. 3. Business of the Committee 2014/15 The business managed by the Committee comprised:

Consideration of the performance of the Chief Executive against agreed objectives for 2013/14. The outcome of this annual performance review was agreed by the Committee and reported to the TDA on 27 June 2014.

Agreeing the Chief Executive’s objectives for 2014/15

Receiving information from the Chief Executive on the performance of each of

the Executive Directors and their objectives for 2014/15

Note: Irrespective of the performance of the Chief Executive and Executive Directors no salary adjustments were considered

Reviewing information from the Chief Executive on organizational changes re Board portfolios.

3

With respect to the Mutually Agreed Resignation Scheme (MARS):

i) On 20 February 2014 agreeing the Trust should apply to the TDA

for MARS and if approved to refer back to the Committee before proceeding;

ii) On 27 March 2014 approving the launch of the scheme on 31 March

2014; iii) On 29 May 2014 agreeing the proposal of proceeding with posts under

the scheme.

Consideration of information from the Chief Executive re succession planning amongst Executive Directors and senior management.

4. Areas for Improvement It is suggested that the following improvements are made to the Committee function;

Wherever possible, and if appropriate, papers are prepared and circulated to the Committee in advance of the meeting.

Formal minutes to be kept for all meetings. This shall be the Director of HR,

where she is in attendance or agreed member of the Committee in her absence In so far as is possible, the business of the Committee is as set out in the table

included in Appendix 1. 5. Recommendation The Board is asked to approve the annual report. Alan McCarthy Chairman March 2015

4

APPENDIX 1 April 2015

Agree performance rating for Chief Executive along with objectives for 2015/16

Receive report from Chief Executive on the annual appraisals for

Executive Directors and their objectives for 2015/16. September 2015

Agree six month appraisal of Chief Executive performance.

Receive report from Chief Executive on Executive Director six month performance.

Receive paper from Chief Executive on succession planning.

Other Dates

The Committee shall meet to consider any other issues relating to its purpose as required throughout the year.

BOARD OF DIRECTORS

Audit & Assurance Committee

Nomination & Remuneration

Committee

Safety & Quality

Committee

Finance & Workforce Committee

Charitable Funds

Committee

For Executive Directors: Appointment Reward Performance Retention Termination Pension matters Successful planning

for senior management



REPORT TITLE: Mutual Draft Feasibility Study

EXECUTIVE SPONSOR: Sue Jenkins Director of Strategy

REPORT AUTHOR (s): Jonathan Knight Bolt Partners


Mutual Project Board

Action Required:


Purpose of Report:

This paper provides an exploration of the suitability of a mutual model for SaSH and guidance for a future more in-depth exploration of a mutual model by the SaSH team once the policy and legislative environment has developed. It sits alongside a knowledge capture document being produced for the Cabinet Office and Department of Health that looks to inform policy development based on the experiences of the Pathfinder trusts.


The study’s overall conclusion is that a move towards greater mutualisation would be an excellent cultural fit for the Trust. As a governance structure, it has the ability to embed at a constitutional level the values and behaviours that the Trust is seeking to encourage. This would provide a resilient basis for staff engagement with less dependence upon the priorities of the current board, and look to start to build similar engagement with the community. Whilst it is not possible for the Trust to develop into this model at the present time due to the current policy guidance and legislative frameworks, in the longer term if these constraints are removed it is recommended that SaSH continue with its exploration of a mutual approach as this has been well-received by staff in early engagement sessions. The model has some important flexibilities and advantages over the standard FT model that may be of benefit to SaSH – although SaSH need to wait for its FT decision and the consequences of this.

Recommendation:

The Board is asked to review the report and to approve the outcome of the draft report which will be submitted to the Cabinet Office as an output of the Mutuals Pathfinder Programme.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our



catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact Compliant

Financial impact N/A


Risk & Performance Management Compliant


Compliant

Attachment:

1

Mutuals in Health Pathfinder: Feasibility Study

2

CONTENTS

1 Introduction ............................................................................................. 4

1.1 Executive Summary ..................................................................................................... 5

1.2 The form of this report ................................................................................................ 5

1.3 SaSH Team ................................................................................................................... 6

1.4 Support Team .............................................................................................................. 7

2 Strategic Context of mutualisation ........................................................... 8

2.1.1 National context – the Mutuals in Health Pathfinder Programme .............................................. 8

2.1.2 SaSH local context as a Pathfinder trust ....................................................................................... 9

2.2 Objectives and Principles of Mutualisation .............................................................. 10

2.2.1 What is a mutual?....................................................................................................................... 10

2.2.2 What would a mutual seek to achieve? ..................................................................................... 10

2.2.3 Putting mutuals in a historical context ....................................................................................... 11

2.2.4 Comparison to the NHS Foundation Trust Model ...................................................................... 11

2.3 SaSH values and Strategic Fit with Mutual Principles ............................................... 12

2.4 Scope of Mutual Model ............................................................................................. 14

2.4.1 Ownership constituencies .......................................................................................................... 14

2.4.2 Red Lines & Requirements ......................................................................................................... 15

2.4.3 Types of Mutual .......................................................................................................................... 19

2.5 Benefits and Risks ...................................................................................................... 22

2.6 Constraints ................................................................................................................ 22

2.7 Dependencies ............................................................................................................ 24

3 Options Appraisal .................................................................................. 26

3.1 Developing Critical Success Factors .......................................................................... 28

3.1.1 What should relations with stakeholders be like? ..................................................................... 28

3.1.2 What should the Trust retain, begin and end from different perspectives? .............................. 28

3.1.3 What Critical Success Factors would a mutual have and how could they be measured? .......... 29

3.2 Mutual Models Considered: Long List ....................................................................... 30

3.3 Short-listing Options ................................................................................................. 36

3.3.1 Methodology for evaluating qualitative benefits ....................................................................... 36

3.3.2 Methodology for Risk Appraisal ................................................................................................. 40

4 Current Preferred Model ........................................................................ 43

4.1 Template Model Specification .................................................................................. 43

4.2 Commercial Considerations ...................................................................................... 44

4.2.1 VAT ............................................................................................................................................. 44

3

4.2.2 Procurement requirements ........................................................................................................ 46

4.2.3 NHS Pension ............................................................................................................................... 46

4.2.4 Financial failure regime .............................................................................................................. 47

4.2.5 NHS Branding & Logo ................................................................................................................. 48

4.2.6 Assets and Liabilities ................................................................................................................... 48

4.2.7 TUPE ........................................................................................................................................... 48

5 Next Steps ............................................................................................. 49

5.1 Project Plan ............................................................................................................... 49

5.1.1 Overview .................................................................................................................................... 50

5.2 Roles and responsibilities .......................................................................................... 50

5.3 Details of phases ....................................................................................................... 53

5.3.1 Exploration and development .................................................................................................... 53

5.3.2 Preparation ................................................................................................................................. 56

5.3.3 Transition .................................................................................................................................... 57

5.3.4 Consolidation .............................................................................................................................. 60

5.4 Finances ..................................................................................................................... 61

5.5 Stakeholder Engagement Plan .................................................................................. 61

5.5.1 Exploration and development .................................................................................................... 62

5.5.2 Preparation phase ...................................................................................................................... 62

5.5.3 Transition .................................................................................................................................... 62

5.5.4 Consolidation .............................................................................................................................. 62

6 Appendices ............................................................................................ 63

6.1 Summary of Project Activities ................................................................................... 63

6.2 Summary of SaSH Mutuals Communications ............................................................ 64

6.3 Details of Rewards & Incentives sessions ................................................................. 65

6.3.1 Influence on SaSH ....................................................................................................................... 65

6.3.2 Incentives and demotivation ...................................................................................................... 66

6.4 Beneficiary Trusts in Pathfinder Programme ............................................................ 67

6.5 Governance Rationale for Foundation Trust ............................................................ 68

6.6 SaSH Pathfinder Application ..................................................................................... 68

4

1 INTRODUCTION

This Feasibility Study was produced for the Mutuals in Health Pathfinder Programme1 designed to

inform policy development for the Department of Health and Cabinet Office and to assist beneficiary

Trusts including Surrey and Sussex Healthcare NHS Trust (SaSH) to investigate whether a mutual model

would be suitable for the Trust.

This paper provides an exploration of the suitability of a mutual model for SaSH and guidance for a

future more in-depth exploration of a mutual model by a future SaSH team once the policy and

legislative environment has developed. It sits alongside a knowledge capture document being

produced for the Cabinet Office and Department of Health that looks to inform policy development

based on the experiences of the Pathfinder trusts.

The project took place between January and March 2015 and consisted of a series of workshops and

focus groups to engage with stakeholders as to the suitability of a mutual structure for the Trust within

SaSH. The outputs of those workshops form the basis of this report along with more technical advice

and planning on the potential to develop into a mutual in the future.

At the time of writing, SaSH is anticipated to go through an important transition to Foundation Trust

(FT) status over the next few months – a key achievement in the transformation of the Trust over the

past several years, recognising the high quality safe care provision provided by the Trust. The

pathfinder project has sought to integrate with the transition to FT. FT status is itself designed as a

form of mutual ownership, based as it is on traditional mutual and co-operative ideas. However given

the constraints within which FTs have had to operate, it has been difficult for them to optimise their

mutuality. This Feasibility Study therefore envisages a potential evolution of the new FT structure

towards a substantially more mutualised structure if policy and legislative conditions become

supportive.

The FT model that SaSH is currently moving to will unlock a number of the benefits that a mutual

model could also produce. The governance of the model is however inherently prescribed by

legislation and has a number of limitations that other Trusts have experienced. This project has helped

to highlight the limitations that other Trusts2 have experienced with FT status and to address some of

these, e.g. assisting with the membership engagement strategy.

Mutual models present a potential next step in the development of the FT model to suit the needs of

SaSH. This report provides a framework for developing the specific model and assessing the benefits

of evolving to a more mutual approach.

1 See https://www.gov.uk/government/publications/mutuals-in-health-pathfinder-programme for more information 2 A specific session to discuss this was held on 17th Feb 2015, and included Oxleas, SaSH, Moorfields, University Hospitals Leicester and Liverpool Heart & Chest

https://www.gov.uk/government/publications/mutuals-in-health-pathfinder-programme

5

1.1 EXECUTIVE SUMMARY

The study’s overall conclusion is that a move towards greater mutualisation would be an excellent

cultural fit for the Trust. As a governance structure, it has the ability to embed at a constitutional level

the values and behaviours that the Trust is seeking to encourage. This would provide a resilient basis

for staff engagement with less dependence upon the priorities of the current board, and look to start

to build similar engagement with the community. Whilst it is not possible for the Trust to develop into

this model at the present time due to the current policy guidance and legislative frameworks, in the

longer term if these constraints are removed it is recommended that SaSH continue with its

exploration of a mutual approach as this has been well-received by staff in early engagement sessions.

The model has some important flexibilities and advantages over the standard FT model that may be

of benefit to SaSH – although SaSH need to wait for its FT decision and the consequences of this.

We have summarised the key messages from each section at the start of that section, and would

recommend this as summary of the different areas of the report.

1.2 THE FORM OF THIS REPORT This Feasibility Study report is laid out to assist with the development of an Outline Business Case

(OBC) in line with the Treasury Five Case Model at a future date. It does not directly follow the form

of an OBC because some of the sections are not feasible or relevant at this stage of SaSH’s thinking.

The table below provides a reconciliation between the sections of this report and a future OBC.

Section of Feasibility Study OBC Sections and Sub-sections

Strategic Case

2 Strategic Context

2.4 Scope of Mutual Model

2.5 Benefits and Risks

2.6 Constraints

2.7 Dependencies

Investment objectives/Business needs

Scope and key service requirements

Main benefits criteria/Main risks

Constraints

Dependencies

Economic Case

3.1 Developing Critical Success Factors

3.2 Mutual Models Considered: Long List

3.3 Short-listing Options

3.3.1 Methodology for evaluating qualitative

benefits

3.3.2 Methodology for Risk Appraisal

Critical Success Factors

Long Listed Options

Short Listed Options

Qualitative Benefits appraisal

Risk appraisal & scoring

Commercial Case

4.1 Template Model Specification

4.2 Commercial Considerations

Required Services

Key Contractual clauses/Risk Transfer/TUPE

Financial Case

5.1.1 Overview Affordability

Management Case

5.1 Project Plan

5.2 Roles and responsibilities

5.3 Details of phases

5.2 Roles and responsibilities

Programme management arrangements

Roles and responsibilities

Project plan

Special advisers required

6

Sections of the OBC to be developed at a later stage in the transition programme are:

Strategic Case: Organisational overview, Business strategies, Other organisation’s strategies, Existing

arrangements – elements dependent on outcome of FT application and changing over time

Economic Case: Methodology for estimating benefits, Methodology for estimating costs, Net Present Cost,

Sensitivity Analysis – elements dependent on outcome of FT application and determination of “Do Nothing” case

Commercial Case: Charging mechanism, Contract length, Procurement strategy & timelines, Accountancy

Treatment – elements dependent upon legislation and policy development

Financial Case: Impact on income and expenditure, Balance sheet impact – elements dependent on outcome of FT

application and determination of “Do Nothing” case

Management Case: Change and Contract Management, Benefits realisation, Risk Management, Post Project

evaluation arrangements, Gateway reviews, Contingency plans – elements to be fully developed in FBC once

chosen option details finalised (FT transition arrangements provide draft template for procedures to follow)

Throughout this report we have included areas to help SaSH continue exploring the feasibility of

mutuality and start developing a full business case, if desired. Specific areas for further development

are indicated by this “Future questions” or “Further discussion” notation.

1.3 SASH TEAM SaSH invited a range of members of staff from throughout the trust to participate in the workshops,

provide their experience and opinions, and help shape the approach taken in this paper. The support

team are grateful for their enthusiasm and commitment to the programme.

Michael Wilson – CEO

Sue Jenkins – Director of Strategy

Yvonne Parker – Director of Workforce and OD

Gillian Francis-Musanu – Director of Corporate Governance

Jane Thomson – Mutuals Project Manager

Laura Warren – Head of Communications

Ben Mearns – Acute Physician and Care of the Elderly Consultant

Linda Judge – Head of Outpatients

Mary Calvey – Senior Occupational Therapist

Caroline Hoyle – Medical Secretary

Nicola Shopland – Divisional Chief Nurse

Michelle Cudjoe – Head of Midwifery

Steve Buck – Assistant Catering Manager

Alan McCarthy – Chair

Barbara Bray – Chief of Surgery

Lorraine Clegg – Deputy Chief Finance Officer

Angela Stevenson – Deputy Chief Operating Officer

Lisa Reindel – Senior Dietician and staff side representative

Paul Millam – Staff side representative

We would also like to thank all the staff who attended other working sessions, in particular the

Rewards and Incentives working groups on 11th March.

7

1.4 SUPPORT TEAM The support team consortium, led by Bolt Partners, has brought together a range of experts from

different organisations to support SaSH in different elements of assessing mutual models.

Representing a national collective of co-operative development agencies, Adrian Ashton has a national reputation for governance, impact reporting, and business planning in public sector bodies. He has also developed acclaimed tools to explore the governance of any organisation

A think-tank facilitating the public debate on citizen collaboration in services, Collaborate develop innovative public service policy and practice.

Anthony Collins are specialist solicitors advising on relationships between the public, private and “Third” sectors. Highly experienced in advising on mutualisation in healthcare and other sectors, they are governance experts in acute trust environments.

Dr Ruth Yeoman of the Centre for Mutual & Employee-owned Business at Kellogg College, University of Oxford is a leading expert in developing an international research agenda on mutuality and brings strategic overview.

As a specialist healthcare management and advisory company, Bolt particularly focus on workforce productivity in acute settings. Bolt previously worked with SaSH from 2006-2008 providing a turnaround and finance director and reviewing the commercial activities of SaSH.

Jonathan Knight

Anna Partington

Sarah Billiald

Henry Kippin

Tracy Giles

Cliff Mills

Ruth Yeoman

Adrian Ashton

8

2 STRATEGIC CONTEXT OF MUTUALISATION

Key messages:

Mutualisation presents a significant opportunity for SaSH to embed its values with staff and develop

as a listening and caring organisation. Culturally, the ownership conveyed by mutualisation is already

felt by some staff constituencies and the plan is to embed this feeling further by linking values to

behaviour through the SaSH+ programme and board development activities planned as part of the

transition to a Foundation Trust. Whilst this opportunity is acknowledged and recognised and the

majority of risks identified can be mitigated through the mutuals structure selected, the constraint of

the legislative and policy environment cannot be overcome at this time.

The process of transitioning to a mutual is known to take several years and the pathfinder work has

laid some of the early groundwork from which to design a future model and to identify the benefits

that mutualisation would bring to SaSH. The FT transition represents an important achievement for

the Trust and a key opportunity to re-define the decision-making structures. Mutuals are a potential

evolution of this organisational form. This report is therefore designed to complement the FT

transition process, providing the ability to compare and contrast mutual structures to the FT, so that

at key points in the transition to FT, the benefits of mutualisation can be assessed.

Ultimately if a supportive policy framework were developed, SaSH could be an excellent candidate to

be a vanguard in a new NHS mutual transformation programme based on the journey undertaken by

the Trust so far and the culture and values developed at the Trust.

2.1.1 National context – the Mutuals in Health Pathfinder Programme

The concept of developing models where public service employees, particularly those in healthcare,

could have a greater say and involvement in their organisations has grown in the last five years.

Support for the idea has been expressed by politicians in the previous Labour government3 and the

current coalition government4. It has also been included NHS strategic direction papers, including the

“Equity and Excellence: Liberating the NHS” document5. In November 2013 Norman Lamb, the

Minister of State for Care and Support in the current coalition government, announced6 that he had

appointed Chris Ham, CEO of the Kings Fund to look specifically at the mutual model in healthcare.

Chris Ham’s report “Improving NHS Care by Engaging Staff and Devolving Decision-Making”7 was

published in July 2014. The review recommended that government support a pathfinder programme

to help NHS trusts and foundation trusts explore the benefits of the mutual model.

In response to the review’s recommendation, the Department of Health and Cabinet Office launched

a joint initiative in July 2014 to support health and care organisations explore the potential advantages

of mutualising their services. The Pathfinder Programme was designed to support a small number of

pioneering trusts, either individually or in partnership. It was open to all foundation trusts and NHS

trusts, and included a support package of technical, legal and consultancy support to help them (a)

3 For example: http://archive.labour.org.uk/tessa-jowells-speech-to-labour-party-conference 4 For example: https://www.gov.uk/government/speeches/francis-maude-speech-unveiling-new-support-for-mutuals 5 See https://www.gov.uk/government/publications/liberating-the-nhs-white-paper and specifically page 36 / section 4.21 of https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf, 6 http://tomorrowscompany.com/norman-lamb-mp-speech 7 http://www.kingsfund.org.uk/publications/articles/improving-nhs-care-engaging-staff-and-devolving-decision-making for more information

http://archive.labour.org.uk/tessa-jowells-speech-to-labour-party-conference

https://www.gov.uk/government/speeches/francis-maude-speech-unveiling-new-support-for-mutuals

https://www.gov.uk/government/publications/liberating-the-nhs-white-paper

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf

http://tomorrowscompany.com/norman-lamb-mp-speech

http://www.kingsfund.org.uk/publications/articles/improving-nhs-care-engaging-staff-and-devolving-decision-making

9

understand what mutualisation means for them and (b) find solutions to practical barriers to

becoming mutual organisations.

The Mutuals in Health Pathfinder Programme ran from January to March 2015 inclusive, and involved

nine beneficiary trusts8 from across England with different challenges and situations, including SaSH.

A number of panel discussions were also undertaken with the other pathfinder trusts throughout the

project9.

2.1.2 SaSH local context as a Pathfinder trust

SaSH applied for the Mutuals in Health Pathfinder programme and set out in its application10 the key

strategic challenges for the Trust and the aims of participating in the programme:

8 See Appendix section 6.4 9 These pathfinder sessions were hosted by The Kings Fund and the Department of Health on 20th Jan, 17th Feb and 19th Mar 2015 10 See section 6.6 for the original SaSH expression of interest

The Trust has a firm foundation and has been transformed in recent years. It has proven its ability

to sustain and consistently deliver high quality care and some of the best national clinical

standards and outcomes […]

The benefits the Trust is aiming to demonstrate are:-

• alternative organisational structures can improve clinical outcomes, experience and staff

satisfaction

• good staff engagement can be harnessed and improved further in a mutual model

• a culture of innovation can be explored to challenge traditional boundaries and ways of

working

• staff can consider and develop incentives and rewards that encourage world class

standards

During 2013/14 the Trust achieved the embedding of values through involving staff more in the

delivery of outputs. It also introduced a “deep dive” process which encouraged specialty teams to

come together and demonstrate in a tangible way how their services were safe, effective,

responsive, caring and well led. This process supported a shift in focus from both teams and

individuals to both understanding and demonstrating how what they did on a day to day basis

directly impacted on clinical outcomes, quality of care and experience for patients. This process

was undertaken without the benefit of a formal mutual structure but demonstrates the readiness

of the organisation and its staff to explore what the next level of engagement and involvement

may look like. The Trust recognise the challenge there is for all of the organisation to be able to

demonstrate compassion and focus on the delivery of best care, and consider what different

rewards and incentives would support and encourage a greater sense of ownership by staff.

The Trust’s current thinking is that undertaking the mutual pathfinder programme will provide an

opportunity to explore what a staff owned model may look like where the Board is accountable to

the owners. They see this as an opportunity to shape what “type” of Foundation Trust they will

be in the future where decisions are led and influenced by those that deliver services moving

both the staff engagement and involvement to another level.

Mutuals in Health Expression of Interest, SaSH, 2014

(emphasis added)

10

In line with the original objectives of the Trust, the project and feasibility study has focused on

establishing the organisational and cultural fit of mutual values with SaSH values to capitalise on good

staff and community engagement and the extent and “types” of Foundation Trust that are possible

with and without legislation change. Flexibility around incentives and rewards for staff and

mechanisms for staff/member engagement that encourage a culture of innovation and a focus on

clinical outcomes, experience and staff satisfaction have all been explored.

2.2 OBJECTIVES AND PRINCIPLES OF MUTUALISATION

2.2.1 What is a mutual?

Mutual organisations have many varied forms and ownership constituencies. This programme focuses

on The Cabinet Office Mutuals Support Programme definition11:

Note that because the term “mutual” is used as an umbrella term for different ownership and

governance models, there will be different definitions of which the Cabinet Office’s is just one (it is

used here because of its relevance to the Pathfinder programme).

Further discussion: SaSH may wish to consider which definition of “mutual” best fits SaSH’s situation

and aspirations.

Whilst the emphasis of this definition is on staff control and its link to engagement, it is important to

note that the involvement of other constituencies, such as patients and the community is not

precluded and in the context of an acute sector organisation may bring considerable benefits to the

organisation.

In formal terms, a mutual with only one type of owner (e.g. staff) is a single constituency model and a

mutual with different types of owners (e.g. staff, community, other providers) is a multi-constituency

model. Although governance costs may be higher in multi-constituency mutuals, there are many

benefits, including the aligning of key interests against an agreed shared purpose. Multi-constituency

mutuals are particularly suitable to public services which must increasingly move to creating

collaborative community and relational expertise if they are to produce integrated, efficient services

which meet peoples’ needs.

2.2.2 What would a mutual seek to achieve?

A mutual structure would seek to reflect and embed the high level of pride and ownership already

present in SaSH’s workforce, build upon the current excellent levels staff engagement and to create a

resilient governance system which ensures the voice of staff, patients and/or the community is

effective in decision-making processes. In workshops staff discussed how SaSH had a participative

11 https://www.gov.uk/start-a-public-service-mutual-the-process

Public service mutuals are organisations with the following three characteristics:

They have left the public sector (also known as ‘spinning out’);

But continue to deliver public services; and,

Importantly, staff control is embedded within the running of the organisation Cabinet Office “Start a public service mutual” July 2014

https://www.gov.uk/start-a-public-service-mutual-the-process

11

nature that was beyond that of most NHS trusts they were familiar with, but concern that this would

not necessarily survive any change of management and leadership. There are also likely to be major

advantages to a mutual increasing the role of community and their engagement with the hospital.

2.2.3 Putting mutuals in a historical context

In the UK, mutual organisational models have traditionally been community-based, founded on a

principle of community self-help and accountability with democratic ownership process where every

member has a vote. Mutuals historically had a community or social purpose and in a number of areas

generated public services (including health services) before state provision was introduced.

Since 2000, mutual structures have enjoyed a renaissance in providing public services with the

benefits of service users and/or the local community and staff having ownership status in social

housing schemes, NHS Foundation Trusts, Leisure Services, Schools and Community Health Services.

There is no current policy to support the formation of mutual organisations in the acute sector other

than NHS Foundation Trusts. The Mutuals in Health programme seeks to develop policy in this area.

2.2.4 Comparison to the NHS Foundation Trust Model

NHS Foundation Trusts were originally conceived as a form of mutual. In the legislation, a new

category of legal organisation – the Public Benefit Corporation – was created, with very specific

requirements as to membership, elected members’ representatives (Governors), and the Board of

Directors. Detailed ownership and governance requirements are set out in primary legislation.

Whilst significant elements of community / employee ownership are present in the Foundation Trust

structure, the statutory constraints on mutuality are considerable, the implementation has tended to

focus on the structural change at the expense of the crucial cultural change, and as a result it has been

criticised for not using the best aspects of mutuality. A 2005 Report by Nuffield Trust highlights

particular concerns12.

The regulator’s role especially for early FTs focused on financial affairs and management

capacity with little interest in governance (p27)

Members have minimal formal roles and are most likely to be passive (p16)

Governors’ powers were quite limited reducing accountability (p28), although these powers

have now been significantly strengthened in the Health and Social Care Act 2012, which

amended the National Health Service Act 2006 (the “Act”)

The structure and constituencies were set out prescriptively in the Act (Schedule 7) rather

than developed to reflect the local circumstances; this led to representation problems e.g.

very small constituencies (p19)

The Foundation Trust structure provides a useful starting point for the development of an acute sector

mutual model and the potential to develop the FT model is considered further in section 3.2.

12 http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/governance-of-foundation-trusts-jun05.pdf

http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/governance-of-foundation-trusts-jun05.pdf

12

2.3 SASH VALUES AND STRATEGIC FIT WITH MUTUAL PRINCIPLES

The values of co-operatives have been drawn upon here as a reference within the context of public

sector mutuals because there is a current and internationally recognised International Co-operative

Alliance’s Statement of Co-operative Identity, setting out these Values as well the Co-operative

Principles13. As is clear from the ICA Statement, co-operatives are accountable to, and based upon a

clear membership, with a wider concern for non-members as well. This would seem to be a closely

aligned fit against the model being explored by SaSH. As illustrated above, the values of SaSH and the

values of modern co-operation are well aligned.

Workshops with SaSH teams also identified how developing a mutual model could assist with

interpreting and evolving the existing values. In particular:

SaSH vision and values have been thought of in terms of staff participation, but with a mutual

there is also the potential to develop in the patient / community context e.g. One Team

includes other public services and consideration of the wider integration agenda across the

local health and social care economy.

There is the potential to add a focus on clinical and financial sustainability of care provision as

a necessary supporting objective to the values.

There is the potential to add a focus on democratic voice of staff and “the vibe” – values

deeply embedded in culture & behaviours of organisation. Participants recognised “the vibe”

as the feeling of an organisation that was well run and staff were professional, focussed on

customers and engaged with their roles – often found in very well, high quality hotels for

example.

13 see http://ica.coop/en/whats-co-op/co-operative-identity-values-principles

SASH: OUR VALUES

As an employee of Surrey and Sussex Healthcare NHS Trust, you have an individual responsibility to treat

everyone with:

o Dignity & Respect: we value each person as an individual and will challenge disrespectful and

inappropriate behaviour

o One Team: we work together and have a ‘can do’ approach to all that we do recognising that we

all add value with equal worth

o Compassion: we respond with humanity and kindness and search for things we can do, however

small; we do not wait to be asked, because we care

o Safety & Quality: we take responsibility for our actions, decisions and behaviours in delivering

safe, high quality care

Vision & Values, Surrey & Sussex Healthcare Trust, February 2015

VALUES OF CO-OPERATIVES

Cooperatives are based on the values of self-help, self-responsibility, democracy, equality, equity and

solidarity. In the tradition of their founders, cooperative members believe in the ethical values of honesty,

openness, social responsibility and caring for others. Recommendation 193, International Labour Organisation, 2002

http://ica.coop/en/whats-co-op/co-operative-identity-values-principles

13

The existing values are more focussed on the role of staff with respect to patients and the

community; an evolution of these values could focus more directly on the community

involvement

One of the key hopes identified in a workshop with SaSH staff is potential for a mutual structure to

embed SaSH’s existing values in decision-making processes and create resilience in the current

communications processes which have produced excellent levels of staff engagement and to extend

this level of engagement to currently less engaged groups.

A mutual structure will not deliver this ambition on its own, nor will a communications processes. Both

are needed, but the real change comes when all the relevant stakeholders engage in deep and

sustained discussion about the values, what they mean and how they are to be enacted in the work

they do together. Being a co-owner establishes an entitlement to speak, placing upon managers an

obligation to facilitate their speaking. Through identity shifts people come to see themselves as co-

owners and therefore their sense of confidence, trust and self-efficacy increases, encouraging them

to give voice to concerns/ideas. For the co-ownership to operate in this way, values-talk must be

deeply embedded in daily conversation,

Underlying this alignment of values is a broader issue of accountability. As an NHS Trust, SaSH

currently feels mainly accountable to patients and the public by ensuring that care is safe, high quality

and focused on patient experience and clinical outcomes. The Trust also feels a sense of accountability

to the TDA and values the opinion and guidance provided by the CQC inspection process and reports.

SaSH’s turnaround journey started with using accountability to patients as a tool for increasing quality

of care and creating accountability to clinicians e.g. making the feedback on patient experience and

the feedback from patients more prominent. This led to the importance of a clinical voice in the

organisation and the introduction of a clinically-led, managerially-enabled model, which has led to

clinical staff taking a greater responsibility for the delivery of care and services to patients.

A crucially important point which must be continually stressed is that it is not changing the corporate

form of an organisation that changes how it works on a day to day basis. Such a change is only brought

about by a cultural change. The difference (crudely) between FTs and the community health spin-outs

praised in Chris Ham’s report is that FTs have mainly been taken through structural change, with

limited cultural change. In the community health spin-outs highlighted, the cultural change was an

imperative because staff buy-in was crucial to the organisations surviving as businesses where staff

were going to need to make concessions in terms and conditions and accept less security than they

had enjoyed before. Giving them more power and voice was the basis of the new deal, and they went

for it.

In SaSH’s vision, the organisation wants to increase accountability especially to patients and the

community, but also to staff. Only “feeling” a sense of accountability is of limited value and runs the

risk of being misplaced.

A mutual organisation is horizontally rich in conversational practice but this held together by a vertical

spine of managerial control (in the case of a hospital this may be between the clinical leads and

managers who share control) where authority to control is subject to democratic authorisation

through the representative mechanisms. Essentially, there will be multiple sources of authority held

together in a balance of power (technically a “polyarchy”) but each one needs to be legitimated and

authorised.

14

So any new structure can support significant cultural change and make it longer lasting and stable; but

on its own, it will not deliver it. Even cultural change may be insufficient and talking about culture in

the absence of values, processes and identity risks putting the mutuality in a ‘culture box’ where it

appears “safe” but not actually effective.

2.4 SCOPE OF MUTUAL MODEL The mutual model investigated by SaSH would incorporate the whole Trust into a new mutual

organisation. The preferred model would be an evolution of the FT structure to empower members

and embed a culture of staff and patient engagement. This is a natural fit given SaSH’s current FT

application, but also helps with the level and pace of change the organisation will need to take on

under each of these scenarios.

Further discussion: it needs to be borne in mind that acute care is a specialised part of healthcare.

With the increase of integration, delivering care outside hospitals and the evolution of different

approaches to healthcare, SaSH may need to look at the question of mutuality not just on its own, but

as part of the wider health community.

2.4.1 Ownership constituencies

The aim of mutualisation would be to increase accountability member (staff and patients) voice and

influence. The members of the mutual would therefore include both a staff and public/patient

constituency as with the current FT governor structure.

In the patient/public constituency, the key decisions on membership to be further developed 14are:

Is there a need to distinguish between patients, those closely involved with parents (relatives

and carers) and the wider public? Could a more relevant approach be who is more interested

in being involved and want to voluntarily contribute their time to improve the organisation?

If so, are how is patient defined? E.g. attended in last 12 months? This needs particular

attention given the changes in how healthcare is being delivered (e.g. care closer to home),

and a definition based on receiving care rather than attending hospital may be more relevant

For the wider public, is the membership limited by geography? Is there a need to treat out-of-

area patients as a separate constituency?

In the staff constituency, the key decisions on membership to be further developed are:

Would there be a minimum qualifying time before becoming a staff member? (Workshop

leant towards no)

Would temporary staff and locums be included? (Workshop leant towards no)

Would volunteers be included? (Workshop concluded yes)

Can staff be both staff and public members? This could present a conflict of interest and it is

likely that the constituency model would look to avoid this by prohibiting staff becoming user

/ patient members.

Would employees of other organisations working on site be eligible as members e.g. social

workers? (Workshop leant towards yes)

14 One useful approach on the architecture for strategic formation could be using the Mutuality Principle:

• Stakeholder inclusive (who is included/excluded from your mutuality) • Organisation to system wide (where does your mutuality lie) • Institutional capability building (how does your mutuality join to institutional design)

15

Due to the risk of conflicts of interest, other public sector bodies and health sector bodies would not

nominate governors as in an FT structure. The benefit of nominated governors is providing information

and insight into wider health initiatives, so it is proposed that representatives of these constituencies

would either have non-voting roles or attendee status at governor meetings. This would need to

balance with the wider strategic direction of closer integration (e.g. Integrated Healthcare

Organisations).

Further discussion: How would SaSH define its membership groups, and what would the implications

be for a mutual organisation?

2.4.2 Red Lines & Requirements

Within the methodology of this study, a number of key overarching concerns and priority themes were

clarified with SaSH (referred to as “red lines” on the grounds that they were areas that shouldn’t be

crossed) through the workshops and focus groups. These were in addition to the initial scope of the

study as agreed with Cabinet Office as commissioners of this Pathfinder programme, but were felt to

be critical in ensuring that this final report and conclusions could be best used by SaSH in the future.

This red lines and requirements were created through engaging staff concerning the values and

purpose of SaSH that will underpin the organisational form chosen.

Through this exploratory study and structuring of workshops and focus groups, these were addressed

and acknowledged in the following ways:

RETAIN NHS BRANDING

A key concern of SaSH is that whatever model they ultimately adopt, that the NHS brand identity will

be able to be retained. This is not only to reflect its history, but also its commitment to the wider

values and ethos of the NHS and wishing to retain this into its future. It is also important in retaining

the goodwill and support of its various stakeholders in ensuring its future success.

The ability of a future mutual to retain this branding would be subject to discussions with the NHS at

the time of an application to transfer into a mutual. However, to date, health mutuals externalising

from within the NHS have largely created a new principle brand identify, and so it is unclear as to how

far this aspiration would be able to be achieved without further future exploration and in light of a

future national policy context.

RETAIN FOCUS ON PROVIDING SAFE QUALITY PATIENT CARE

As a provider of clinical care services, SaSH needs to ensure that whatever model it adopts will allow

it to be able to always act in the interests of assuring appropriate standards in the quality and safety

of patient care. The challenge for healthcare providers with alternative governance structures is to

ensure that this objective has credibility, particularly when there may be cynicism as to whether a

primary motive is in fact profit. To achieve this, SaSH would need to be able to say that its commitment

to care is underpinned by its commitment to public, not private benefit and their answerability to their

members and community for their performance.

As either an acute Trust, or a Foundation Trust, the legislation and mechanisms through which SaSH

manages and assures this are well documented and understood. However, given the limited incidence

of whole Hospital Trusts moving into a mutual model, and lack of history of such care being provided

through these models, the ability for SaSH to assure this focus would need to be more clearly detailed

and explored with these current regulatory bodies. SaSH would still be subject to Regulatory

16

Requirements in the same way that other providers are now – this may not necessarily be Monitor,

although the CQC will still be important.

To date, this has begun to be explored through some aspects of supporting SaSH to reflect on its

current membership strategy, and the role of membership with regards to patient safety and care.

However, it is recognised that should SaSH wish to pursue a mutual model in the future, this is an area

that would require significant additional development.

ENCOURAGE INNOVATION

SaSH recognises the value of current staff engagement in encouraging this key stakeholder group to

act as a source of innovation generation in its services. Moving to a mutual model and giving staff a

much greater level of voice and influence is felt to offer the potential to open additional sources

through which further innovation might be generated and captured through these different and

additional membership groups. A similar argument can be made in relation to patients and

community, whose expert knowledge could equally well be harnessed better for the benefit of the

community.

To this end, a separate discussion and reflection was held to reflect on SaSH’s current membership

strategy and offer suggestions as to how this might be reviewed and further enhanced to stimulate

and encourage the realisation of such future innovation.

PROVIDE GREATER FLEXIBILITY FOR STAFF REWARD AND INCENTIVES

SaSH has developed high levels of staff engagement15 and is keen to build upon these to ensure that

its workforce are fully engaged in supporting the success of the Trust and in the realisation of its vision.

Within its current structure, or that of a Foundation Trust, there are limits on how far SaSH might be

able to enact a more flexible and wider range of incentives and rewards for staff that it might wish to

otherwise offer.

Some of the earlier health spin outs, as a result of the “Right to Request” and Transforming

Community Services initiatives, took advantage of being able to move away from some of the

traditional requirements of working within the NHS, including, but not limited to moving away from

Agenda for Change terms and conditions (subject to any overarching TUPE requirements), looking at

harmonisation of terms and conditions where possible considering alterative pension provision and

or a menu of employee benefits, which employees could select from

A mutual model, in being separate to the wider NHS’ employability structures, could offer considerably

more freedom on how staff might be further incentivised and rewarded.

As part of the methodology in undertaking this study, a series of consultative events were staged to

explore what a preferred rewards and incentives structure might look like if a mutual were created to

allow more flexibility in enacting these.

These highlighted that staff preferences with regards to rewards and incentives more related to

intrinsic values (recognition, flexibility over working structures, etc.) rather than a material or financial

gain. Given that the key difference a mutual would offer over other forms would be a greatly increased

level of voice and influence, then a mutual approach would very much meet the aspiration of staff in

this respect.

15 http://www.surreyandsussex.nhs.uk/nhs-staff-survey-ranks-surrey-sussex-healthcare-nhs-trust-among-best-country/

http://www.surreyandsussex.nhs.uk/nhs-staff-survey-ranks-surrey-sussex-healthcare-nhs-trust-among-best-country/

17

Further details of how these sessions were run and the findings are included in the appendix section

6.3.

PROVIDE GREATER FLEXIBILITY IN PROCUREMENT PROCESSES

SaSH recognises that in utilising a considerable supply chain to support its services and activities, it

has great potential to further impact upon its local community if it were able to have more flexibility

over its ability to procure from local suppliers and agencies, and also have more responsiveness within

in its supply chain management. However, many of these suppliers might otherwise struggle to comply

with regulations associated with supplying NHS bodies under national public procurement legislation,

and so it is keen to explore how becoming a mutual might offer it more flexibility in addressing this.

While public sector mutuals are separate legal organisations to the state, and so in theory, not bound

by the public procurement regulations that SaSH is currently required to abide by, it is unclear at this

time as to how far this aspiration would be able to be achieved through a mutual structure. This is

because NHS England have taken a position of reviewing such changes to procurement terms on a

‘case by case’ basis.

This point is explored in further detail in this report in section 4.2.2.

ENABLE OR (AT A MINIMUM) DO NOT INHIBIT FORMING PARTNERSHIPS WITH PUBLIC, PRIVATE AND THIRD

SECTOR BODIES

SaSH recognises that it is a key body within the wider local community, and through its size, economic

contribution, and services, has the potential to act as a catalyst to enable wider impacts to be created

through engaging with other bodies and agencies in a variety of ways.

As an acute Trust or Foundation Trust, it has considerable flexibility over how it can explore and

achieve this through delivery partnerships, and service level agreements. However, legislation within

these forms limit the extent to which these options might be able to be more fully realised at higher

levels of Governance, including such partner bodies serving as Directors. There are additional

constraints around non-NHS income, significant transactions and financial investment and stability.

A mutual form outside FT would offer considerable flexibility with regards to governance and Board

configurations, and so would potentially offer SaSH more options with regards to how it might

approach the development of collaborative partnerships with other bodies in the future.

CONTINUE TO HOST STUDENT TRAINING AND TRAINEES

SaSH takes pride in its ability to support future generations of medical staff through its involvement

in student training programmes, and hosting trainees throughout its operations and services, and is

keen to continue this.

Any move to adopt mutual status should not preclude this aspiration from being able to be realised.

Given the additional flexibility that a mutual form would offer at all levels, becoming a mutual would

also offer SaSH more flexibility over the ways in which it supports such students and trainees through

not only ‘opting in’ to the wider NHS programmes relating to them, but also engaging with other

training providers and bodies as well.

LIMITS ON NON-NHS WORK

SaSH is keen to ensure that if it moves to become a mutual, the flexibility over its ability to take on

non-NHS paying work will not grow to an extent where it compromises its primary role as a provider

of public services.

18

Many public sector mutuals have taken the opportunity of the flexibilities and freedoms offered within

their new form to begin to seek and secure private work as a means to grow the service and also

generate additional revenues to reinvest in their core operations and activities. However, there is a

balance to be found in doing so in ensuring that the mutuals original purpose does not become

‘diluted’ or compromised.

Within the context of this study and report it would seem that there are two principle ways in which

this concern can be managed: one is that SaSH would continue to be subject to regulatory oversight

from bodies such as Monitor who may deem that the quality of care to public patients is being

adversely affected by the taking on of too much private work and so instruct SaSH to take steps to

scale it back. The other is that through its stated purposes in its adopted governing document it could

set such a limit itself. It would be up to its own membership, elected representatives and Board then

to enforce such constitutional commitments.

RETAINING THE ROLE OF TRADES UNIONS

SaSH has built strong relationships with the Trades Unions that staff are members of, and is keen that

any move into a mutual form would not put these at risk.

Trades Unions have taken an active interest16 in the emergence of the political agenda relating to

mutualisation from the outset and despite stated concerns, have worked positively with services

whose staff are keen to pursue this option. This is largely a reflection of their recognition that if

planned and structured well, mutuals can place more control and influence in the hands of staff and

their members, than current employment arrangements can otherwise allow for. They also recognise

the potential for mutuals to enhance the quality and impact of public services delivered through this

form.

Within the context of SaSH, it would therefore seem that there should be no obvious grounds as to

why its existing relationships with Trades Unions could not be further strengthened by a move to a

mutual form in the future.

PROTECTING STAFF EMPLOYMENT TERMS AND PENSIONS

A concern expressed through the methodologies utilised within this study was in relation to the risks

to the staff’s current employment terms and pensions that a move to a mutual form might incur in

seeing them being transferred out of the employment of the NHS into a new legal entity (the mutual).

In keeping with the Transfer of Undertakings (and Protection of Employment) (TUPE) regulations, any

staff that were to be transferred into a new mutual would be entitled to have their current

employment terms protected and preserved at the point of transfer (including pension provision). This

would also be a key area that formed part of the consultations with key stakeholders in advance of

the decision to become a mutual with relevant stakeholders (primarily staff and Trades Unions).

While of assurance to staff, the potential liability of this would need to be calculated within the

financial model for the new mutual to ensure that it could sustain and meet these obligations. This

would usually be expected to be undertaken as part of the ‘preparation stage’ of any future process

SaSH adopts in transitioning to a mutual form. This is detailed further in this report in section 5.3, and

TUPE and Pension issues and considerations are detailed further in section 4.2.7 and 4.2.3

respectively.

16 For examples of union views on mutuals, see https://www.unison.org.uk/upload/sharepoint/On%20line%20Catalogue/19946.pdf and http://www.acas.org.uk/media/pdf/p/t/Mutual_Advantage_The_future-implications_of_mutualism_for_employment_relations.pdf

https://www.unison.org.uk/upload/sharepoint/On%20line%20Catalogue/19946.pdf

http://www.acas.org.uk/media/pdf/p/t/Mutual_Advantage_The_future-implications_of_mutualism_for_employment_relations.pdf

19

NO MAJOR REORGANISATION OF THE DECISION-MAKING PROCESSES E.G. COMMITTEE STRUCTURES

Given SaSH’s recent history in strengthening staff engagement and patient and community

representation through the development and introduction of a range of forums and structures, it is

understandably keen that these need not be ‘dismantled’ before they have been able to generate

their potential returns and impacts.

As SaSH is also pursuing an application for Foundation Trust status, it has begun to consider through

its membership strategy and governance rationale how these structures will be extended and built

upon in this new arrangement. A subsequent further transition into a mutual model would mean

further changes to these decision-making processes, but at this stage it is hard to clarify how far these

would impact upon current processes. This is because it is not clear as to the exact governance

configuration such a future mutual might adopt, and neither has SaSH had opportunity to reflect on

how well the processes that will be enacted through it gaining Foundation Trust status will be effective

or need to be subsequently reviewed and assessed.

Further discussion: These redlines and requirements came out of discussions with a diverse group of

staff involved in the pathfinder programme, but this is a key area to involve the whole organisation

and wider stakeholders in if SaSH wish to further pursue a mutual model.

2.4.3 Types of Mutual

Within the context of exploring the options of mutualisation and the roles it can offer, for the sake of

completeness within this study it was felt useful to also briefly consider and profile the different types

of mutual model that exist, and how each can be structured within respective legislative frameworks.

Historically, mutuals have usually adopted a specific legal model based on that of Friendly or (what

used to be called) Industrial and Provident Societies (now referred to in legislation as Co-operative

and Community Benefit Societies). These organisations developed around an ethos of existing

primarily for the benefit of its members, though from the first co-operative society in 1844 it is clear

that they had a wider social purpose and operated for the good of the communities they served.

The recent move to reconsider public services within the values of mutuality has seen the traditional

co-operative model being recognised as having certain draw-backs, in particular through its ability to

distribute surplus to members. A public sector mutual must be inherently committed to the interests

of the public and its community, and not any private constituency of users or employees. This has

resulted in a much greater use of community benefit societies, which are becoming the longer-term

vehicle for public service mutuals.

Further, in seeking to harness the potential of mutual values in transforming public services, the State

has recognised that there needs to be a range of models that can be adopted to allow a flexibility of

approach to enable further innovation in different contexts according to both service type, and the

geographic scale at which the mutual will be operating. These fall into one of three broad types

(although each of these types can be incorporated within different legal forms):

Employee owned - where employees hold a significant stake through one of various types of

membership or shareholdings (either in the organisation directly, or in a Trust, through which

they have influence from that Trust being a majority shareholder in the organisation). Where

such organisations enable employees to derive a personal financial benefit, they are generally

not regarded as operating for a public purpose. In other cases such as the community health

spin-outs, there is no intention for employees to receive any financial benefit from

membership and they remain committed to the public good.

20

Co-operative – where the organisation is majority or wholly owned by its members who are

defined by having a common interest or shared defining characteristic (such as being

employees, all using the services offered, or all residing in the immediate locality). No

substantial co-operative public mutuals are known by the team – new co-operatives tend to

be small in scale

Wider social enterprise - where the organisation is defined primarily by its social objectives

rather than its membership

2.4.3.1 – Different legal forms for mutuals to incorporate within

As referred to above, these types of public sector mutuals can be incorporated within a range of

different legal forms, and the principle options usually adopted are briefly: Companies including

Community Interest Companies, Community Benefit Societies and Charities. However, it is also of note

to highlight that within each there can be significant flexibility with regards to how membership is

defined and structured, and how governance arrangements can be enacted. These are explored

further in this report in relation to SaSH’s own vision.

A study of public sector mutuals in 2014 by the Transition Institute17 identified that against the above

choices, there appears to be a clear preference for Companies that are Limited by Guarantee, and

Community Interest Companies:

Legal form Proportion of organisations incorporating with this form

Company Limited by Guarantee 38.5%

Community Interest Company 33.8%

Company Limited by Shares 12.3%

Community Benefit Society 12.3%

Charity 3.1%

The data should be treated with some caution and read in the context of the whole report, as not all

of the organisations came from positions relevant to SaSH.

The below briefly profiles each of the principle options in more detail for reference:

COMPANY (OTHER THAN A COMMUNITY INTEREST COMPANY)

The Company form is very flexible in being able to accommodate a range of different governance and

Membership structures. It is also widely recognised. Within the context of mutuals, generally only

companies limited by guarantee are used, because distribution of profits to shareholders (the principle

of companies limited by shares) is contrary to the Co-operative Principles.

Companies limited by guarantee see their Members guaranteeing any debts to a pre-set amount

(usually £1) and are widely used by non-profit organizations; worker co-operatives have also used this

model.

COMMUNITY INTEREST COMPANY (CIC)

CICs were introduced by the State as a legal form specifically for social enterprises, and act as an

additional layer to an ordinary Company (see above) – in effect a CIC must also be either a Company

limited by guarantee or shares. A CIC limited by guarantee is prohibited from making any distribution

to members. A CIC limited by shares may make a distribution, but subject to a dividend cap.

17 See table 4.7 (page 24) of http://www.transitioninstitute.org.uk/wp-content/uploads/2012/03/Public-service-spin-outs.pdf

http://www.transitioninstitute.org.uk/wp-content/uploads/2012/03/Public-service-spin-outs.pdf

21

Crucially, a CIC is subject to an additional regulatory body (the CIC Regulator) whose powers allow it

to intervene in the Board and trading activities of a CIC to ensure that it does not become subverted

or start to act in ways that may be felt to be contrary its stated community purposes. The CIC Regulator

is generally more of a “light touch” regulator, but it is necessary for CICs to file annual Reports with

the Regulator to demonstrate that it is complying with its requirements for being a CIC.

Additionally, CICs are subject to a statutory ‘asset lock’, protecting the value of the CIC in the interests

of the community in perpetuity, which also underpins the dividend cap.

CO-OPERATIVE SOCIETY

A Co-operative Society is formed primarily for the benefit of its members, and is able to distribute

surpluses amongst its members. Although being structured in legislation on a ‘one member one vote’

governance structure, these other characteristics and its inability to include an asset-lock mean it does

not make it an easily reconcilable option within the context of public sector mutuals or SaSH’s values.

COMMUNITY BENEFIT SOCIETY

In contrast to a Co-operative Society, a Community Benefit Society’s principle focus in on benefitting

a wider local community, with membership being drawn from anyone with an interest in its activities

and services (although still on a ‘one member one vote’ basis). In this way it will have membership

drawn from different constituencies, with each such group having a different interest in the

organisation and subsequently, their expected relationship with it.

A Community Benefit Society may also include a statutory asset lock (a standard feature of both CICs

and charities). Community benefit societies have been used on other occasions to create public

service mutuals based on the Foundation Trust model – e.g. Rochdale Boroughwide Housing18.

CHARITABLE INCORPORATED ORGANISATION (CIO)

The CIO model was introduced to simplify the previous arrangement of charities needing to be

registered with both the Charity Commission and Companies House in order to afford their Members

a protection of their personal liability.

While charities must have exclusively recognised charitable purposes in order to quality as such, they

are able to trade and enter into various contracts.

Important: The final determination of the appropriate corporate form to use is something to be dealt

with at a late stage when all other aspects of a proposal are fully developed. It is a matter of detailed

legal advice, which needs to take into account a range of issues including ownership, governance,

funding, tax, and intended relationships with different stakeholders. At this stage we would suggest

that the likely options for SaSH will be a public benefit corporation (if legislation can accommodate

what is desired) or a community benefit society.

Further discussion: SaSH would need to carry out detailed assessment and legal advice on the

appropriate corporate form.

18 For further reference on Rochdale Boroughwide Housing see: http://www.rbh.org.uk/about_us/history_our_mutual_vision.aspx, http://www.rbh.org.uk/about_us/our_mission,_vision_and_values.aspx and http://www.rbh.org.uk/about_us/governance-1.aspx

http://www.rbh.org.uk/about_us/history_our_mutual_vision.aspx

http://www.rbh.org.uk/about_us/our_mission,_vision_and_values.aspx

http://www.rbh.org.uk/about_us/governance-1.aspx

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2.5 BENEFITS AND RISKS In the staff engagement workshops with SaSH employees, the key benefits that were identified by

staff members were:

Empowerment of staff and increasing personal responsibility

Sense of ownership – beyond formal legal structures (i.e. including psychological ownership)

Increase pride in the organisation

Greater control of own destiny and ability to author own story (more autonomy)

Broader representation and a shared voice

Pioneer status & opportunity to shape national policy

Potential to become a more agile organisation

Potential to create a new NHS sub-brand

Process of engagement is good of itself

There are also a range of “mutual assets” that are commonly found in mutual organisations, which

can be audited, measured and disseminated. For example increased innovation and overcoming

organisational silence.

In the staff engagement workshops with SaSH employees, the key concerns that were identified by

staff members were:

Need to ensure governance is agile and unlocks potential benefits

Scale of potential membership could become unwieldy

Lack of a safety net, being on your own financially

Increasing scrutiny on organisation as a vanguard

Lack of reference points and precedents

Complexity – hard to explain the model and wide parameters make it feel like a big step

Potential to lose NHS brand

Further discussion: These benefits and risks were drawn up in the staff engagement workshops but it

was only possible to include a small group of the Trust’s thousands of staff and wider stakeholders,

and this was done over a limited time period. If SaSH were to progress with becoming a mutual then

this should form a far wider programme based on the ideas in these workshops. This would form a

two-way discussion on these topics (e.g. allowing stakeholders to express their concerns about the

risks and the Trust to further understand potential risks), and also helping stakeholders to become

comfortable with the concepts and be able to fully engage in discussions and decisions.

2.6 CONSTRAINTS The main constraints identified for the Trust to become a mutual are the policy and legislative

environment. At this stage in the feasibility study, these constraints will prevent the Trust from

developing into a fully mutualised model. Based on recent political history it seems reasonably likely

that these constraints will be removed in time, however this would require legislative change and at

the time of writing this there is a high degree of political uncertainty that will delay any immediate

legislation (at the very least until the outcome of forthcoming elections).

The table below sets out the list of constraints identified and potential responses to overcome these

barriers:

23

Constraint Description Impact Response

FT Legislation Legal barriers to incorporating elements of mutuals

High Specific areas of legislative change requested highlighted through pathfinder participation

Policy environment Supportive national policy required High Continued participation in path finder programme and contribution to policy and legislative change.

Maintaining staff enthusiasm Staff members needed to shape and drive mutual model

High Initial engagement positive, however communications plan will be paused whilst FT commences to prevent distraction. Staff engagement planning undertaken for future mutuals project, interface with SaSH+ programme reviewed. Staff involvement and voice to be monitored through FT membership engagement strategy to provide baseline to articulate benefits of mutualisation in future.

Board Development Different skills required from board in mutual organisation

Medium Board development planned as part of transition to FT status. Board development work-stream planned into next steps of project.

FT Transition Time required for FT model to be tested and bedded in

Medium Transition to FT will required board time and attention in short term, so mutual project will be paused whilst this process undertaken. Mutuals communications plan used to position mutual organisation as a potential future evolution of FT model and Mutuals programme included in FT post-evaluation review planning and in membership engagement strategy to allow evaluation of whether FT model meeting Trust’s needs or evolution beyond FT would be beneficial.

Community engagement Support from community essential High Preferred mutual model incorporates community and patient voice, however all mutual models likely to increase staff voice. Engagement programme planned in next steps planning.

External stakeholder engagement: Commissioners

Support from commissioners required

Medium Engagement programme planned in next steps planning.

External stakeholder engagement: Politicians

Support from local politicians beneficial

Medium Engagement programme planned in next steps planning.

External stakeholder engagement: Unions

Support from unions beneficial Medium Initial involvement of union representatives on project board positive. Agreement on transparency of working on project and clarity agreed. Engagement programme planned in next steps planning.

Change Management Strong processes required to ensure successful transition

Low Well organized change management processes developed for FT transition. Constraint to be reviewed when mutuals project reassessed to ensure robust process still in place.

Cultural alignment Mutual values need to align with Trust values to create mutual organisation

High SaSH values and principles of mutualisation closely aligned already. Constraint to be reviewed if SaSH values further developed to ensure continued compatibility.

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2.7 DEPENDENCIES

Dependencies for SaSH becoming a mutual have been divided into internal activities over which SaSH

largely has control of timing and external environment factors where SaSH will have little influence on

the activities required. It is important to note that these dependencies refer to the process of

becoming a mutual; the ‘mutual difference’ will be manifested in collaborative working, generating

momentum around innovation in inter-departmental, functional or organisational processes

The key barrier to SaSH becoming a mutual is the policy development and legislative change

programme. Whilst all other activities can be taken speculatively independent of the wider policy

support, ultimately SaSH’s plans will be determined by the policy context, so it is not recommended

to commence detailed mutual model development work in advance of policy guidance. Due to the

electoral cycle, this policy guidance is not expected before summer 2015, with an expectation that it

would become available in Autumn/Winter 2015 at the earliest.

This dependency fits conveniently with SaSH’s application for Foundation Trust status where a

decision is expected in summer 2015. Allowing for a period of bedding in the Foundation Trust model

if (as expected) the application is accepted, or allowing for a period of strategic recalibration if the

application is not accepted, the next steps planning for the mutuals programme assumes a review of

the potential to create a mutual in late 2015, early 2016 (subject to any delays in the FT application

process). This is expected to coincide with a six month Post Evaluation Review (PER) of the Foundation

Trust model in operation and therefore the interface with the Foundation Trust PER is a key

dependency of the mutuals project.

•Purdah begins

March 2015

•General election

May 2015•FT Decision

Summer 2015?

•Mutuals in Health legislation?

Autumn/Winter 2015 at earliest

25

The outcome of that review is expected to either identify (1) no changes required, (2) minor changes

that can be made within the FT model, (3) changes required to meet SaSH’s vision of staff engagement

that do not sit within the FT model. The matrix provided in section 3.2 is designed to assist the

evaluators to understand the flexibility provided within the FT model and determine whether a mutual

model outside the scope of current FT legislation could better meet SaSH’s objectives. The

membership engagement strategy will help provide a baseline for the levels of engagement achievable

through the FT model. In the event that the PER identifies that SaSH would like to improve these

metrics, the staff engagement programme set out in section 5.5 could be used to identify

modifications to the FT model to improve the metric targeted and to re-commence the process of

engagement to develop a mutual model to suit SaSH’s needs. The pace of this development process

and detail that can be developed will be determined by the policy environment and changes to

legislation.

2016/17

Outcome of review

End of 2015

Outcome of decision

Spring/Summer 2015

FT application decision

FT application approved

FT post evaluation review

FT model provides staff engagement desired

Review amendments permitted if minor

improvement sought

FT model not providing staff engagement

desired

Commence staff engagement on mutualisation?

FT application Declined

Commence staff engagement on mutualisation?

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3 OPTIONS APPRAISAL

Key messages:

To determine the preferred mutual model, further staff and stakeholder engagement will be required

once the FT model has been embedded at SaSH. The section below sets out the “Long List” of potential

models that could be adopted as a continuum from evolution to a new form of FT with greater voice

and participation of members to revolution to create a fully staff controlled mutual following existing

community services precedents.

Short-listed options along this continuum can be selected once the current FT application has been

decided and the new governance models embedded and reviewed for effectiveness. Areas of

potential change are set out in a matrix in Section 3.2 below to aid future discussions of which areas

of SaSH’s governance framework could be developed. The matrix separates potential changes into

those which sit within the existing legal framework and those where legislative change will be

required. It also orients to what extent changes would be consistent with a modified FT model or a

new type of organisational form.

The selection of options will ultimately rely on the critical success factors (CSFs) determined, balancing

the benefits and risks of the potential models. This section develops an initial list of CSFs to be refined

with future engagement and sets out methodologies that can be utilised for assessments of the

qualitative benefits and risks of the short-listed models.

Due to the lack of policy guidance and legislation, the options appraisal produced takes a blue-sky

thinking approach to organisational design, and then identifies where legislative and policy barriers

currently inhibit SaSH’s desired outcome. The viability of the options cannot be fully considered until

the trajectory of policy development is known.

The options appraisal also does not focus on the “do nothing” option due to the current uncertainties

stemming from the dependency on the FT application outcome. In particular:

1) Prior to a decision on the FT application, SaSH’s future organisational model (when the policy

and legislative framework is established to permit a mutual model) is unknown.

2) Assuming a transition to FT, there is currently no relevant baseline to reference. The next steps

planning seeks to integrate with the FT transition and utilise the FT PER to provide an

opportunity to assess the value of a fully mutual organisation compared to the emergent FT

structure.

A further caveat to performing an options appraisal at this stage in the development of a mutual

organisation relates to the timeline of the potential transition to a mutual model. As noted above in

section 2.7, this timeline is dependent upon policy formation and the FT application process and as

noted below in section 0, a typical transition process will last many years.

In the wider Mutuals in Health sessions with other pathfinder Trusts, a key concern of the programme

panel is maintaining momentum in developing mutual organisations in the acute sector. Previous

programmes that have resulted in mutual spin-outs have gained momentum from “burning platforms”

that have required organisations to develop new organisational forms. In particular, the Transforming

Community Services (TCS) policy in 2008 triggered a wave of mutuals because it required PCTs to

divest themselves of their community services. The main options pursued were to merge the services

27

with an NHS body e.g. an acute or mental health trust19, create a community NHS Trust/Foundation

Trust20, become a “social enterprise” (mutual organisation)21 or contract the services to a private

firm22. Creating a mutual spin-out presented an attractive option in numerous areas for various

reasons including freedom, independence and innovation. A Parliamentary Seminar in 2009 provides

a comprehensive discussion of the choices faced by commissioners and service providers at the time23.

Between 2009 and 2014, 42 new mutuals were formed from parts of the NHS24 – largely community

services, with some examples of highly successful organisations resulting. It is currently too early to

evaluate the sustainability of these spin-outs as most have not yet reached the end of their initial

service contracts.

Whilst the Transforming Community Services policy has been used as a reference point for the current

pathfinder, there is currently no directly analogous immediate drive or crisis to fundamentally change

the way acute services are provided that would create the “burning platform” seen with the TCS

policy. In workshop discussions with SaSH it became apparent that a more approach than a “burning

platform” may be areas that would “build appetite” for a mutual. This approach focusses on the

potential upsides of a mutual and what it may enable SaSH to achieve rather than events that would

force it to become a mutual. Initial ideas included the possibility of far deeper involvement of a wider

community in a possible “health campus” at the East Surrey Hospital site through their participation

in a SaSH mutual.

A workshop with the other pathfinder Trusts also investigated the potential “trigger” issues that would

provide momentum for policy development to support the mutuals programmes, at which it became

clear that whilst the crisis was not immediate, it was approaching rapidly:

• Productivity/Efficiency improvements and savings required for financial survival and to

meet increasing service demands

• The Five Year Forward View vision of a “more engaged relationship with patients, carers

and citizens” which is a radical new approach

• Integration initiatives within the health care system and between health and other sectors

which need to be genuinely transformative

At the time of writing it is unclear whether the “leading cohorts” investigating Primary Acute Care

Systems (PACS) and Multi-Specialty Community Provider (MCP) models may be fore-runners of a

wider sector organisational transition driven by integrating health services25.

Future question: SaSH should engage with internal and external stakeholders to understand what

would truly build an appetite for a mutual (and ensure that there is genuine appetite). This will help

inform the direction of any mutual programme and also build stakeholder understanding and support.

19 E.g. Rotherham NHS FT http://www.therotherhamft.nhs.uk/community_health/ 20 E.g. Birmingham Community Healthcare NHS Trust http://www.bhamcommunity.nhs.uk/ 21 E.g. Essex community health provision http://www.provide.org.uk/who-we-are/ 22 E.g. Surrey community health provision http://www.virgincare.co.uk/virgin-care-signs-contract-for-community-services-in-surrey/ 23 “A Mutual Health Service” 18th December 2009 https://www.conted.ox.ac.uk/research/projects/AMutualHealthService.pdf 24 http://www.theguardian.com/society/2015/jan/25/nhs-mutuals-not-all-like-hinchingbrooke 25 http://www.england.nhs.uk/wp-content/uploads/2014/12/forward-view-plning.pdf

http://www.therotherhamft.nhs.uk/community_health/

http://www.bhamcommunity.nhs.uk/

http://www.provide.org.uk/who-we-are/

http://www.virgincare.co.uk/virgin-care-signs-contract-for-community-services-in-surrey/

https://www.conted.ox.ac.uk/research/projects/AMutualHealthService.pdf

http://www.theguardian.com/society/2015/jan/25/nhs-mutuals-not-all-like-hinchingbrooke

http://www.england.nhs.uk/wp-content/uploads/2014/12/forward-view-plning.pdf

28

3.1 DEVELOPING CRITICAL SUCCESS FACTORS

3.1.1 What should relations with stakeholders be like?

Staff were asked to provide an ideal vision of the relations of the staff, patients and community with the Trust in 2025:

Stakeholders: Staff Patients Community

Ideal Relationship by 2025

Staff feel empowered, listened to and valued and take responsibility for service provided.

Staff are driven but not stressed, know why they are doing their job and how they contribute to outcomes

Staff influence decisions, innovate, are competent and excelling

Patients choose SaSH and are confident of feeling looked after

Patients receive integrated, quality care and then leave with all the information to not need to return.

Patients receive a consistently good experience that they would recommend to friends and family

Patients take personal responsibility for own health.

Everyone receives seamless service across health and care regardless of where they live in Surrey & Sussex

There is an understanding of who does what in community care.

The social value of the Trust is understood. The community is loyal to their local hospital and the 3rd sector supports the hospitals activities

2015 progress towards ideal

6-7 /10 5/10 3/10

3.1.2 What should the Trust retain, begin and end from different perspectives?

Staff were asked to set out the key activities that they believed the Trust should start, stop and continue from a range of perspectives:

Perspective: Staff Patients Carers & Relatives Other health & public services

Start these activities

Increase support staff levels with activity

Increase ways to listen to good ideas staff generate and implement

Embed values and behaviours in line with values

Empower staff with more info to enable them to do their job

Better access – 7 day services

Set patient expectations appropriately

Make navigating the system easier

One point of contact in hours and better contact out of hours

Improve facilities for dad’s in maternity

Use technology better

Work more collaboratively

Demonstrate how we evidence social value

Stop these activities

Using escalation areas Stop rescheduling appointments

Don’t give defensive answers

Being rigid in approach e.g. visiting hours

Admitting patients to hospital

Planning without wider stakeholders input

Continue these activities

Culture of patient safety

Stable management team

Recruitment to ensure minimal vacancies and less reliance on temporary staff

Training provision

High quality treatment + service

Maintain patient focus

Improve communications e.g. texts

Patient opinion

Engagement & co-design of services

Providing an excellent service

Working in partnership

Focus on quality & safety

Put patients first

Delivering more efficient services

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3.1.3 What Critical Success Factors would a mutual have and how could they be

measured?

In order for SaSH to be able to commit to pursuing mutual status at a future date, it was agreed

through the workshops and focus groups that a series of Critical Success Factors that are distinctive to

the Trust would need to be met. These reflect the Trust’s key priorities, values, and likely concerns of

its stakeholders – all of which the prospect of becoming a mutual will need to clearly meet and be able

to be subsequently reported against in order to elicit their support.

These supplement the list of ‘Red Lines and Requirements’ at section 0 in this report that SaSH have

previously identified as being key to assuring themselves that the pursuit of a mutual form should

enable it to be able to further achieve its vision (or if not, that they can be successfully managed and

mitigated). This subsequent list of issues further clarify what SaSH would be keen to monitor on an

ongoing basis in assuring itself that a mutual form is realising the benefits it anticipates for itself and

its stakeholders.

While these will be subject to future review in light of the outcomes of the Trust gaining Foundation

Trust status, and future legislation and changes within the wider political context, these were captured

as being the below for the time being:

POSITIVE IMPACT ON PATIENT SAFETY

The broadening of the Trusts’ membership within a mutual model would need to be managed with

regard to patient expectations – patient members may begin to expect and demand changes to the

care they receive by virtue of their membership which would be at odds with the regulatory context

in which SaSH delivers its services.

Patient safety is already the key focus for SaSH, with patient surveys already under-taken as part of

national NHS Survey programmes and specific local surveys as required. A Patient Engagement Forum

already provides the Trust with feedback from patients, as do the patient representative groups and

tools such as “Patient Opinion”. These initiatives could be supplemented within a mutual context by

seeking the views of its patient members as part of regular surveys of this group. Making forecasts

about the extent to which the adoption of a mutual status would enhance this in advance could be

explored through focus groups drawn from patient and staff representative forums and asking them

to reflect on the likely impact that the change of status and associated impact on services through

having relationships reframed through the focus of membership might create.

POSITIVE IMPACT ON PATIENT EXPERIENCE (FRIENDS & FAMILY TEST SCORE/PATIENT OPINION FEEDBACK)

As with the above consideration regarding patient safety, a mutual model would allow SaSH a greater

flexibility with regards to possible options through which it could elicit feedback and reflect on current

patient experiences. To this end, the same method of using existing forums to explore potential

impacts and identify possible concerns might also seem prudent.

However, as with patient safety, the use of wider membership models to directly seek views and

inform decision-making within SaSH with regards to patient experience would need to be carefully

managed to ensure that expectations amongst these stakeholders were not allowed to inflate to levels

where they believed that they would be able to have more influence that legislation would allow, thus

giving rise to resentments and conflict.

30

INCREASED COMMUNICATION AND INFORMATION

In order for a mutuals’ governance to fulfil its potential, its membership need to be actively engaged

and will need access to timely and relevant information to enable them to do so. Part of this overall

study has begun to explore the implications of what becoming a mutual might mean with regards to

expectations from information by different stakeholder groups within the context of the membership

strategy. However, this still is felt to need further exploration with regards to the types of information

that members of a mutual might expect, would need, and what the Trust would be able to share with

them in the context of sensitive and commercial information as members would be accessing this

knowledge and be able to share it with others in the wider public realm.

INCREASED INNOVATION TO IMPLEMENT STAFF IDEAS AND IMPROVE PATIENT EXPERIENCE (CO-DESIGN)

A key aspiration of SaSH is to harness the wider latent potential innovation that may exist amongst its

constituent stakeholders. A mutual model would clearly need to offer a route through which this might

be not only encouraged but also appropriately captured in continuing to maintain and further enhance

SaSH’s standards of service.

Methods through which potential innovations might be identified and begun to be enacted have

begun to be explored within the context of the additional support offered to this study in reflecting

with SaSH on their existing membership strategy.

ARTICULATION OF SOCIAL VALUE (E.G. SROI – SEE SECTION 3.3.1.1)

Part of articulating a final business case for the pursuit of a mutual would need to include the

identification of the wider social and qualitative impacts that this model would create. This would not

only need to be on a forecast model as part of supporting the business case, but also within a

framework that would allow the Trust to subsequently ascertain how far these expected benefits have

been realised.

An initial review of such existing frameworks and models has been included in this Study and detailed

in section 3.3.1.

Further discussion: As referred to above, this list is not a final schedule of Critical Success Factors that

SaSH will wish to consider at any point at which it begins to formally pursue the move to a mutual

status. SaSH should revisit this initial list at that time with key stakeholders, and it is suggested that

this be done through the methodologies enacted through this Study, which engaged with key

stakeholders, and from which this initial list was generated. Details of these workshop schedules and

structures are included as appendices to this report, see section 6.2.

3.2 MUTUAL MODELS CONSIDERED: LONG LIST The “Long List” of options developed for this feasibility study is a spectrum of options ranging from

the FT model being adopted by SaSH to the maximum freedom permitted under the FT legislation (FT

possible) to a modified FT structure not permitted under the current legislation (FT +) to a full mutual

structure based on a community benefit society structure (Beyond FT).

The details of SaSH’s vision for its organisation are in development, but sit broadly in the area of FT+

i.e. not permitted under existing legislation, but clearly an evolution from the existing permitted

structure. This could be enabled with some minor modifications to the FT legislation.

31

Comparison FTs Now FT Possible FT + Beyond FT

Description Structures seen in current FTs Based on where SaSH is with its draft constitution at the moment and other options it may want to consider

Modifications to the FT legislation that may meet SaSH’s requirements if enacted

Broadly, this summarises models seen in the health spin-outs in other health sectors

Ownership Members (legally), but continuing public dividend capital, monitor regulation etc. and other state interference diminishes that

Active member engagement strategy, but no constitutional powers beyond electing governors.

Establish members as custodians for themselves and future generations and increase their power and influence (NB this would require a reduction in the influence of regulators and Secretary of State)

Shareholders of CICs Members of mutuals. Those cited generally employee-owned

Purpose Provision of goods and services for the purposes of the health service in England and ensuring financial constraints met regarding NHS/private income. General duty to exercise its functions “effectively, efficiently and economically”.

May be possible in Standard Constitution to include further wording which does not conflict with statutory purpose but is more inspiring for staff and patients e.g. by greater reference to benefits to patients, quality of care, community engagement etc...

Per FT Possible Generally carrying on business for the benefit of the community (public purpose)

Ability to distribute profits

Not possible – though note many FTs do have charitable activities.

Potential to use surpluses more effectively in meeting principal purposes.

Potential to allow more integrated and joined up thinking about how to use its funds, capital assets etc… within its local health and social care economy, beyond just payment and capitation models.

Surpluses reinvested to meet purposes for those established as CICs without shares or a community benefit society. If a CIC with share capital, there is power to distribute to members with some limitations

Legal structure Public Benefit Corporation which is a body corporate constituted in accordance with Schedule 7 of NHS Act 2006.

Per FTs Now Legal form not a key driver provided that organisation remains within NHS (if it remains an FT then it would continue to be a Public Benefit Corporation).

Community Interest Company, Community Benefit Society

Governance Prescribed by NHS Act 2006. Three tiers: members, Council of Governors, Board of Directors. Act also prescriptive about eligibility criteria.

Per FTs Now Three tier structure preferred. Composition of tiers and powers to be considered.

Subject to the legislation governing incorporation. Those cited are either two tier (members and a multi-constituency board) or three tier similar to FTs

Power of Regulators

FT is less restricted than NHS Trusts, but subject to Monitor who impose financial monitoring & regulatory restrictions. CQC also imposes regulatory requirements. Also need to ensure compliance with any Monitor Licence requirements and/or conditions. General power to do anything which appears to it to be necessary or expedient for the principal purposes of or in connection with its functions.

Potential to interpret general power to undertake activity “necessary or expedient for the principal purposes” more widely e.g. to pursue partnership and healthcare integration opportunities, but will need regulatory permission.

Less prescriptive regulatory oversight preferred and more accountability to patients. SaSH’s growth strategy would benefit from greater power to form partnerships and provide wider more integrated services in line with patient expectations.

Generally unrestricted, subject as below. Need to comply with CQC Regulatory Requirements if undertaking regulated activities.

32


Borrowing No longer subject to Prudential Borrowing Code, but effectively subject to Monitor. Secretary of State also has power to give financial assistance. May borrow money for the purposes of or in connection with its functions subject to any limits imposed by its authorisation.

Possibility of using its existing powers more widely in the delivery of its functions and in order to benefit the wider health economy, if Trust in financial position to do so.

Wish to retain access to public support capital and have freedom to use other funding sources as appropriate.

Unrestricted (subject to constitutional limits)

Disposal of Assets

Protected assets governed by NHSA 2006 although importantly not assets of the Crown.

May be more that can be achieved through rationalisation/shared usage, particularly regarding the integration and links with primary care and social services.

Would want more flexible approach to asset ownership to complement partnership model and creation of health campus at East Surrey Hospital.

Unrestricted, subject to asset-lock which preserves asset value and prevents distribution to members (apart from dividends in CICs subject to overarching cap levels or permitted disposals for market value)

Investment Broadly unrestricted – but for the purposes of or in connection with its functions.

Per FTs Now – note that the limits are currently being explored by some of the new “Vanguard” models in response to the Five Year Forward View

Flexibility to form partnerships and integrate with other healthcare providers beneficial where not already granted.

Unrestricted (subject to constitutional limits)

Purchasing Subject to public procurement rules/ any specific NHS procurement requirements.

Per FTs Now Would potentially want flexibility to opt out of procurement regulations, but not if this prevented retention of NHS organisation status. Unlikely to be able to “opt out” of procurement regulations under this model.

Potentially unrestricted, provided the new entity is not caught by the definition of a “body governed by public law” in the Regulations. See section 4.2.2 for further details.

Rewards and Incentives to Employees

Agenda for Change Per FTs Now Modifications to Rewards and Incentives may be possible but are likely to be largely based on AfC

Unrestricted subject to any positions inherited on TUPE Transfers and any subsequent harmonisation exercises

Pension NHS Pensions Per FTs Now Per FTs Now Due to TUPE, generally been a mix of LGPS Admitted Bodies, NHS Direction Status and private pension provision.

Ability to generate other income

Private patient income restricted – cannot interfere with fulfilment by the FT of its principal purpose, and NHS income must be more than 50%. Requirement for more an increase of more than 5% in non NHS income to be approved by Council of Governors.

Per FTs Now Further flexibility potentially required for integration and forming partnerships with other bodies e.g. Macmillan cancer information centre.

Unrestricted – subject to any overriding requirements e.g. if public sector Teckal vehicles.

33


Membership Very prescriptive and set out in NHSA 2006. Any deviations from Schedule 7 and Standard Constitution have to be explained to Monitor – “comply or explain” approach adopted. Act also makes it clear, even if approved, amendments are of no effect if the result of the amendments would be non-compliant with Schedule 7.

Discussion e.g. on staff re agency staff and bank staff as members may be possible. Also, if a new vision suggests this, SaSH could adopt Patient and Carer constituencies which it does not presently have.

Would like more flexibility to define constituencies as below

Subject to incorporating legislation, their choice.

Categories of members

Public (compulsory), staff (compulsory), patients and carers (optional)

Public including out of area & Staff constituencies used

Patients/Public & Staff Membership constituencies and categories not the focus – wish to ensure that governors are able to represent members

Health spin-outs generally had employee share-holders because of pensions/NHS contracting restrictions, some also extended to service users and Carers. Public Sector entities limited to participating contracting authorities and no external private ownership, including employees.

Definition of public members

Living within a local authority ward Per FTs Now. Out of area patients defined separately.

Flexibility to create locally appropriate definition especially in light of strategy to increase market share of elective services geographically.

Their choice – might be geographical, or related to usage of services

Definition of Employee

Full or part time employees, and others “carrying out functions” for the trust, e.g. seconded people. Can’t include short-term employees

Discussions with Monitor would be needed – more could be done in relation to other staff “carrying out functions” in integrated models, particularly in relation to the cross over between health and social care.

Flexibility to define employee to include volunteers, partnerships and other services provided on site e.g. social workers. Would potential want to exclude agency/temporary staff?

Their choice

Definition of patient members

Those who have attended “any of the corporation’s hospitals” as a patient within a specified period

The wording about attending hospitals is clearly out of date and arguably inappropriate e.g. in relation to mental health FTs and initiatives to move care close to home.

The wording about attending hospitals is clearly out of date and arguably inappropriate e.g. in relation to mental health FTs and initiatives to move care close to home.

Their choice

Definition of carer members

Those who have attended one of the hospitals within a specified period. Excludes professional carers

As above As above Their choice

Volunteers Have to be included in public constituency, unless they can fall within the “carrying out functions” test for employees above (but then problematic)

Per FTs now Would want to classify as staff members Their choice

Sub-dividing constituencies

Can (effectively) subdivide any of the constituencies (but cannot subdivide wards)

Geographic constituencies being used to enable member engagement, but members also being asked for interest to enable other types of engagement.

Other categorisations e.g. by type of service used may be more relevant than geography

Their choice

34


Power of members

Although members are notionally “the owners”, there is no real sense of this as members do nothing except elect representatives. They can’t call a meeting, remove anyone from office or hold anyone to account. Members don’t even have to approve changes to the constitution, which means they are more or less insignificant in governance terms. Any decision making powers from a member perspective effectively rest with the Council of Governors and so is reliant on that being representative and effective in its function.

Training being provided to governors to assist them in representing members. Member engagement strategy developed to give members additional voice and input.

Greater power to members to increase accountability to members.

Their choice. Generally all provide that members have to approve constitutional change. Some have the power to appoint and remove the CEO and NEDs. Organisations also have difficulty engendering a sense of member ownership, but easier because there are clearly no other owners (state/DH/investors play no part in ownership).

Representation: Composition of elected representatives

NHSA 2006 very prescriptive about composition of Governors. Must have overall majority of public/patient governors. Must have at least 3 staff governors, 1 local authority, 1 university where relevant

Per FTs now Would want to increase staff and patient/public representation relative to appointed constituencies.

Their choice, subject to incorporating legislation. Generally the spin-outs cited have elected representatives of members on the board (in a two tier structure) or comprising the majority of the Council of Governors in a three tier approach.

Public and patient representation vs Employee representation

Because the majority of the Governors are public or patients, they have more influence than staff. This is deliberate as do not want staff to have a greater voice than the public. Effectiveness of representation varies greatly and concerns that in some cases more closely aligned with senior management teams than the public constituent they are supposed to represent.

Training and membership engagement strategy to increase effectiveness of representation

Would seek to increase staff representation (initial target 50% public/patient, 50% staff) to benefit from long term commitment of staff and in-depth knowledge of processes and impact on patient experience and outcomes. Note requirement to address the conflicts position presently protected by the Act e.g. staff influence not overriding public constituencies.

Generally much less substantial than employee representation as they tend to be employee-led or owned. Some have public governors or NEDs on the board. Generally employee-led or owned.

35


Powers of elected representatives

All precisely set out in legislation, and limited scope for real change. Certain nuclear powers, such as ability to remove NEDs, but limited in practice. Board “must have regard to the views” of governors in forward planning, but do not necessarily have to follow them. Governors now required to approve strategic corporate decisions such as mergers, acquisitions, disposals and other significant transactions, big increases in private income, amending the constitution etc.

Ability to further enhance these and grant further powers, but would need Monitor approval. Need to ensure this did not operate so at to become divisive though.

Per FT Possible Their choice, but those with three tier structure generally have the power to appoint/remove NEDs like FTs. Ability to give elected representatives more power than in an FT, e.g. in relation influencing forward planning.

Board composition

Prescribed by NHSA 2006. Must have a majority of NEDs which includes chair; certain executive directors specified.

Per FTs now Per FTs now Their choice. Generally includes executive directors and NEDs. In two tier structures, NEDs tend to represent different interests; in three tier structures, tend to independent

Board powers Board has all the powers except those reserved elsewhere. Limited flexibility.

Options to give greater powers to Council of Governors and Members, but would require further discussions with Monitor.

Their choice.

Financial viability/ financial failure

NHS Failure regime would apply – potential for merger and dissolution, acquisitions and de-authorisation.

Per FTs now Per FTs now, although further discussions may involve a change in failure regime to reduce the disempowerment of members in the process

Depends on form adopted. For companies (including CICs), generally sold and or wound up in accordance with Companies Act/Insolvency Act requirements, though CICs would need to transfer any residual assets to specified asset locked body or as determined by the Regulator. Community Benefit Societies have the additional option of transfer of engagements, which has traditionally been the way that restructuring has taken place in the mutual sector without the economic and social costs of insolvency/failure.

Inclusion of partnered organisation

Not represented on Council of Governors or Board unless specified in legislation e.g. local authorities

Per FTs now Flexibility to include partner employees or organisations in governance structure for integration or cultural assimilation

Subject to incorporating legislation, their choice.

36

Further development: SaSH needs time to let its (hopefully successful) FT status settle in before

deciding whether any shortcomings need addressing and if so which are the most important (including

reflecting on the effectiveness of the membership engagement strategy). SaSH would also need to

continue to consider its major growth plans and ambitions, and how well the FT structure supports

these.

3.3 SHORT-LISTING OPTIONS In a future business case, the short listed options will be dependent on policy development and the

legislative framework. This feasibility study sets outs a methodology for evaluating options qualitative

benefits and risks to assist with short-listing options when a business case is being created.

3.3.1 Methodology for evaluating qualitative benefits

A key part of the business case for a mutual and the engagement plan will be an ability to explain and

demonstrate the qualitative benefits anticipated by the organisational changes. There are several

methodologies that exist to allow this – Social Return on Investment (SROI) and Cost Benefit Analysis

(CBA), both endorsed by the government are outlined below. The challenge with several of these

methodologies are producing consistent, meaningful outputs without over-investment of resource

into the analysis. As an alternative, many previous pathfinders have continued to use internal tools

and methodologies.

It has been identified with SaSH that the setting of the FT membership engagement strategy presents

an opportunity to collect baseline data on the performance of the FT model in the areas where a

mutual may be beneficial. By building in these metrics to the membership engagement strategy, the

Trust may be able to define specific qualitative benefits that it would hope to achieve through a mutual

in the future.

3.3.1.1 Social Return on Investment (SROI)

The Cabinet Office recommend the use of “Social Return on Investment26” (SROI) to articulate the

social value produced by an organisation.

SROI as a methodology originated in the US in 1997 with an employability support charity seeking to

better understand and article the benefits its support was creating. This initial model was

subsequently explored through various national and European networks before an agreed framework

to use in enacting this methodology was finalised in 2005.

It is designed as a comprehensive process that maps affected stakeholders to an organisation

(although principally in relation only to a specified service), and then consults with them to identify

and understand the impacts and outcomes (both intention and unintentional, and positive and

negative) that each stakeholder experiences. These are then assigned a monetary value, and

compared to the cost of delivering the original service in order to create a ratio (allowing for outcomes

that would have been generated regardless, and any displacement of existing activity from other

providers). This ratio is a comparable model to accountancy practices of a ‘financial return on

investment’, but in considering qualitative impacts and benefits, represents the wider ‘social’ return

on investment.

26 Further details can be found in http://www.bond.org.uk/data/files/Cabinet_office_A_guide_to_Social_Return_on_Investment.pdf

http://www.bond.org.uk/data/files/Cabinet_office_A_guide_to_Social_Return_on_Investment.pdf

37

As a change management and stakeholder engagement model, SROI offers a strong methodology

through which an organisation might better identify and understand how its activities impact on

stakeholders in different ways.

However, SROI is also recognised as complex and requiring significant resource to fully enact.

Additionally, although a recognised and auditable methodology, there are no universal guidelines as

to which stakeholders should be consulted with regards to specific services; and there are also various

approaches that can be taken in assigning monetary values to the same outcomes and impacts. This

means that any SROI report cannot be easily compared or externally benchmarked by commissioners

of public services, and internal decision makers.

Also, researches commissioned by other Government bodies have concluded that owing to the range

of methods and methodologies through which wider qualitative benefits might be captured and

quantified, and the complexity arising from the range of ways in which similar services can be

delivered in different localities, that while SROI offers some benefits, commissioners of services should

not mandate that organisations adopt a specific approach27.

3.3.1.2 Cost Benefit Analysis (CBA)

Although based on a French economic model from the 19th century, CBA has recently begun to be

revisited by modern policy makers as a robust framework within which to reflect on the anticipated

relative gains of policy and service proposals.

Building on consultative work commissioned in the late 2000’s in relation to the ‘troubled families’

agenda, the new economy strategy and research consultancy has created an ‘open source’ CBA model

with pre-set public policy outcomes and values that have been endorsed by Government. This enables

an organisation to more readily and easily evidence and argue its business case for a proposed service

with policy makers and public commissioning bodies. It has also led to some Government bodies

endorsing this approach over SROI with organisations it is considering investing support into, or in the

case of local authorities, in considering the benefits of asset transfers of public buildings into local

community ownership.

CBA begins with the development of a ‘theory of change’ model – mapping out the context and

rationale for the intervention or service model, its required inputs and expected outputs, outcomes

and impacts. This is then used to map the model against the pre-populated framework of a range of

public policy outcomes using proxies and values that have already been agreed with government. The

framework then captures costs, and considers how far the proposed model may be able to justifiably

claim it will be generating these benefits by drawing on other research into comparable models

elsewhere.

It also outputs the benefits of the proposal model in both financial and social terms – collectively and

with regards to each stakeholder.

The CBA model therefore offers a more practicable and appropriate framework to consider the

qualitative benefits that are expected to be created – it is designed as a forecasting tool only (whereas

SROI was originally designed to be reflective against activity already delivered). Further, it is based on

a more rigorous and objective approach in considering how far outcomes and impacts might be

attributable to the model, and uses standardised outcomes and values agreed by government to be

able to make a more credible case with commissioners and also more easily benchmark externally.

27 creating sustainable social enterprises in the criminal justice system – a comparative study, 2012 pan-regional social value commissioning project final report (ref p6), NHS and cpc, 2010

38

However, it is a complex tool that considers all affected stakeholders and requires extensive research

into evaluated comparable models elsewhere to inform its adoption. Given the relative lack of

published research into public sector mutuals to date, this would mean that this approach would

require significant additional support to fully inform its completion.

3.3.1.1 Use of metrics within existing management accounts information

In considering the qualitative benefits that will be created, it would be prudent to also look to data

that SaSH is already capturing through its existing management accounts and other information

systems.

These could be interrogated to identify the extent to which SaSH is impacting upon:

- the wider local economy through the extent of its procurement with local suppliers and

employees who live locally;

- the wider community through the extent of volunteering activity of staff and support to local

charities and groups on in-kind basis;

- its engagement with the community through profiling the makeup of its Board and the

makeup of other senior governance structures against demographic data;

- its environmental impact through energy use, waste management, and staff travel habits

These could all be captured as baseline figures at the outset of the transition to a mutual model, and

subsequently monitored to identify the extent to which the new mutual structure has enabled it to

further impact upon these themes.

This approach would require little additional resource, and also allow SaSH to be able to present its

role and impact in local and global contexts in ways that all stakeholders would be readily able to

engage with.

While not as sophisticated as the other frameworks profiled in this section, this approach may also be

beneficial in encouraging such impact reporting to be more easily embedded, and subsequently

enhanced in the future. It would also easily enable staff to identify the tangible impact of their actions

and choices within the larger role, contribution, and impact of SaSH as a whole.

3.3.1.3 Balanced Scorecard Approach/Specific Metrics

Kaplan & Norton’s Balanced Scorecard is a process designed to provide balance between short and

long term objectives, financial and non-financial measures, lagging and leading indicators and external

and internal perspectives. In 2005 the Chartered Institute for Management Accountants published “A

Practitioner’s Guide to the Balanced Scorecard”28 that provides a comprehensive guide to the

methodology and theory of the approach and provides a case study of the Scorecard being

implemented in a health economy setting.

The four quadrants highlighted by the Scorecard help to focus attention on the importance of

developing organisational capabilities through processes and learning & growth in order to achieve

outcomes for customers and financial returns.

28 http://www.cimaglobal.com/Thought-leadership/Research-topics/Management-and-financial-accounting/A-practitioners-guide-to-the-balanced-scorecard2/

http://www.cimaglobal.com/Thought-leadership/Research-topics/Management-and-financial-accounting/A-practitioners-guide-to-the-balanced-scorecard2/

http://www.cimaglobal.com/Thought-leadership/Research-topics/Management-and-financial-accounting/A-practitioners-guide-to-the-balanced-scorecard2/

39

Whilst the Scorecard was originally developed for commercial organisations, this model has been used

by public sector organisations with the CIMA research from 2005 identifying a similar level of uptake

between large UK corporates and public sector organisations in a telephone survey (p47 of the

Practitioner’s Guide). One of the main strengths of the Scorecard is its adaptability.

Implementing the full Scorecard process is a significant organisational development programme that

may be of benefit to SaSH in the future. For the purposes of understanding the qualitative benefits of

different organisational models, the principles and metrics of the Scorecard approach can be quite

simply adapted to create reliable baseline data to better understand the development of SaSH as an

organisation.

Mutualisation would be expected to have the most direct impact on the “Internal Business Process”

and “Learning & Growth” quadrants. Through developing metrics in these areas to understand the

impact of the member engagement strategy of the FT, a baseline of data can be collected.

Typical metrics to develop in this area include:

Employee satisfaction

Productivity measures

Employee retention

Employee training / competency levels

Based on the feedback from workshops, appropriate specific measures may include:

Use of member voice mechanisms – attendances of events, improvement suggestions made

and followed through

Use of staff engagement mechanisms – innovations / improvements introduced

metrics against key elements of the membership strategy to reflect on how far the Trust has

been able to engage and actively involve members – growth in membership, proportion of

members voting, contested elections

Further discussion: There are different methodologies for evaluating benefits and measuring

performance. SaSH may wish to engage in a wider discussion on which measurement system(s) are

most appropriate, useful and workable for the organisation and its stakeholders. Questions could

include: For whom does the measurement system exist? Who in the organisation / system needs to

know how well the organisation is doing? What do they need to know? How is this knowledge to be

acquired?

FinancialInternal Business

Process

Customers Learning & Growth

Vision & Strategy

40

3.3.2 Methodology for Risk Appraisal

This sections presents a methodology for assessing risk and highlights the general concerns raised by

staff members during a workshop on the principles of mutualisation.

In section 4.2 below, consideration is given to some specific commercial concerns such as asset

ownership, VAT and TUPE considerations that are likely to apply. The nature of these risks will be

highly dependent on the specific policy and legal framework development and cannot be assessed at

this stage. The commercial considerations and risk implications for the Trust have been reported to

the Department of Health and Cabinet Office through a Project Report and participation in the

Pathfinder workshops to assist with policy formation.

3.3.2.1 Managing Risk?

The risk management methodology presents here is based upon the Chartered Institute of

Management Accountants (CIMA) methodology29 and the risk management advice given in the Green

Book30 in Chapter 5 “Appraising the Options” and Annex 4 “Risk and Uncertainty”

3.3.2.2 Risk Assessment

Risks have been identified through a workshop approach to understand the concerns of staff regarding

a mutual organisation. These risks have been further investigated and developed for this report to

allow analysis and response development.

An initial estimation of their impact and likelihood has been undertaken by the project team to create

an initial risk register for development when the policy and legislative framework is agreed.

A template risk register is given on page 80 of the Green book in Box 4.1. The items included on the

register below were identified at a workshop on the 3rd February 2015 with the project board.

# Description Type Dependencies Likelihood Impact Date

identified

1 Increased scrutiny from regulators and media

Strategic/ Compliance

Model chosen Legislation

Medium Low 3rd Feb 15

2 Loss of NHS Brand Strategic Model chosen Legislation

Medium31 High 3rd Feb 15

29 http://www.cimaglobal.com/Documents/ImportedDocuments/cid_tg_intro_to_managing_rist.apr07.pdf 30 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/220541/green_book_complete.pdf 31 Retention of the NHS Brand may be dependent upon the level of autonomy granted to the mutual e.g. GP partnership retain NHS brand, but have prescriptive contract of services and regulation, Community Interest Companies do not generally retain brand, but have more operational autonomy

Risk assessment

Identification

Description

Estimation

Creation of Risk Register

Risk management policy

Risk response

Risk reporting

“Managing Risk – a generic approach” CIMA 2007

http://www.cimaglobal.com/Documents/ImportedDocuments/cid_tg_intro_to_managing_rist.apr07.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/220541/green_book_complete.pdf

41

# Description Type Dependencies Likelihood Impact Date

identified

3 Scale of membership becoming unwieldy

Operational Model chosen Legislation

Medium Medium 3rd Feb 15

4 Lack of financial safety net in failure regime

Financial Model chosen Legislation

Low High 3rd Feb 15

5 Complexity – members/governors may not understand roles

Operational Model chosen Legislation

Medium Medium 3rd Feb 15

3.3.2.3 Risk response

A list of typical risk responses is given on page 81 of the Green book in Box 4.2. The items included on

the register below were identified at a workshop on the 3rd February 2015 with the project board.

CIMA provide a more generic risk response matrix based on impact and likelihood of risk events:

Based on the generic strategies, a specific mitigation can be developed or investigated for each risk:

# Description Risk Strategy Mitigation Actions

1 Increased scrutiny from regulators and media

Accept Increased communication with regulators, members and the wider community

2 Loss of NHS Brand Avoid Mutual to be structured as NHS organisational form

3 Scale of membership becoming unwieldy

Reduce Utilise technology solutions to improve mass communications e.g. “gamefied” solutions to sift comments and suggestions e.g. Idea Street used by DWP32

4 Lack of financial safety net in failure regime

Transfer Continuity of care is a key concern for policy makers and regulators. It can be assumed that in development of the Mutuals in Health policy a robust failure regime will be developed (see section 4.2.4 for further discussion)

5 Complexity – members/governors may not understand roles

Reduce Training events for members and governors tailored to new roles. Lessons learnt from FT board development sessions

Further development: As SaSH develop their thinking and direction for a mutual model, this risk

assessment and response framework should continue to be developed. It is also a good tool for

engaging stakeholders in an honest conversation about the potential risks and mitigating actions of

becoming mutual (including some ‘myth busting’).

32 http://www.sparkcentral.co.uk/showcase/show/idea-street

http://www.sparkcentral.co.uk/showcase/show/idea-street

42

3.3.2.4 Comparison to FT application risk management

Whilst the risks above are specific to a mutual model, the risk assessment of developing and

implementing a mutual model will sit within the wider risk assessment of the governance system. The

excerpt below shows the current status of the risk assessment during the FT transition process:

In transitioning to a mutual model, it is envisaged that a similar process to the current FT project would

be under-taken e.g. Mutual Project Board, Mutual Project Plan. The development and transition would

be included in the Long Term Financial Model and Integrated Business Plan. The BGAF and QGAF

would be refreshed and any action plans implemented to provide assurance. An external assessment

of BGAF and QGAF could be undertaken to provide further assurance. The level of assurance required

would depend on the nature and complexity of the changes required by the proposed mutual model.

The role of the regulator in the transition will be determined by legislation, but it is anticipated that

Monitor would provide support and guidance to the project corresponding to the TDA Readiness

Review.

The current preferred model in section 4 below represents an evolution of the proposed FT structure.

To address the risks in developing this model, as the role of Governors and the Board would remain

similar, but the voice of patients and staff increased, it would be anticipated that a more extensive

refresh of the membership engagement strategy and Public Consultation would be required with less

emphasis on a refresh of the Board Development Programme or Governor Awareness Sessions may

be required.

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4 CURRENT PREFERRED MODEL

Key messages:

From the pathfinder engagement a preferred model would be an evolution of the current FT structure,

building from the proposed FT governance structures and increasing staff voice and engagement and

accountability to patients.

This model is specified in a template below that can be adapted as this model is designed to be

adapted in future engagement sessions.

The key commercial considerations for the feasibility of the mutual model chosen are discussed in this

section and should be reviewed once the short-listed models are chosen and in the light of revised

legislation and policy guidance. At present, VAT is the key concern and a potential barrier to the

feasibility of a mutual model; the Department of Health are liaising with HMRC to address concerns in

this area.

4.1 TEMPLATE MODEL SPECIFICATION The template below sets out a potential model that subject to legislative change could be adopted by

SaSH as an evolution of the FT model:

Element Specification

Structure Three Tier Structure: Owned by Members who elect Council of Governors to oversee Board of Directors (as

per FT)

Organisational Form Public Benefit Corporation, Community Interest Company33 or Other legal form34 dependent on legislation.

Note: see earlier caution on choosing organisational forms in section 2.4.3

Purpose of Organisation Provision of high quality, safe health care for patients

Members

Constituencies

Patients & Public (per existing FT definition)

Employees (per existing FT definition with potential addition of partner organisation staff

working on site and potential exclusion of some temporary staff, potential further sub-division

to increase number representatives)

Council of Governors All governors elected by members in constituencies.

Representation of Patients & Public and Employees (in proportions weighted towards staff)35

Chair of Board also chairs Council of Governors

Powers &

Responsibilities of

Governors

Represent members: Bringing innovative ideas from members, enabling members to become

involved in service co-design, provide

Oversee board: Holding to account NEDs and Chair, ability to appoint Chair and approve

appointment of CEO, setting of NED and Chair remuneration

Involvement in strategy implementation: Assist board in choosing between strategic options

and providing member voice in implementation decisions provide external view to Board to

assist decision-making,

Statutory role of FT governors in approving significant transactions etc.

33 This has some risk; if CIC is used without share capital, then that may inhibit the financing of the organisation in the long-term. If you use the CIC with share capital, (a) this leaves the organisation open to distribution of surplus to shareholders; and (b) the mechanics of running a share register a large and fluid membership with Companies Act requirements in relation to redeeming shares is very laborious. 34 Most likely alternative option is the community benefit society, which avoids the CIC problems and has the benefit of an asset lock. 35 this is because SaSH have an understandable concern that as its staff will be actively engaged with its services on an ongoing basis, whereas public constituencies of membership may be more transitional or subject to specific interests, that the respective influence of each group reflect this to ensure the standard of service and ability to continue to act in the wider interests of being a public service.

44

Element Specification

Attendees at Council of

Governors

Standing invitation to attend given to key community and healthcare organisations e.g. CCGs, Local

Authorities, University, Healthwatch and Council of Voluntary Services as non-voting participants in the

Council.

Board Powers All powers not reserved elsewhere. Set strategic direction of Trust

Rights of Members More extensive rights to systematic consultation36 on service co-design and strategy

In the future, SaSH may wish to consider further member rights (including formal annual members

meetings which receive the annual report and accounts, members approving constitutional changes etc.),

all of which would need primary legislation.

Regulation and

Oversight

Monitor (or other regulatory body as set out in statute) to provide guidance and support to organisation,

less oversight than present FT structure expected in accordance with greater oversight37 of members and

Governors.

CQC inspections as per statutory requirements.

Integration of health

sector

Purpose of organisation expanded to facilitate integration 38with other healthcare providers if

commissioned to provide such services.

Other healthcare and public sector organisations not formally included in governance structure unless

strategic partnership exists. Stakeholders will be able to input into Council of Governors meetings, but

integration efforts to be mainly directed through System Resilience Group, Chief Accountable Officers

group and other committees answerable to Board.

Strategic Partnerships Enabled through ability to incorporate organisations into governance structure. Active process for defining

strategic partners to create more meaningful involvement.

All other elements to remain as per current FT governance proposal39

Further discussion: The technicalities and implications of these different elements require a lot of time

and consideration, and the initial views above are almost certainly not the final structure that SaSH

would decide on. In particular the options on how the Members Constituencies should be decided

were hotly debated and this would need to be discussed far more widely and in far greater detail.

4.2 COMMERCIAL CONSIDERATIONS

4.2.1 VAT

Healthcare services are exempt supplies under EU directives and UK legislation. Currently NHS entities

such as CCGs, NHS Trusts and NHS Foundation Trusts are covered by the VAT rules in Section 41 of the

1994 VAT Act. Under this Act, VAT is reclaimable on “business activities” e.g. Car parking, private

patient income under normal VAT rules (i.e. if the supply of the services is VAT-able (e.g. drug sales),

VAT can be recovered, if it is exempt (e.g. Creche income), VAT cannot be recovered on associated

running costs). There is then a special concession that allows s41 bodies to reclaim an amount equal

to the VAT incurred for “non-business activities” providing that if falls under the list of “Contracted

36 If the organisation is to become more mutual (i.e. transfer more power to the grass roots), it may want to move from the idea of “consultation”, and instead give members / Governors the power to approve things like forward plans after being involved in the development of ideas 37 Note that this may be difficult if the members and Governors do not have the skills and experience to “interfere” more in the governance 38 SaSH may wish to pursue this further to include explicit commitments to work co-operatively with other organisations committed to the public good. This includes looking beyond organisational boundaries and accepting that the public good can come before local institutional interests. 39 Per section 6.4 Governance Rationale for Foundation Trust

45

Out Services”40. Through these rules, the majority of VAT is in some form recoverable for the Trust

with little “VAT-leakage”.

In addition to the “non-business” activities concession, the majority of NHS bodies are also included

in the NHS Divisional VAT registration. VAT is not charged between on any transaction between NHS

bodies within the Divisional VAT registration with further reduces VAT-leakage and VAT administration

for the health economy.

Community health spin-outs have experienced significant increased costs due to VAT treatment. In

general they are neither section 41 entities (and so do not receive the non-business activity

exemption), nor are they included in the NHS Divisional VAT registration (so VAT is chargeable on

services supplied to or received from NHS entities at applicable rates). If as a mutual, the VAT rules

applied to SaSH in this way, it could mean that all VAT incurred on input costs would be essentially

irrecoverable. Based on the 2013/14 annual report, this would be a maximum of £15m cost to the

Trust41.

The Department of Health is discussing the VAT implications of mutualisation with HMRC currently.

As part of this Pathfinder programme, they may suggest that a new mutualised form of NHS Acute

Trust is added to Section 41 and included within the NHS Divisional VAT registration (ensuring that the

VAT position of mutualised Trusts would be no different to NHS Trusts or NHS Foundation Trusts).

Another precedent exists in education where local authority schools received a similar concession

under section 33 of the Act to allow them to reclaim amounts equal to the VAT incurred on costs

despite education services being VAT exempt. Academies – as they were not controlled by the local

authority - initially did not receive this concession. Section 33b of the Act was subsequently created

to allow Academies to be able to reclaim amounts equal to VAT incurred on costs using a “non-

business activities” concession.

The issue of VAT has been raised as a “show-stopper” by a number of pathfinder projects and it is

therefore anticipated that a solution will be found to the VAT leakage as the policy and legislative

framework for mutual Acute Trusts is developed. Whilst inclusion of the new organisation in section

41 (as per Foundation Trusts) or the creation of a section 33d giving mutual Acute Trusts a specific

exemption along the lines of Academies could ensure the same VAT position as currently, it is possible

that other solutions could be enacted.

Depending on the specific legislative solution found, the key questions to consider are:

Is the new entity part of the NHS divisional VAT registration?

o If not, what VAT will be chargeable on suppliers to/from other NHS entities?

o Could any VAT leakage be reduced through cost sharing groups or joint employment

contracts for shared staff?

o Will VAT inhibit future integration in the health economy even if the immediate

additional costs through VAT leakage can be mitigated or absorbed?

Will the new entity benefit from the COS non-business activity concession?

o Which services that the Trust has contracted out would the Trust not be allowed to

reclaim an amount equal to the VAT on (e.g. Soft/Hard FM)?

o Would VAT leakage make contracting out a service unaffordable in the future?

40 See Enclosure B S41 Guide for NHS Apr 2014 provided by Department of Health for current list. 41 20% VAT potentially irrecoverable on £72.8m “Other Operating Costs”

46

VAT is presently the most significant risk to the affordability of a mutual model, however the risk is

acknowledged by the Department of Health and may be mitigated through legislation or VAT guidance

to support the Mutuals in Health policy.

4.2.2 Procurement requirements

Public Procurement regulations are designed to ensure a level playing field for suppliers wishing to

provide goods or services to public entities and are governed by a number of Directives and

Regulations which are then implemented in national legislation, the most recent being The Public

Contracts Regulations 2015 (the “Regulations”). They are a key part of the Common Market.

Some entities spinning-out from the public sector have been freed from the constraints of the

procurement Regulations to enable more flexibility with regards to how they procure goods and

services for their business and/or enter into strategic partnerships. As analysis would be required to

ensure that any new entity is not inadvertently construed as a “Contracting Authority” for the

purposes of the Regulations by virtue of the fact it is a “body governed by public law”. There may be

other negative impacts associated with this too such as it impeding access to procurement frameworks

and the volume discounts and competitive prices achieved.

Mutual spin-outs from the NHS in community services are not caught by the Regulations as they are

no longer public sector bodies nor do they fall within the definition of “bodies governed by public

law”, though this does need to be assessed on a case by case basis.

There is a precedent for an entity indefinitely providing health care services as an NHS entity without

being subject to procurement regulations. GPs providing services under a GMS contract as an

independent contractor are also exempt from procurement regulations and have an indefinite

contract subject to re-tendering. A recent policy challenge has highlighted the legality of services being

commissioned in this way. In August 2014, NHS England policy was changed to prevent procurement

of indefinite GMS contracts on the basis that they could not be procured under international

procurement law on competition grounds as a temporary alternative (APMS) existed42. After taking

legal advice, the Chair of the GPC wrote to NHS England arguing that “NHS procurement regulations,

as well as guidance from Monitor, clearly allows flexibility on whether to choose open competition,

taking into consideration ‘securing the needs of patients’ as well as ‘value for money’.”43 NHS England

subsequently reviewed their policy and agreed to review procurements on a “case-by-case basis”

allowing procurement of GMS contracts.44

Despite this precedent, the option to be exempt from public sector procurement legislation is unlikely

to be included in legislation. The regulations that apply will likely be determined by legislation. The

experience from community providers that have become mutuals suggests that there is a risk to new

mutuals from commissioners retendering services, however this same risk is increasingly applying to

NHS Trusts and FTs and in the view of pathfinder panel community mutuals it is counterbalanced by

the increased control of their own destiny.

4.2.3 NHS Pension

The change to NHS Foundation Trust status would not affect the ability of staff to remain in the NHS

Pension Scheme. If SaSH were then to change legal structure to a different kind of mutual organisation,

42http://www.pulsetoday.co.uk/home/stop-practice-closures/revealed-all-new-gp-contracts-will-be-thrown-open-to-private-providers/20007596.article#.VPWSNXmzXX4 43 http://www.pulsetoday.co.uk/story.aspx?storyCode=20007695&preview=1#.VPWYvHmzXX4 44http://www.pulsetoday.co.uk/home/stop-practice-closures/nhs-managers-backtrack-on-vow-that-all-new-gp-contracts-will-be-apms/20007915.article#.VPWqWnmzXX4

http://www.pulsetoday.co.uk/home/stop-practice-closures/revealed-all-new-gp-contracts-will-be-thrown-open-to-private-providers/20007596.article#.VPWSNXmzXX4

http://www.pulsetoday.co.uk/home/stop-practice-closures/revealed-all-new-gp-contracts-will-be-thrown-open-to-private-providers/20007596.article#.VPWSNXmzXX4

http://www.pulsetoday.co.uk/story.aspx?storyCode=20007695&preview=1#.VPWYvHmzXX4

http://www.pulsetoday.co.uk/home/stop-practice-closures/nhs-managers-backtrack-on-vow-that-all-new-gp-contracts-will-be-apms/20007915.article#.VPWqWnmzXX4

http://www.pulsetoday.co.uk/home/stop-practice-closures/nhs-managers-backtrack-on-vow-that-all-new-gp-contracts-will-be-apms/20007915.article#.VPWqWnmzXX4

47

then we would expect that the staff would be able to continue to participate in the NHS Pension

Scheme through the Secretary of State making a Direction Order.

4.2.4 Financial failure regime

For NHS Trusts and NHS Foundation Trusts, there is a similar financial failure regime called the “regime

for unsustainable NHS providers” also known as the Trust Special Administrator regime45. This regime

has been used twice since it was established in 2009 and in both cases resulted in the dissolution of

the Trust and transfer of services to other health providers with no financial loss to employees or

suppliers. It is particularly noteworthy that in the case of Hinchingbrooke hospital, run by private firm

Circle, the provider exited the contract again with no loss to employees or suppliers to the hospital or

impact on continuity of care. It is also worth noting that whilst the precedent has been set that all

creditors have been paid in acute sector financial failures, the regulator has required significant

savings programmes to be enacted with redundancy programmes and cuts to services.

Other NHS institutions do not always have formal financial failure/commercial distress regimes, a

notable recent example being Commissioning Support Units (CSUs), who were set up to provide IT and

other support services to Clinical Commissioning Groups (CCGs). NHS England created the Lead

Provider Framework (LPF) in 2014/15 to allow CCGs to procure professional support services that they

require through the framework. At the time of the announcement an NHS England board paper noted

that fourteen out of eighteen CSUs were already planning redundancies in order to cut costs. In

response to the procurement of the LPF, Central Eastern CSU decided to close down in October 2014.

Two further CSUs – North West CSU and Yorkshire and Humber CSU – were unsuccessful in their bids

to join the framework and are expected to no longer be financially viable.

Non-NHS institutions generally do not receive special support in financial distress. Community

provider mutuals set up under Transforming Community Services have mainly not yet faced re-

tendering of their contracts, although this is starting to become an issue. There is no government

supported regime to assist these organisations if they fail to secure new contracts, although many

frontline staff would likely TUPE to a new provider if the contract for services were not renewed with

the mutual provider.

Due to the importance of acute services in the community, it would be anticipated that a formal

financial failure regime would be created for any new organisational forms of acute provider (this

would require primary legislation). This “financial safety net” should provide reassurance to staff and

suppliers that the Trust would continue to receive support from public money should financial deficits

be incurred. However, it is likely that this regime will require oversight of the Trust by a regulator as

currently. Depending on the development of the legislation and regulatory framework, there is a

concern that as with the current FT model, the regulator could reduce the autonomy of the

organisation and ability of members to influence the direction of the Trust. Ultimately the balance

between autonomy and provision of a financial safety net will be struck by policy development.

It is to be noted that in the mutual sector, different failure arrangements come into play which results

in a far lower failure rate than with profit-maximising businesses. This is the “transfer of

engagements” mechanism, whereby the members of a mutual in financial distress can pass an

appropriate resolution to transfer all of its assets and liabilities to a mutual of similar type. For 150

years or so, this has been the mechanism by which weaker mutual societies have “merged” with

stronger societies. This option would be open to SaSH if it was established as a community benefit

45 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/268689/Factsheet_18_TSA.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/268689/Factsheet_18_TSA.pdf

48

society, but this would only really be effective in the event that this corporate form became common

in the future, providing potential merger partners when required.

4.2.5 NHS Branding & Logo

Membership of the NHS family was identified as an important concern for staff. It is anticipated that

the new organisation detailed above would be able to retain NHS branded. The most direct precedent

is Hinchingbrooke Hospital where the hospital retained full NHS branding, but added the Circle logo

to key documents and marketing e.g. the Trust website46.

A range of other branding is possible, for example GPs as independent contractor are allowed to use

NHS branding and typically do not develop strong brands or logos separately, with a few exceptions

where chains of practices have been formed such as Hurley Group47 and Vitality Partnership48.

Community Interest Companies spun out of the NHS typically use the NHS logo to indicate that they

provide NHS services, but have separate logos and brands that are fully developed, for example CSH

Surrey49. In all these scenarios, SaSH would need to continue to comply with NHS Brand Guidelines50.

It may be desirable for SaSH to develop a unique brand or identity as a mutual organisation. In the

workshops, the ability to develop an NHS sub-brand was particularly highlighted as an opportunity.

4.2.6 Assets and Liabilities

If SaSH were to move to an alternative form of legal structure, it would be necessary for it to consider

how existing assets and liabilities would transfer to that new entity. Many of the NHS organisational

changes that arose as a result of the Transforming Community Services Agenda (transfers to

Community NHS Trusts) and the implications of the Health and Social Care Act were achieved through

the Statutory Transfer Order process which, transferred everything to those new successor entities.

However, some of the NHS “spin outs” to new mutuals and social enterprises were achieved through

agreeing and negotiating business transfer agreements, which essentially transferred everything to

the new entity that it needed for the purposes of delivering the services. The usual apportionment of

risks between the parties on these sorts of arrangements is that the transferor takes the risk of all

liability up to the point of the Transfer Date and the Transferee takes the risk of everything post

transfer date, subject to any specifically negotiated exceptions such as pensions or redundancy

liabilities etc.

The transfer and apportionment of assets and liabilities and risk is crucial to the underlying financial

model for the services and it would therefore be necessary for SaSH to undertake a substantive

amount of both commercial and financial due diligence before making a decision on moving to

alternative forms or vehicles.

4.2.7 TUPE

Where there is a transfer to Foundation Trust status, TUPE will not apply because there will not be a

change in legal structure and so there will be no change in employer. If SaSH were to change legal

structure, then TUPE would apply at that time and it would be necessary to comply with obligations

to inform and consult with trade unions which would inevitably impact on the timing of such a move.

46 http://www.hinchingbrooke.nhs.uk/ 47 http://www.hurleygroup.co.uk/ 48 https://www.vitalitypartnership.nhs.uk/ 49 https://www.cshsurrey.co.uk/about-us/about-csh-surrey/csh-brand 50 http://www.nhsidentity.nhs.uk/

http://www.hinchingbrooke.nhs.uk/

http://www.hurleygroup.co.uk/

https://www.vitalitypartnership.nhs.uk/

https://www.cshsurrey.co.uk/about-us/about-csh-surrey/csh-brand

http://www.nhsidentity.nhs.uk/

49

5 NEXT STEPS

Developing the Trust to become a mutual will require a significant investment of time and money to

achieve (and this is hard to quantify). The plan outlined below is intended to aid planning of the project

and set out the key tasks to be achieved during the business case processes.

External specialist support is likely to be required at various stages in the project, however internal

costs, especially the investment of time from senior personnel should also be considered when re-

commencing investigation of mutual models.

Transitioning to FT whilst implementing this project plan could risk confusion in communications and

overload for senior personnel. SaSH will need to balance this risk with the risk of the mutual

transformation project losing momentum, including possibly pausing the mutuals project whilst the

FT governance structure beds in.

Assuming the FT application is successful, the post evaluation review of the FT transition may provide

a suitable trigger to commence looking at mutual models, responding to any concerns or deficiencies

in the FT model identified. This will however be dependent on the speed of formation of a supportive

policy and legislative framework.

5.1 PROJECT PLAN The Cabinet Office have published template guidance51 on the process to start a public sector mutual,

and this following section is mapped against this.

The following project plan is also subject to the assumption that the Trust subsequently decides to

pursue becoming a mutual in further extending the benefits it anticipates realising through becoming

a Foundation Trust.

In pursuing becoming a mutual, it is assumed that following the transition to becoming a Foundation

Trust that it has identified following an internal review that the full range benefits it seeks to realise

cannot be fully achieved within this form, following its operation within this form for an initial period,

and neither is it able to evolve this status into the ‘Foundation Trust Plus’ model imagined earlier in

this report.

It also assumes a supportive political context and environment at the time of the decision, that there

is sufficient resource available to it to be able to enact the required stages, and that the Trusts’ services

are stable, allowing the senior management the time needed to fully enact this plan without it being

at risk of disruption.

The plan is also subject to a number of review points at which the Board of SaSH would agree to

commit to the next phase, or to cease pursuing this option. This ensures that the risks associated with

such a transition can be appropriately managed, with resources and costs required rising as the plan

progresses, and subject to the outcomes of each phase, the next elements of the plan can be

subsequently reviewed and refocused appropriately. Regulators would also need to be on-board with

any transition plan.

51 See https://www.gov.uk/start-a-public-service-mutual-the-process


50

The below sections profile a summary of what this plan would entail, supplemented by additional

detail against each stage, and how SaSH has either already progressed against them, or might begin

to approach in the future.

5.1.1 Overview

The plan has been structured in four phases, with three decision “gates” separating them. The key

objectives of each phase are explained in greater detail below.

Phase Objectives Timescale Cost

1. Exploration and development

A. Explore concept of mutuals B. Clarify values and support C. Develop business case

>=12 months £275k

RECOMMENDATION APPROVED BY BOARD

2. Preparation phase D. Develop five year business plan E. Engagement and consultation

>=6 months £240k

BUSINESS PLAN BOARD APPROVAL

3. Transition planning F. Development of legal framework G. Resolving TUPE and HR issues H. Finance, governance and IT systems

3 months £280k

LAUNCH

4. Consolidation I. Develop membership J. Align management and governance practices K. Iterate reporting frameworks

13-18 months

£350k

5.2 ROLES AND RESPONSIBILITIES Against this overview, the below table also profiles the key areas of work likely associated roles, and

needed deliverables against each aspect of the above, with indicative timescales as to how long might

be needed for the completion of each. These are then combined into the subsequent summary Gantt

chart.

Area of work Responsible Deliverables Phases in plan Costs

Commercial and market analysis

Heads of services Business case; Business plan

1, 2 £90k

Future plans for services Heads of services Business case Business plan

1, 2 £65k

Management review (including risk and audit)

Chief Exec Business case; Business plan; Implementation plan

1,2,3,4 £165k

Membership and governance

Board Business plan; transition plan; consolidation

2, 3, 4 £100k

Communications & stakeholder engagement

Communications team

Business plan; implementation plan

2, 3 £520k

Transition planning Chief exec Implementation plan 3 £100k

Identifying and securing investment needed

FD Business case; Business plan; Implementation plan

1, 2, 3 £105k

Important: These phases, their details and timing have been written based on the team’s experience

of change management, those of other mutual organisations and the outline direction discussed with

SaSH during the pathfinder programme. There have been no direct precedent mutualised services to

compare timing with, so all plans outlined below should be approached with an element of caution.

Costing is done on very broad assumptions and far more detailed costing exercise would need to be

completed.

51

Further development: If SaSH wish to further pursue a mutual model, far more work will need to be

done on refining this project plan, including refinement throughout all further development. It is an

area where we would recommend SaSH seek specific experience and advice52.

52 The support team are able to provide further details upon request about the architecture for change, include the elements of: values, processes and identity. These can guide a change process which integrates different levels, includes diverse stakeholders and balances (permanent) tensions such as control/empowerment. By incorporating the Mutuality Principle as a strategic philosophy and set of organising values at this early stage, the organisation will be able to prepare the ground for transitioning to a new legal form.

52

Enacting of mutual Month

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26+

Exploration and development

identification of benefits

map risks and contingencies

creation of case by management

RECOMMENDATION APPROVED BY BOARD

Preparation

business plan development Development may be started earlier

financial case development

consultations


Transition planning

legal frameworks

transfer agreements

financial and operational systems


Transition enacting- launch

Consolidation

membership ongoing

embed governance structures ongoing

review with stakeholders ongoing

53

5.3 DETAILS OF PHASES

5.3.1 Exploration and development

The initial stages (phase 1) through which any public service would begin to explore and consider

redeveloping itself into a public sector mutual are crucial for shaping the whole programme. It is

extremely difficult to place a firm timescale on this phase, as it is more based on the progress the

organisation is making than the time invested, however a minimum period of one year should be

considered. SaSH’s involvement in the wider Pathfinder programme has given a flavour of these

discussions and considerations but importantly these need to be developed far deeper (with more

time available to consider) and involving a far wider stakeholder group.

The enacting of each of the stages within this initial phase allow for a clear picture to be established

as to the relevance, interest, and potential ability for the service to pursue mutual status. Once this

has been established, the Board will be in a position to review this and decide whether it is appropriate

to continue the process, or whether to end at this initial stage.

While SaSH has not been able to fully engage in, and complete, all these initial stages, this is a

reflection of it having engaged with this process to explore how it might build upon its success and

future progression after its gaining of Foundation Trust status which has been continuing in parallel

to this feasibility study.

Should SaSH revisit this plan at a future date, it shall therefore already have initial processes and

findings on which it can commence the process, offering it a ‘head start’:

A. Explore concept of mutuals

(started through Pathfinder programme)

The initial exploratory stage of the plan would consider the potential benefits and implications that

pursuing a mutual form might create and offer to the organisation and its service(s). As referred to

above SaSH has already begun to explore these with support from Bolt Partners through the feasibility

study and so is able to identify and article the potential benefits that might make pursuing the mutual

option appealing and relevant:

BENEFITS TO SERVICE OFFER/DELIVERY

Through a series of workshops with key internal stakeholders, SaSH has now considered at a strategic

level the potential benefits that may accrue to its services through the pursuit and adoption of a

mutual model.

Through the workshops that were staged, these were broadly identified as being in relation to further

entrenching SaSH’s values into all of its processes, systems and procedures so that behaviours that

are sought to be encouraged can be done so in a sustainable way, and not just when there is felt to

be the time and resource to do so. The identity of a mutual was also felt to offer a stabilising factor

for the long term development and operation of SaSH in offering staff and other stakeholders more

control and autonomy than other forms might be able to.

54

BENEFITS TO STAFF

The same workshops have also, in parallel, begun to identify and capture not only idealised benefits

that SaSH understand and believe that the pursuit of a mutual model will afford them, but also

concerns amongst staff as to the impact that doing so might create. Identifying such concerns are a

positive outcome to these workshops as it allows SaSH to better critically reflect on any likely

resistance or specific objections that a subsequent decision to commit to pursuing mutual status will

need to address.

Further details are included in the appendix on the Rewards & Incentives working sessions, see section

6.3.

POTENTIAL FOR VALUE FOR MONEY IN PUBLIC SERVICES

Within the wider context of acting as a provider of public services funded by the State, it was not

possible to begin to explore the ways in which a mutual model might enhance its existing financial

profile and model.

However, within the framework of this report, a range of potential methodologies and approaches

have been profiled at section 3.3.1 which SaSH might enact to begin to identify the potential financial

case that transitioning to a mutual might have with regards to public value for money.

B. Clarify values and support

Started through Pathfinder programme.

Having ascertained the in principle benefits that a mutual form could offer, SaSH has subsequently

also begun to reflect how well the adoption and move to such a model would impact upon its current

operational practices. This is a crucial stage to ensure that the move to a mutual enhances and

strengthens organisations existing values and systems, rather than disrupt them – and is even more

important within the context of health services where patient safety and care needs to manage to

avoid any potential deterioration in standards.

WORKSHOPS WITH STAFF AND OTHER KEY STAKEHOLDERS

As an organisation that prides itself on its values, SaSH has been keen to reflect on the potential for

how becoming a mutual might further embedded and deepen their enactment. It has done this

through the workshop programme that has profiled these alongside the values of mutuals.

In having these workshops engaged with by senior management and other key internal stakeholders

to SaSH, it has also been possible to assure that there are no critical barriers to moving to become a

mutual in the future from the perspective of existing systems and practices.

EXPLORING DIFFERENT PUBLIC SECTOR MUTUAL MODELS (LEGAL, MEMBERSHIP, AND GOVERNANCE) AND AGREE

PREFERRED CONFIGURATION(S)

The Pathfinder workshops have offered SaSH the opportunity to begin to identify and reflect on the

range of mutual models and potential configurations of their governance that might be most

appropriate to its own vision.

55

Given its current progress in applying for Foundation Trust status, it was not appropriate to openly

explore the full range of these with key stakeholders, but this should be revisited at a future date to

enable SaSH to develop and articulate a preferred specific model to be able to use in explaining its

interest in becoming a mutual by defining how it will be structured and operate in practice.

C. Develop business case

Started to be explored through Pathfinder programme.

Through being engaged with the Pathfinder programme, SaSH has begun to start to develop an outline

business case to support an argument to become a mutual, but this still requires further detailing and

clarifications before its Board would be able to formally approve or decline the proposal:

WHAT BECOMING A MUTUAL WILL MEAN IN PRACTICE REGARDS OPERATIONS/GOVERNANCE/ETC.

(What difference will it make in how things are done?)

Until such time that SaSH’s have been granted Foundation Trust status, and been able to objectively

reflect on how well it has enabled them to realise their vision and expectations of it, it is not possible

to identify the extent to which there may be additional potential benefits that becoming a mutual

might subsequently offer.

LIKELIHOOD OF HAVING TO COMPETE IN FUTURE FOR CONTRACTS TO DELIVER CURRENT SERVICES?

Given some of the uncertainties regarding the future of clinical commissioning at the time of the

Pathfinder programme and this feasibility study, it is unclear how well a mutual model would further

enhance SaSH’s ability to renew contracts and commissions it currently holds, as well as pursing new

ones. As with the Foundation Trust status (above), it is suggested that this be reviewed by SaSH as

part of a future review and reflection.

STRATEGIC FIT WITHIN LOCAL AND WIDER CONTEXTS

As highlighted earlier within this document, there is a clear national strategic context and interest in

encouraging the emergence and growth of public sector mutuals. However, it is less clear how this is

reflected within the local context – to date, only 2 of the 101 public sector mutuals are located within

Surrey and Sussex53, and it is likely that the outcomes of the forthcoming national elections will impact

upon the local political interest in seeing more.

At the time of the future revisiting and enacting of this plan, the level of such political interest and

support for mutual would need to be carefully considered in being either an enabling or restrictive

one.

COMMERCIAL CASE (INCLUDING APPRAISAL OF ‘DO NOTHING’ OPTION)

SaSH will have already created a commercial case as part of the process of its application to gain

Foundation Trust status. This approach and framework could be readily repeated by SaSH with little

additional support required from it having previously developed the skills to do so.

53 First Community Health and Care CIC, and Bewbush Nursery

56

INVESTMENT NEEDS AND PROJECTED RETURNS

Part of the initial business case being developed through this initial phase of the plan will need to

include a profiling of any future investment needs that SaSH would incur in relation to transferring

into a mutual model (including transfers of pension liabilities, contract securities, etc.) from coming

out of ‘State ownership’. This development of the commercial case would also help to identify the

extent to which such a need for any additional investment might exist, and the options that exist to

how these finances could be raised within the context of the type of mutual model selected as the

preferred option.

IDENTIFY RISKS, CONTINGENCIES, DEPENDENCIES AND MITIGATIONS TO THREAT OF FAILURE

Through the Pathfinder support, SaSH has already begun to identify and map key risks, contingencies

and dependencies to the pursuit of becoming a mutual and these are detailed earlier in this report in

section 0. However, these would need to be further explored to agreed appropriate mitigation

strategies and approaches to manage them.

Upon completion of these stages, there would be sufficient detail and findings to collate a case that

the Board could consider in deciding whether it would be appropriate for SaSH to subsequently pursue

the next phase of becoming a mutual.

5.3.2 Preparation

Once agreed by the Board, SaSH would need to plan for how the proposed new mutual form will

operate in practice – not just in terms of its governance, but how wider services and finances will be

impacted and subject to change within this new form.

This would take the form of a detailed business plan with supporting financial projections, and these

would be used to support subsequent wider consultations to gain approval and support for the

proposed change to a mutual:

D. Develop five year business plan

Continuing from the initial business case developed in phase 1, a fully detailed 5 year business plan

will be drafted – as well as detailing the operations of the mutuals’ services and governance

arrangements, this will also profile its financial model in light of how investment needs identified will

be met and serviced, and how it will be able to use its status as a mutual in the further enhancement

of services and activities.

A key part of the plan would need to consider and detail measures through which impact and

innovation will be able to be identified and captured as occurring within the new mutual form, (as

these are key political drivers and expectations on the part of wider commissioners and with the

political context). However, some of these issues have already begun to be explored by SaSH through

the Pathfinder feasibility support and so as with elements of phase 1 in this plan, it would have an

initial position from which to build.

The plan will also need to detail how its proposed enacting and the transition in to the mutual form

will be resourced appropriately to ensure that staff are able to be engaged in the process without

disruption or displacement to their ‘day jobs’ – again, within the context of delivery health services

and patient care, this will be a critical success factor as previously identified by SaSH.

57

E. Engagement and consultation

Part of the business plan will also need to profile how SaSH will retain the engagement of current key

internal and external stakeholders through the period of transitioning into a mutual, and how it will

ensure that the associated required resources are able to be secured.

Once completed, this plan will be subject to approval and agreement by the Board and form the basis

of consultations with wider constituencies to elicit and gain the necessary support and approvals

needed to move into a mutual form.

Detail within the plan will also inform the next development phase. It will also allow the Board another

opportunity at which to consider the practical relevance, benefits and implications of moving to a

mutual form, having previously considered the broad arguments to do so, in order to ensure that the

mandating of this progression can be renewed in support of undertaking the next phase.

5.3.3 Transition

F. Development of legal framework

DEVELOPMENT OF PROJECT/IMPLEMENTATION PLAN

Once the necessary due diligence, assurance process and full business plan have been approved, a

detailed transition plan will need to be drawn up and agreed, through which to enact the transfer of

SaSH into the new mutual structure to enable it to be able to deliver the plan and realise its vision.

This will involve a number of distinct elements profiled below in summary:

INCORPORATION OF NEW ENTITY

Dependent upon the identified preferred mutual model, this will entail an application to either

Companies House (Company), the Financial Conduct Authority (Community Benefit Society), CIC

Regulator (Community Interest Company), or the Charity Commission (Charitable Incorporated

organisation).

A key part of this work will also be agreeing and documenting the governance and ownership structure

for the new entity to ensure that it encapsulates and is cable of achieving the main aims and visions

of the new model. The Articles of Association or constitutional documents will be an important aspect

of this work.

‘BUSINESS TRANSFER AGREEMENT’

The Business Transfer Agreement will need to be agreed and negotiated to reflect the agreed financial

and commercial risk apportionment between the parties. This contains all of the provisions regarding

how everything required to deliver the services will be transferred to the new entity. It will cover areas

such as assets to be transferred or licensed, premises arrangements, third party contract novation,

apportionments of risks and liabilities pre- and post-transfer, insurance and NHSLA implications,

warranties and indemnities agreed between the parties, TUPE/Pensions, transfer of records and

sharing of data and other areas such as branding and IPR.

SERVICES AGREEMENTS

Depending upon the Services in question, the legal entity may need to enter into Standard NHS

Contracts for the provision of the services with its NHS Commissioners and so these will also need to

be agreed and negotiated.

58

Subject to existing sub-contractual arrangements that SaSH may hold, and the detail of its intend

operational activities and structures as profiled within its agreed full business plan, it may need to

review existing Service Level Agreements, as well as drawn up additional ones with new partners and

supporters.

SHAREHOLDERS AGREEMENT

Depending upon the final model chosen, e.g. if a joint venture arrangement, it may be necessary to

have an agreement which documents what the shareholders have agreed in relation to the business

of the Company going forward and their respective roles, responsibilities and contributions.

REGULATORY APPROVALS, REGISTRATIONS AND CONSENTS

The new entity would also need to ensure that it had all of its required regulatory approvals,

registrations and consents in place.

G. Resolving TUPE and HR issues

HR will present perhaps the largest and most resource intensive element of the transition into a

mutual, and need to consider a number of specific themes:

MAPPING OF SKILLS NEEDED WITHIN THE NEW MUTUAL STRUCTURE, AND SUBSEQUENT STAFF AND BOARD

DEVELOPMENT PLANS (INCLUDING SUPPORT DURING TRANSITION NEEDED FROM ‘EMOTIONAL IMPACT’)

It cannot be assumed that the new structures and systems being created within the mutual can be

automatically fulfilled amongst existing staff and governance bodies – there needs to a review of the

skills, competencies, and aptitudes that will be needed throughout the new mutual structure. Against

this, SaSH should reflect on its current staffing profiling and plan and enact a programme of training

and skills enhancement as appropriate.

MANAGING CONFLICTS OF INTEREST

(Staff due to transfer shouldn’t be involved in negotiating terms of transfer)

As a new body, all staff will need to be formally transferred into the new mutual. At the point of this

transfer there is the opportunity to review and enact a refreshed set of terms and conditions that may

be felt appropriate within the new structure, its values, and in keeping with the agreed business plan

for it. In keeping with principles of good governance and mitigating any future threat of recrimination

against this process, any staff who are likely to be directly affected by any such proposed changing of

terms should not be directly engaged with the negotiations associated with their agreement.

UNIONS, MEDIA, PROFESSIONAL BODIES

In making sure all staff and wider stakeholders are comfortable and confident about the processes

that the transfer into the new mutual structure will entail, there needs to be a clear and throughout

communications and engagement plan with all external stakeholders.

Details of the communication plans used in the programme are included in section 6.2.

59

TUPE, PENSIONS

In transferring staff into the new mutual, there will need to be appropriate consultations and

representations made to ensure that relevant TUPE legislation is met, and will not subsequently stall

the process from it being discovered that there was a procedural error made in this process. Linked to

this, staff pension programmes and schemes will also need to be transferred, or arrangements made

for them to be retained in their current provision – the cost of the pension liability both at the point

of transfer, and projected liability within the life of the full business plan will be a key influencing factor

as to the viability of the mutual.

REGULATORY COMPLIANCE

As a statutory health body, SaSH is accountable to Monitor with regards to its clinical services, but is

also subject to additional regulatory bodies with regards to other aspects of its operations (public

licensing, pensions authority, HMRC, etc.). All of these agencies will all need to agree to the transfer

of SaSH into the new mutual and so all should be engaged with early in the transfer planning process

to ensure sufficient time to resolve any arising queries or clarifications that they may demand before

agreement is made.

H. Finance, governance and IT systems

BANKING, AUDITORS AND INSURANCE

As part of the transition, all financial services and support will also need to be migrated – discussions

therefore need to be held with SaSH’s bankers, auditors, and insurance agents to ensure that it can

schedule the transfer date in line with the transfer of these services that the new mutual will need to

continue to draw upon as part of its ongoing activities and operations.

FORMALISATION AND CONVENING OF GOVERNING BODY/IES

The exploration stage will have identified a preferred governance structure within the new mutual,

and the HR elements of the transition plan will have subsequently identified and agreed the skills and

competencies that officers within these will need to hold.

As part of ensuring a smooth transition, and that these structures will act as needed from the point of

formal transfer into the new mutual, a series of ‘shadow boards’ with nominated initial officers that

will hold the posts in the new structure should be convened to run in parallel to SaSH’s existing

structures. Board development requirements should be considered as a separate work-stream with a

skills and capability gap assessment undertaken of the new skills required from the Board of a mutual

organisation. Depending on the form of mutual considered, the Governor Development programme

would also need to be refreshed and the membership engagement strategy reviewed.

IT INFRASTRUCTURE

As with its financial services and support, there will need to be a formal a transfer of IT infrastructure

and services into the new mutual. The implications of this will need to be mapped in detail so that it

can be managed to assure that any disruption this will entail can be either mitigated or minimised to

ensure the continuation of services.

Given SaSH’s role as a provider of clinical and health services, this will be a critical aspect of the transfer

in ensuring the continuation of patient care, and the appropriate management of clinical data.

60

FINANCE

The full business plan will have profiled the financial model of the new mutual, and a process of

clarification will be needed to ensure that the assumptions made within this are robust, and that any

additional finance identified as being needed is secured.

Once finalised, this implementation plan will be subject to a final approval by the Board – the final

stage at which the process to becoming a mutual may be halted by its current Governance, should the

preparation of this final stage phase have highlighted concerns that are not felt able to be sufficiently

managed against SaSH’s own critical success factors.

However, following its approval, adoption and enacting, SaSH would then transition into its new

mutual form. At this point of final approval SaSH will also need to develop a consolidation plan as part

of its final phase of transitioning into a mutual.

5.3.4 Consolidation

The final phase of the plan to transition into a mutual concerns the period following the transfer into

the new form. SaSH will need to ensure that it appropriately consolidates itself within this new

structure to best realise its planned benefits and outcomes from doing so.

To this end the consolidation plan, which will have been informed by both the full business plan, and

the implementation plan will be concerned with the following broad themes:

I. DEVELOP MEMBERSHIP

At the point of becoming a mutual, SaSH will have an initial membership defined by its preferred

model and governance structures. However, membership bodies need to actively manage and

develop their memberships to ensure that this key stakeholder group remain fully engaged, and are

also able to be supported as wider services and operating environments change in the future. Failure

to do so would erode this defining feature of the mutual model, and cause weaknesses to emerge

within its wider governance and leadership.

There should therefore be a clear strategy linked to the mutual model adopted as to how its

membership shall be pro-actively supported, remain positively engaged with the governance of the

mutual, and where appropriate, grown.

J. ALIGN MANAGEMENT AND GOVERNANCE PRACTICES

Part of the preparation for transferring into the mutual will have included the modelling of ‘shadow

Boards’ to ensure that the initial post holders within the governance structures are appropriately

skilled and able to enact these roles post-transfer.

Post transfer, these post-holders should be engaged with to ensure that they remain confident and

competent to retain these roles, and be able to fulfil the duties associated with them. Further, given

that for the sake of expediency it is likely that these initial post-holders will not have been fully or

formally appointed by the future membership, their appointments should be subject to a ratification

as part of the wider membership development strategy and plans.

K. ITERATE REPORTING FRAMEWORKS

As part of the agreements with external stakeholders and relevant regulatory bodies during the

transition process, a schedule of revised reporting and returns will have been agreed with each.

61

Within this initial period (and final phase of the transition plan), the new mutual should review and

reflect on how well these reports and returns are not only able to be made within its new structure,

but also engage with these stakeholders to ensure their satisfaction with the new arrangements now

that they are being enacted to ensure their future and ongoing support for the mutual.

HR STRATEGY

Within the transition plan, a revised HR strategy will have been explored and agreed for the new

mutual to adopt. As with the other aspects profiled above, this should be reviewed and reflected upon

during the initial period to ensure that it is delivering the anticipated and needed outcomes in support

of the new mutual.

5.4 FINANCES Through the creation of the business case and the subsequent 5 year business plan, the financial

model of the new mutual will become apparent, as will the extent of any additional investment it will

need to secure to realise its ambitions and vision.

Additionally, there are also various national and global social investors with an interest in supporting

public sector mutuals. However, these should be approached on the basis that the mutuals model will

be capable of generate sufficient surpluses and returns to service these investment.

However, the overall costs associated with pursuing and transferring into a mutual model at this time

cannot be forecast with a high degree of certainty – this is due to a number of factors that need to be

clarified:

the identification of a preferred mutual model

potential legislative changes with regards to the mutuals agenda that may have implications

with regards to fees and costs

the extent of any payment terms agreed within existing SaSH contracts that would need to be

enacted in order for them to be able to be transferred into the new mutual

that if it was to pursue a mutual model, SaSH would be a vanguard in doing so from no other

acute Trusts, or Foundation Trusts having done so54

Further funds for development of the mutual model may become available from the Cabinet Office.

An application can be made through the Mutuals Information Service: https://www.gov.uk/start-a-

public-service-mutual-the-process

5.5 STAKEHOLDER ENGAGEMENT PLAN A thorough communications strategy to negotiate stakeholder relationships effectively, and managing

staff expectations throughout a potentially lengthy and inconvenient process will be crucial to the

lasting success of the project.

Mutualisation requires a rewriting of the ‘social contract’ between employees and employer, and so

staff relationships need to be handled particularly carefully throughout. For this not only must the

vision be clear and shared amongst staff, but the transition itself must be professional an efficient,

embodying the principles of the new organization

54 To the best knowledge of the project support team at the time of writing



62

5.5.1 Exploration and development

During the exploration phase, the focus has been on internal stakeholders. The leadership team and

staff representatives have been engaged primarily through workshops. All staff were made aware of

the pathfinder program and given access to materials on the intranet to get further understanding of

the project. They have also been able to contribute to the discussion through a dedicated email

address.

Before this phase can be complete, external stakeholder groups (patients, public and government)

should also be consulted in small/focused fora to explain the options under consideration, the

implications of these and obtain high-level feedback. To prevent the messages becoming confused, it

will be necessary in the case of SaSH to facilitate these discussions after a response to the Foundation

Trust application has been received.

5.5.2 Preparation phase

Staff interactions must become more focused, and are primarily to align the organizational

goals and to set expectations for the coming program.

Consider use of existing staff engagement programmes such as SaSH+

Review existing staff voice mechanisms through membership of FT and internal processes

More comprehensive engagement with the wider patient body and the public as well as

commissioners, local politicians and union representatives. The Trust’s members must be

consulted.

Debates and objections should be dealt with during this period.

5.5.3 Transition

Interactions focused around achievement of specific objectives

Administrative burden for TUPE and financial transition will require dedicated resources to

handle issues

5.5.4 Consolidation

differentiation in messages to separate constituencies of membership to be agreed to

encourage their continued engagement, but also consistency with other communications

initial outcomes of new governance structures to be identified to further encourage

engagement by membership groups through maintaining interest, awareness and

commitment of their role(s) within these

focus on achievements against key critical success factors identified in 3.1.3, regularly

reported to sustain commitment to mutual model amongst all stakeholders

63

6 APPENDICES

6.1 SUMMARY OF PROJECT ACTIVITIES

13th January 2015: Project kick-off meeting

20th January 2015: Panel discussion with other Pathfinder Trusts

27th January 2015: Workshop 1 on principles and values of mutualisation

3rd February 2015: Workshop 2 on principles and values of mutualisation

17th February 2015: Panel discussion with other Pathfinder Trusts

23rd February 2015: Discussion group on communications and next steps plan

27th February 2015: Workshop 3 on development of SaSH vision for mutual model

3rd March 2015: Focus group on membership engagement strategy

11th March 2015: Discussion sessions on incentives and reward for SaSH staff

11th March 2015: Workshop 4 on draft report

27th March 2015: Workshop 5 on next steps for SaSH

64

6.2 SUMMARY OF SASH MUTUALS COMMUNICATIONS Mutuals in Health - Pathfinder programme

Version 1.4 - RA - 9th Febuary 2015

Objectives

1

2

3

Methods

In person Distributed Timing

Stakeholder

Engageme

nt level Approach and actions

One-to

-one

Invite

mee

tings &

wo

rkshops

Dep

artmen

tal

mee

tings

Walk &

talk

Open

mee

tings

Clo

sed fora

Personal

written

/em

ail

correspo

nden

Email

newsletter

Printed

repo

rts /

newsletters

Intranet page

Web

site

Social m

edia

Help line /

email /p

ostal

address

Lead

05-Jan-15

12-Jan-15

19-Jan-15

26-Jan-15

02-Feb-15

09-Feb-15

16-Feb-15

23-Feb-15

02-Mar-15

09-Mar-15

16-Mar-15

23-Mar-15

30-Mar-15

06-Apr-15

13-Apr-15

20-Apr-15

27-Apr-15

04-May-15

04-May-15

Public / patients Patients -

Patient engagement not relevant during pilot stage.

Public members (5,000) can be involved at next stage.

PALS team briefed to handle and refer questions.

Y LW

Community groups

Health and wellbeing boards not considered relevant at

this stage, no proactive communications. Simplify

message during FT application.

Y LW

Press L

Involvment made public with release of board papers

(January). Simplify explicit messaging during FT

application.

Reactive strategy if press enquiries come in.

Y LW

Internal

Staff communications must reach all groups and to

include:

1. Create single internal reference point on trust intranet

to disseminate correct information and reduce

rumours/concerns.

Y LW

2. Inclusion in weekly all staff briefing (electronic)Y LW

3. Blog post from CEO ('Michael's Message') Y Y MW

4. Agenda item in all staff meeting and senior leaderss'

briefingsY SJ

5. Focus groups in Feb & Mar Y SB

Clinical staff

(specifically)H

Included in specific focus groupsY Y Y Y

Unions H

Unions updated on situation 20th Jan. [TBC - update

from Michael].

Invitation to workshops

Y Y LW

Leadership team HAgenda item at senior leaders' meetings, involvement in

workshops, 1 on 1 meetingsY Y Y Y

Board HAgenda item at January and February board meetings.

CEO verbal update.Y SJ

Wider HC

economyOther acute providers L

Communications through CEO at 'Other Accountable

Officer' meetingsY Y MW

Commissioners L Email from CEO to make aware of project. Y LW

GPs - None. n/a

Other providers (MHT,

private)L

MHT - Communications through CEO at 'Other

Accountable Officer' meetings.

Private provider - none

Y Y

LW

Other Gov't

stakeholdersCouncils M

Inform with a summary of the project and its objectives.Y

LW

MP(s) MInform with a summary of the project and its objectives

YLW

Department of Health HThree pathfinder workshops, fortnightly catch up calls &

project status updatesY Y Y JK, SJ

Monitor & TDA LMonitor and TDA have been made aware.

Y JK

Meaningful discussions with key stakeholders on the pros and cons of mutualisation

Distribute accurate information on mutualisation to inform discussions and engage the wider staff body for

their feedback

Prevent spread of misinformation regarding project

All staff H

Comms strategy - pilot stage

65

6.3 DETAILS OF REWARDS & INCENTIVES SESSIONS On the 11th of March, Sarah Billiald of Collaborate led five one hour workshops with staff from across

SASH on one day to explore levels of engagement, what currently motivates and demotivates them

and what rewards/incentives might look like in the future. Each workshop was in two halves: the

participants’ views on the influence various parties could have on SaSH, and key motivating and

demotivating factors.

6.3.1 Influence on SaSH

We asked individuals to self-assess their answers on a sliding scale (from "yes always" to "no never")

to four questions:

1) I feel I have the opportunity to input my views/ideas into SASH

2) I feel my (and my teams) views are listened to and acted upon by SASH

3) I feel that patient views are sought, heard and acted upon

4) I feel I can influence decisions about the long term future of SASH

Overall most were very positive about the first question, recognising this was clearly a priority for

SASH however there was more of a mixed picture in response to listening and acting upon those views

with several participants saying that their line manager listened but then the organisation didn't act,

or than more broadly not only were views not acted upon but there was no feedback as to what had

happened or why things had not been taken forward. HQ staff felt the hierarchy and clinical /

managerial divide got in the way of good ideas being heard and taken forward, whereas for those

working directly with patients the quality of their line manager was the key differential in whether

they were happy with the feedback loop. Several felt that good ideas were not heard because of an

organisational resistance to change and that recent engagement activity was a veneer or after the fact

rather than genuine consultation.

In regards to the third question there was a marked

difference between HQ and administrative staff and those

working with patients: the two focus groups comprised of

corporate and secretarial staff felt strongly that patient

views were always sought, heard and acted upon, whereas

the two groups of therapists and nurses were not quite as

positive putting their assessment in the middle of the

spectrum, saying they were sometimes heard but more in

reaction to complaints than routine feedback or

engagement. There was a strong feeling of missed

opportunity here particularly from the therapists who had a wealth of knowledge from long periods

of time with patients which was currently untapped but also that they were preventing complaints

escalating because of their pastoral role.

66

The fourth question had most consistency of response

with all bar one respondent saying they had no influence

in decisions about the long term future of SASH and that

there was no forum for this type of conversation although

there was a strong appetite for these longer term strategic

conversations from all attendees (not always the case in

organisations) and a desire to create a safe space to have

a more challenging dialogue about the future.

6.3.2 Incentives and demotivation

The second half of the workshop explored three themes:

- What one thing currently incentivises you to deliver the best outcomes?

- What one thing currently demotivates you at work?

- What two things would incentivise you personally in the future?

We asked people to consider these because understanding what currently motivates people (and

protecting it) is often more useful than developing a wish list which people struggle with as they can't

see beyond the existing constraints/package.

KEY MOTIVATORS ALL CENTRED AROUND THREE MAJOR THEMES:

1) Job satisfaction due to knowing I'm making a real difference by fulfilling my role (to patients

and/or colleagues),

2) Strong team ethos - particularly acute with operational teams - there maybe something of

Leicester's autonomous, incentivise teams worth exploring here, so strong was the sense of

team

3) Good work/life balance

DEMOTIVATING FACTORS CLUSTERED AROUND THE FOLLOWING FIVE THEMES:

1) Not feeling valued or supported - particularly due to a lack of feedback (more emphasis on

this from corporate/secretarial staff)

2) Lack of capacity to do job or staff shortages (only an issue for operational staff)

3) Barriers to doing a good job e.g. things not working, people passing the buck, poor processes

and systems, too much paperwork.

4) Negativity from other staff particularly to change

5) Poor patient outcomes

IDEAS FOR INCENTIVES

Looking to the future people struggled with the concept of thinking flexibly about what might

incentivise them, with most operational staff purely wanting to 'fix' the demotivating things for

example through more staff, increased resources, better team-working, more supportive

managers. However there were some other ideas including:

a) Personalised recognition and a more well developed feedback loop - trite as it may sound this

came up frequently as a quick fix, both corporate communications but also

recognition/acknowledgement from both managers and the organisation of a job well

done. Thinking creatively about how this might be done would be an obvious next step - there

was a plea for a more positive feel to this (more praise, less problems and a more positive

67

culture) so using techniques such as appreciative enquiry or a strengths/asset based approach

could work well.

b) More flexible rewards package e.g. ability to buy/sell annual leave, be paid for overtime rather

than taking ‘Time Off In Lieu’ (TOIL) which never happens, and preserving work/life balance

options.

c) Social, health and well-being space and facilities: good feedback on the recent wellbeing event

but a desire that this is more routine and to explore longer term on site facilities such as

classes, gyms and a social space to allow people to enhance their own well-being but surround

by colleagues as friends. Worth considering as part of health campus concept.

The workshops had variable attendance and, in future, we would recommend better advance

communication of the date/issues and taking the questions out to people in the hospital rather than

asking them to come to HQ.

6.4 BENEFICIARY TRUSTS IN PATHFINDER PROGRAMME

Trust Type Notes

Norfolk and Norwich University Hospitals NHS Foundation Trust

Acute Left programme due to operational pressures

Oxleas NHS Foundation Trust Mental health and learning disability

Surrey and Sussex Healthcare NHS Trust

Acute

Tameside Hospital NHS Foundation Trust

Acute Investigating mutualising cardiology pathway

Cheshire and Wirral Partnership NHS Foundation Trust

Mental health and learning disability

Moorfields Eye Hospital NHS Foundation Trust

Specialist Investigating whole Trust mutualisation and senior staff mutualisation

Norfolk and Suffolk NHS Foundation Trust

Mental health and learning disability

Left programme due to operational pressures

University Hospitals of Leicester NHS Trust

Acute Investigating Automated Incentivised Teams as well as mutualisation of the whole Trust

Liverpool Heart and Chest Hospital NHS Foundation Trust

Acute Specialist

68

6.5 GOVERNANCE RATIONALE FOR FOUNDATION TRUST See separate document.

6.6 SASH PATHFINDER APPLICATION See separate document.

2014 National NHS staff survey

Brief summary of results from Surrey And Sussex HealthcareNHS Trust

Table of Contents

1: Introduction to this report 3

2: Overall indicator of staff engagement for Surrey And Sussex Healthcare NHS Trust 5

3: Summary of 2014 Key Findings for Surrey And Sussex Healthcare NHS Trust 6

4: Full description of 2014 Key Findings for Surrey And Sussex Healthcare NHS Trust(including comparisons with the trust’s 2013 survey and with other acute trusts)

13

2

1. Introduction to this report

This report presents the findings of the 2014 national NHS staff survey conducted in Surrey AndSussex Healthcare NHS Trust.

In section 2 of this report, we present an overall indicator of staff engagement. Full details of howthis indicator was created can be found in the document Making sense of your staff surveydata, which can be downloaded from www.nhsstaffsurveys.com.

In sections 3 and 4 of this report, the findings of the questionnaire have been summarised andpresented in the form of 29 Key Findings.

These sections of the report have been structured around 4 of the seven pledges to staff in theNHS Constitution which was published in March 2013(http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution) plus two additionalthemes:

• Staff Pledge 1: To provide all staff with clear roles and responsibilities and rewarding jobs forteams and individuals that make a difference to patients, their families and carers andcommunities.

• Staff Pledge 2: To provide all staff with personal development, access to appropriateeducation and training for their jobs, and line management support to enable them to fulfiltheir potential.

• Staff Pledge 3: To provide support and opportunities for staff to maintain their health,well-being and safety.

• Staff Pledge 4: To engage staff in decisions that affect them and the services they provide,individually, through representative organisations and through local partnership workingarrangements. All staff will be empowered to put forward ways to deliver better and saferservices for patients and their families.

• Additional theme: Staff satisfaction

• Additional theme: Equality and diversity

• Additional theme: Patient experience measures

Please note that the NHS pledges were amended in 2014, however the report has beenstructured around 4 of the pledges which have been maintained since 2009. For moreinformation regarding this please see the “Making Sense of Your Staff Survey Data” document.

As in previous years, there are two types of Key Finding:

- percentage scores, i.e. percentage of staff giving a particular response to one, or aseries of, survey questions

- scale summary scores, calculated by converting staff responses to particularquestions into scores. For each of these scale summary scores, the minimum scoreis always 1 and the maximum score is 5

A longer and more detailed report of the 2014 survey results for Surrey And Sussex HealthcareNHS Trust can be downloaded from: www.nhsstaffsurveys.com. This report provides detailedbreakdowns of the Key Finding scores by directorate, occupational groups and demographicgroups, and details of each question included in the core questionnaire.

3

http://www.nhsstaffsurveys.com

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution

http://www.nhsstaffsurveys.com

Your Organisation

The scores presented below are un-weighted question level scores for questions Q12a - 12dand the weighted score for Key Finding 24. The percentages for Q12a – Q12d are created bycombining the responses for those who “Agree” and “Strongly Agree” compared to the totalnumber of staff that responded to the question.

The Q12d score is related to CQUIN payments for Acute trusts participating in the National NHSStaff Survey. 2013/2014 guidance on CQUIN payments can be found via the following linkhttps://www.supply2health.nhs.uk/eContracts/Documents/cquin-guidance.pdf.

Q12a, Q12c and Q12d feed into Key Finding 24 “Staff recommendation of the trust as a place towork or receive treatment”.

Your Trustin 2014

Average(median) foracute trusts

Your Trustin 2013

Q12a "Care of patients / service users is my organisation'stop priority"

80 70 74

Q12b "My organisation acts on concerns raised by patients /service users"

81 71 74

Q12c "I would recommend my organisation as a place towork"

70 58 61

Q12d "If a friend or relative needed treatment, I would behappy with the standard of care provided by thisorganisation"

77 65 68

KF24. Staff recommendation of the trust as a place to work orreceive treatment (Q12a, 12c-d)

3.93 3.67 3.74

4

2. Overall indicator of staff engagement for Surrey And Sussex Healthcare NHSTrust

The figure below shows how Surrey And Sussex Healthcare NHS Trust compares with other acutetrusts on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicatingthat staff are highly engaged. The trust's score of 3.86 was in the highest (best) 20% whencompared with trusts of a similar type.

OVERALL STAFF ENGAGEMENT

This overall indicator of staff engagement has been calculated using the questions that make upKey Findings 22, 24 and 25. These Key Findings relate to the following aspects of staffengagement: staff members’ perceived ability to contribute to improvements at work (Key Finding22); their willingness to recommend the trust as a place to work or receive treatment (Key Finding24); and the extent to which they feel motivated and engaged with their work (Key Finding 25).

The table below shows how Surrey And Sussex Healthcare NHS Trust compares with other acutetrusts on each of the sub-dimensions of staff engagement, and whether there has been a changesince the 2013 survey.

Change since 2013 survey Ranking, compared withall acute trusts

OVERALL STAFF ENGAGEMENT No change Highest (best) 20%

KF22. Staff ability to contribute towardsimprovements at work

(the extent to which staff are able to make suggestions toimprove the work of their team, have frequent opportunitiesto show initiative in their role, and are able to makeimprovements at work.)

No change Above (better than) average

KF24. Staff recommendation of the trust as a placeto work or receive treatment

(the extent to which staff think care of patients/service usersis the Trust’s top priority, would recommend their Trust toothers as a place to work, and would be happy with thestandard of care provided by the Trust if a friend or relativeneeded treatment.)

Increase (better than 13) Highest (best) 20%

KF25. Staff motivation at work

(the extent to which they look forward to going to work, andare enthusiastic about and absorbed in their jobs.)

No change Highest (best) 20%

Full details of how the overall indicator of staff engagement was created can be found in thedocument Making sense of your staff survey data.

5

3. Summary of 2014 Key Findings for Surrey And Sussex Healthcare NHS Trust

3.1 Top and Bottom Ranking Scores

This page highlights the five Key Findings for which Surrey And Sussex Healthcare NHS Trustcompares most favourably with other acute trusts in England.

TOP FIVE RANKING SCORES

KF21. Percentage of staff reporting good communication between senior managementand staff

KF11. Percentage of staff suffering work-related stress in last 12 months

KF9. Support from immediate managers

KF29. Percentage of staff agreeing that feedback from patients/service users is used tomake informed desisions in their directorate/department

KF23. Staff job satisfaction

6

For each of the 29 Key Findings, the acute trusts in England were placed in order from 1 (the top ranking score) to138 (the bottom ranking score). Surrey And Sussex Healthcare NHS Trust’s five lowest ranking scores are presentedhere, i.e. those for which the trust’s Key Finding score is ranked closest to 138. Further details about this can be foundin the document Making sense of your staff survey data.

This page highlights the five Key Findings for which Surrey And Sussex Healthcare NHS Trustcompares least favourably with other acute trusts in England. It is suggested that these areasmight be seen as a starting point for local action to improve as an employer.

BOTTOM FIVE RANKING SCORES

! KF7. Percentage of staff appraised in last 12 months

! KF16. Percentage of staff experiencing physical violence from patients, relatives or thepublic in last 12 months

! KF18. Percentage of staff experiencing harassment, bullying or abuse from patients,relatives or the public in last 12 months

! KF5. Percentage of staff working extra hours

! KF17. Percentage of staff experiencing physical violence from staff in last 12 months

7

Because the Key Findings vary considerably in terms of subject matter and format (e.g. some are percentage scores, othersare scale scores), a straightforward comparison of score changes is not the appropriate way to establish which Key Findingshave improved the most. Rather, the extent of 10-11 change for each Key Finding has been measured in relation to thenational variation for that Key Finding. Further details about this can be found in the document Making sense of your staffsurvey data.

3.2 Largest Local Changes since the 2013 Survey

This page highlights the four Key Findings where staff experiences have improved the most atSurrey And Sussex Healthcare NHS Trust since the 2013 survey.

WHERE STAFF EXPERIENCE HAS IMPROVED

KF14. Fairness and effectiveness of incident reporting procedures

KF21. Percentage of staff reporting good communication between senior managementand staff

KF24. Staff recommendation of the trust as a place to work or receive treatment

KF26. Percentage of staff having equality and diversity training in last 12 months

8

3.2. Summary of all Key Findings for Surrey And Sussex Healthcare NHS Trust

KEY

Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the2013 survey.Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the2013 survey.Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2013survey.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asterix andin italics, the lower the score the better.

Change since 2013 survey

9


KEY

Green = Positive finding, e.g. better than average. If a is shown the score is in the best 20% of acute trustsRed = Negative finding, e.g. worse than avearge. If a ! is shown the score is in the worst 20% of acute trusts.Grey = Average.For most of the Key Finding scores in this table, the higher the score the better. However, there are some scoresfor which a high score would represent a negative finding. For these scores, which are marked with an asterix andin italics, the lower the score the better.

Comparison with all acute trusts in 2014

10


KEY

Green = Positive finding, e.g. in the best 20% of acute trusts, better than average, better than 2013.

! Red = Negative finding, e.g. in the worst 20% of acute trusts, worse than average, worse than 2013.'Change since 2013 survey' indicates whether there has been a statistically significant change in the KeyFinding since the 2013 survey.

-- Because of changes to the format of the survey questions this year, comparisons with the 2013 score are notpossible.

* For most of the Key Finding scores in this table, the higher the score the better. However, there are somescores for which a high score would represent a negative finding. For these scores, which are marked with anasterix and in italics, the lower the score the better.

Change since 2013 survey Ranking, compared withall acute trusts in 2014

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

KF1. % feeling satisfied with the quality of work andpatient care they are able to deliver


KF2. % agreeing that their role makes a difference topatients


* KF3. Work pressure felt by staff No change Below (better than) average

KF4. Effective team working No change Highest (best) 20%

* KF5. % working extra hours No change ! Above (worse than) average

STAFF PLEDGE 2: To provide all staff with personal development, access to appropriate education andtraining for their jobs, and line management support to enable them to fulfil their potential.

KF6. % receiving job-relevant training, learning ordevelopment in last 12 mths


KF7. % appraised in last 12 mths No change ! Lowest (worst) 20%

KF8. % having well structured appraisals in last 12mths


KF9. Support from immediate managers No change Highest (best) 20%

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

Occupational health and safety

KF10. % receiving health and safety training in last 12mths

No change Average

* KF11. % suffering work-related stress in last 12 mths No change Lowest (best) 20%

Errors and incidents

* KF12. % witnessing potentially harmful errors, nearmisses or incidents in last mth

No change Average

KF13. % reporting errors, near misses or incidentswitnessed in the last mth


KF14. Fairness and effectiveness of incident reportingprocedures


KF15. % agreeing that they would feel secure raisingconcerns about unsafe clinical practice -- Above (better than) average

11

3.3. Summary of all Key Findings for Surrey And Sussex Healthcare NHS Trust(cont)

Change since 2013 survey Ranking, compared withall acute trusts in 2014

Violence and harassment

* KF16. % experiencing physical violence from patients,relatives or the public in last 12 mths

No change ! Highest (worst) 20%

* KF17. % experiencing physical violence from staff inlast 12 mths

No change ! Above (worse than) average

* KF18. % experiencing harassment, bullying or abusefrom patients, relatives or the public in last 12 mths

No change ! Above (worse than) average

* KF19. % experiencing harassment, bullying or abusefrom staff in last 12 mths

No change Lowest (best) 20%

Health and well-being

* KF20. % feeling pressure in last 3 mths to attend workwhen feeling unwell

No change Lowest (best) 20%

STAFF PLEDGE 4: To engage staff in decisions that affect them, the services they provide and empowerthem to put forward ways to deliver better and safer services.

KF21. % reporting good communication between seniormanagement and staff


KF22. % able to contribute towards improvements atwork


ADDITIONAL THEME: Staff satisfaction

KF23. Staff job satisfaction No change Highest (best) 20%

KF24. Staff recommendation of the trust as a place towork or receive treatment


KF25. Staff motivation at work No change Highest (best) 20%

ADDITIONAL THEME: Equality and diversity

KF26. % having equality and diversity training in last 12mths

Increase (better than 13) Above (better than) average

KF27. % believing the trust provides equal opportunitiesfor career progression or promotion


* KF28. % experiencing discrimination at work in last 12mths

No change Average

ADDITIONAL THEME: Patient experience measures

Patient/Service user experience Feedback

KF29. % agreeing feedback from patients/service usersis used to make informed decisions in theirdirectorate/deparment

-- Highest (best) 20%

12

1Questionnaires were sent to all 3337 staff eligible to receive the survey. This includes only staff employed directly by thetrust (i.e. excluding staff working for external contractors). It excludes bank staff unless they are also employed directlyelsewhere in the trust. When calculating the response rate, questionnaires could only be counted if they were receivedwith their ID number intact, by the closing date.

4. Key Findings for Surrey And Sussex Healthcare NHS Trust

1866 staff at Surrey And Sussex Healthcare NHS Trust took part in this survey. This is aresponse rate of 56%1 which is in the highest 20% of acute trusts in England, and compares witha response rate of 68% in this trust in the 2013 survey.

This section presents each of the 29 Key Findings, using data from the trust's 2014 survey, andcompares these to other acute trusts in England and to the trust's performance in the 2013survey. The findings are arranged under six headings – the four staff pledges from the NHSConstitution, and the two additional themes of staff satisfaction and equality and diversity.

Positive findings are indicated with a green arrow (e.g. where the trust is in the best 20% oftrusts, or where the score has improved since 2013). Negative findings are highlighted with a redarrow (e.g. where the trust’s score is in the worst 20% of trusts, or where the score is not asgood as 2013). An equals sign indicates that there has been no change.

STAFF PLEDGE 1: To provide all staff with clear roles, responsibilities andrewarding jobs.

KEY FINDING 1. Percentage of staff feeling satisfied with the quality of work and patientcare they are able to deliver

KEY FINDING 2. Percentage of staff agreeing that their role makes a difference to patients

13

KEY FINDING 3. Work pressure felt by staff

KEY FINDING 4. Effective team working

KEY FINDING 5. Percentage of staff working extra hours

STAFF PLEDGE 2: To provide all staff with personal development, access toappropriate education and training for their jobs, and line management support toenable them to fulfil their potential.

KEY FINDING 6. Percentage of staff receiving job-relevant training, learning ordevelopment in last 12 months

14

KEY FINDING 7. Percentage of staff appraised in last 12 months

KEY FINDING 8. Percentage of staff having well structured appraisals in last 12 months

KEY FINDING 9. Support from immediate managers

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

Occupational health and safety

KEY FINDING 10. Percentage of staff receiving health and safety training in last 12months

15

KEY FINDING 11. Percentage of staff suffering work-related stress in last 12 months

Errors and incidents

KEY FINDING 12. Percentage of staff witnessing potentially harmful errors, near missesor incidents in last month

KEY FINDING 13. Percentage of staff reporting errors, near misses or incidents witnessedin the last month

KEY FINDING 14. Fairness and effectiveness of incident reporting procedures

16

KEY FINDING 15. Percentage of staff agreeing that they would feel secure raisingconcerns about unsafe clinical practice

Violence and harassment

KEY FINDING 16. Percentage of staff experiencing physical violence from patients,relatives or the public in last 12 months

KEY FINDING 17. Percentage of staff experiencing physical violence from staff in last 12months

KEY FINDING 18. Percentage of staff experiencing harassment, bullying or abuse frompatients, relatives or the public in last 12 months

17

KEY FINDING 19. Percentage of staff experiencing harassment, bullying or abuse fromstaff in last 12 months

Health and well-being

KEY FINDING 20. Percentage of staff feeling pressure in last 3 months to attend workwhen feeling unwell

STAFF PLEDGE 4: To engage staff in decisions that affect them, the servicesthey provide and empower them to put forward ways to deliver better and saferservices.

KEY FINDING 21. Percentage of staff reporting good communication between seniormanagement and staff

KEY FINDING 22. Percentage of staff able to contribute towards improvements at work

18

ADDITIONAL THEME: Staff satisfaction

KEY FINDING 23. Staff job satisfaction

KEY FINDING 24. Staff recommendation of the trust as a place to work or receivetreatment

KEY FINDING 25. Staff motivation at work

ADDITIONAL THEME: Equality and diversity

KEY FINDING 26. Percentage of staff having equality and diversity training in last 12months

19

KEY FINDING 27. Percentage of staff believing the trust provides equal opportunities forcareer progression or promotion

KEY FINDING 28. Percentage of staff experiencing discrimination at work in last 12months

ADDITIONAL THEME: Patient experience measures

Patient/Service user experience Feedback

KEY FINDING 29. Percentage of staff agreeing that feedback from patients/service usersis used to make informed desisions in their directorate/department

20

Minutes of the Finance and Workforce Committee

Held on 24 February 2015 at 8.30am

In AD77, East Surrey Hospital, Redhill

PART 1

Present

Alan Hall

Paul Biddle

Paul Simpson

Ian Mackenzie

Gillian Francis-Musanu

Non-Executive Director (Chair)

Non-Executive Director

Chief Finance Officer

Director of Information and Facilities

Director of Corporate Affairs

In attendance

Yvette Robbins

Lorraine Clegg

Peter Burnett

Janet Miller (part meeting)

Bill Kilvington (part meeting)

Phil Stone (part meeting)

Catriona Tait

Deputy Trust Chair

Deputy Chief Finance Officer

Associate Director of Finance

Deputy Director of Human Resources

Associate Director of Operations

Medical Records Manager

Head of SLR & Minute Taker

1 WELCOME AND APOLOGIES FOR ABSENCE

Apologies:

Apologies were received from Richard Durban (Non-Executive Director), Fiona Allsop (Chief Nurse),

Paul Bostock (Chief Operating Officer) and Yvonne Parker (Director of Human Resources).

Declarations of Interest: There were no declarations of interest.

2 MINUTES AND ACTIONS OF THE PREVIOUS MEETING

The minutes of the 27th

January 2015 meeting were approved with the following amendments:

- Page 4 para. 4 should read “Alan Hall questioned whether a 15% turnover was sustainable and

should the Trust be more rigorous about resourcing when approving business cases if we

cannot recruit the nursing staff.”

- Page 5 EPR Contract Update para. 2 should read “Richard Durban asked that as the FBC agreed

a like for like replacement this would suggest that the first opportunity for quantifiable benefits

would be between September and December 2015. Ian Mackenzie replied that was correct.

Review of Actions

The action tracker was presented and noted that the items would be discussed within the presented

papers.

3 BUSINESS CASE INVESTMENT

McMillan Information Centre FBC

Bill Kilvington presented the Full Business case for the McMillan Cancer Information Centre for the

Committees approval. He highlighted that the project has been out to tender and prices have come

back higher than the pre-tender estimate, however the optimism bias included in the Outline Business

Case (OBC) means that the total funding envelope is not exceeded. The total capital cost (using the

tender process) is expected to be £1.95m and includes a 10% contingency. Of this, £1.50m is being

2

funded by Macmillan and £0.45m by the Trust.

Alan Hall asked about the fundraising that McMillan are doing to raise the funds for the project. Bill

Kilvington replied that the fundraising has started and goes on to February 2016. The construction of

the centre will run from March to October 2015 with the building due to open in November 2015.

Yvette Robbins asked what would happen if the money was not raised. Ian Mackenzie advised that

the risk sits with McMillan and that the project will be completed before the fundraising ends.

Alan Hall queried what future obligations the trust would have for the project. Bill Kilvington replied

that the centre manager will be funded by McMillan for the first two and half years of the centre after

which the manager will be funded by the Trust. The Trust will also be responsible for the cleaning of

the centre.

Yvette Robbins asked if any of the services provided in the centre will be commissioned. Bill Kilvington

advised that they will not initially, with the centre providing value added services to the Trust, although

other services may develop.

The Committee approved the McMillan Information Centre Full Business Case.

4 BUSINESS PLANNING

Communication Strategy and Annual Plan

Action: This will be presented to the April FWC – Gillian Francis-Musanu

Foundation Trust Update

Gillian Francis-Musanu gave a verbal update to the Committee on the Trust’s Foundation Trust

application. The Monitor pre-assessment did not raise any concerns informally and we are waiting for

communication on our progress to the next stage. Gillian Francis-Musanu advised that the Foundation

Trust membership has reached 9988 members but we cannot hold our Governor elections until we are

in the Monitor assessment phase.

5 FINANCE

Financial Performance M10 and CIP Update

Paul Simpson presented the M10 Finance Report and CIP Update. The following were highlights:

• The Trust is on plan for M10 2014/15, with a £1.9m surplus year to date (taking into account

accruals for non-recurrent income).

• The risks forecast has been reduced

• Cash is being managed and the Trust is applying for a temporary borrowing loan, repayable by

the end of March 15, due to CCG non-payment of activity income.

• East Surrey CCG is challenging £3.5m of activity which has been added as a risk to the risk annex

• January was not a good month for activity as Electives were again reduced and February is a

short month.

3

Alan Hall asked if the CIP £8.5m achievement includes £5m of non-recurrent CIPs. Lorraine Clegg

stated that we are not assuming that the non-payment of fines is non-recurrent as we would expect to

achieve this again next year.

Action: Include monthly CIP achievement as well as YTD achievement in CIP report – Paul Simpson

6

WORKFORCE AND ORGANISATIONAL DEVELOPMENT

Workforce & Organisational Development Report M10

Janet Miller presented the M10 Workforce and Organisational Development Report and highlighted

the actions from the last meeting:

- Surgery are working with HR on vacancy data, they have 19 nurses and 12 HCAs under offer and

a further 18 vacancies advertised. That plus sickness, high agency and workload pressures

have led to lower appraisals and statutory training.

Janet Miller advised the Committee that the biggest vacancy gaps are in Theatres which is a hard area

to recruit staff into. An increase in budget has made the position worse. It was agreed by the

Committee that this would be discussed at the next workforce committee and an update would come

to the next meeting.

Action: Surgery workforce issues to be discussed at the Workforce Committee and an update to the

March FWC – Yvonne Parker

Janet Miller then updated the Committee on appraisals. The Trust is building up a values based

appraisal system alongside the values based recruitment, and is currently working on the paperwork

after which all staff will be appraised by the summer based on a cascade of the Trust objectives.

Yvette Robbins asked what staff group currently had values based recruitment. Janet Miller replied

that Nurses and HCAs already use it and it is being rolled out the Medical Staff. Janet Miller advised

the Committee that the Executive team meeting on Wednesday 25 March will discuss the new

appraisal process which is for Agenda for Change staff but the process does not currently include

Executives or Medical Staff. Janet Miller then advised the Committee that a risk was being added to

the risk register around sickness absence. Alan Hall asked if it would include mitigations of the risk and

Janet Miller confirmed it would include a treatment plan and mitigations.

Action: The Sickness absence risk and mitigations to be presented and reviewed at the March meeting

– Yvonne Parker

Ian Mackenzie asked if the Trust holds local recruitment days for nurses as he had anecdotal evidence

that this had worked at other local Trusts. Janet Miller replied that the divisions here had advised that

they did not get the return for the investment of time.

7 CAPITAL AND ESTATES

Capital & Estates Report M10

Ian Mackenzie presented the Capital & Estates M10 report. He highlighted the following from the

report:

- the Committee that the second additional ward, Tilgate Annex, would open next week after

which AMU annex would close and the Cardiology build would continue.

4

- EPR is going well and is on track.

Yvette Robbins asked about whether any of the delays to the Theatre project have been caused by the

Trust. Ian Mackenzie confirmed that some of the delays are due to work being paused due to activity

in the Theatres.

8 IT

IT Report M10

Ian Mackenzie presented the IT report and the Committee accepted it as read.

9 GENERAL

Action: The Internal Control Framework to be presented to the April 15 meeting – Richard Durban /

Paul Simpson

There was no any other business.

Date of next meeting

Tuesday 24th

March 2015 11am – 1pm – Room 1, PGEC

SQC Minutes 5th February 2015

Page 1 of 10

Safety & Quality Committee

Thursday 5th February 2015 14.00 - 16.00 AD77 Trust Headquarters, East Surrey Hospital

Minutes of Meeting

Present: Richard Shaw RS Non-Executive Director (Chair) Yvette Robbins YR Deputy Chair, Non-Executive Director Pauline Lambert PL Non-Executive Director Paul Simpson PS Chief Financial Officer Paul Bostock PB Chief Operating Officer

Fiona Allsop FA Chief Nurse Barbara Bray BB Chief of Surgery Bruce Stewart BS Chief of CSS Debbie Pullen DP Chief of WACH Jonathan Parr JP Clinical Governance Compliance

Manager Katharine Horner KH Patient Safety & Risk Lead Ben Emly BE Head of Performance

Ashley Flores AF Lead Nurse & Deputy DIPC Michele Cudjoe MC Michelle Cudjoe Denise Newman DN Denise Newman Apologies

Des Holden, Michael Wilson, Virach Phongsathorn, Karen Devanny, Victoria Daley, Colin Pink, Ed Cetti

Action 1 GENERAL BUSINESS

1.1. Chair welcomed everyone to the meeting and apologies were noted.

1.2. Minutes of the previous meeting RS asked for an amendment to page 5: Take assurance from the actions being taken to manage a difficult set of pressures but was concerned that that a higher risk was falling on the hospital trust as a result. Otherwise the January meeting minutes where agreed as an accurate record.

KH

1.3. Actions from previous meeting were discussed as follows C/F 2nd October 2014

• On the agenda

C/F 4th December 2014

• PB reported that an audit had been conducted for CQUIN on patients


Page 2 of 10

discharged between 18:00 and 07:00 on 4 elderly care wards and 2 orthopaedic wards over 2 quarters. The conclusion was that very few patients were discharged after 20:00 and even fewer after 22:00. The audit has been sent to the CCG for their view. PB offered to bring the audit results and the CCG view back to a future SQC. RS made the point that SQC would be looking for assurance that there was appropriate provision made for each of the patients discharged within these hours. BE added that Q4 would be audited to see if any improvements had been made. Audit to be reported at the March meeting.

• All other items due March 2015 C/F 8th January 2015

• A&E survey has been deferred to the March meeting because it needs to go to Patient Experience Committee first.

• PS had raised the question as to whether there was reliable data on falls per 1,000 bed days going back 5 years to get a better trend analysis to assess whether the recent changes made have impacted the numbers. FA made the point that it needs to be falls with harm. BE explained that the bed data is reliable back to 2012. FA suggested looking at 2011/12, 2012/13 and 2013/14, total falls and falls with harm.

• RS suggested that the improvements made to Capel (old Godstone patients) be built into the next Falls report, for the June meeting.

PB

FA BE FA

COMMITTEE BUSINESS

1.2.1 Highlights from Executive Committee for Quality, Risk YR referred to page 5 section 2.3c (Patient Opinion results for WACH) asked what was being done to address the adverse comments that had been posted by dissatisfied patients. MC explained that the Division will endeavor to identify the each of the women concerned, make contact and offer a meeting to resolve any outstanding issues that the women may have with the care that they received. MC has met with two of the women and established contact with a third. She acknowledged that they have not then updated Patient Opinion which she accepted is important from the point of view of reassuring future patients. The issues raised relate to environment and attitude of staff. The environment for some women has not been ideal due to capacity issues, leading to issues of privacy and dignity. With regard to attitude, MC sent out a letter before Christmas to all staff to reinforce Trust values, and is picking up a number of issues with individual members of staff. MC will request access to Patient Opinion from the Communications department. FA reported that a meeting has been set up with Communications to increase the number members of staff who have access to the system and assess whether any training is required. Action: FA to report back in April on the action being taken.

FA


Page 3 of 10

2.3b RS asked about the post Christmas performance review. PB reported that the meeting had taken place. The meeting looked at the impact of the pressures on the Trust as a whole and then each of the Divisions reported on their own experiences. An assessment has been made of what might be done differently in the future. The feedback will be formalised in a report to the Board and this will include the impact of cancellations. RS asked that the data includes the impact on the ability of the Trust to get stroke patients a bed within 4 hours and the fractured neck of femur pathway. DP reported the pressures that paediatrics had faced which, it was acknowledged, doesn’t always receive the same attention as the adult pathway. This caused problems in flow, safety, quality, potential breaches in ED, extra registrars for a month, to provide senior input, which is a cost pressure, and pressure on intensive care beds. P4 2.1 - YR asked for confirmation on the report of the Virginia Mason project, which essentially established a Virginia Mason “way” through standardized processes and reduction of variation. This had caused some staff at Virginia Mason Hospital to leave. PB asked for clarification on 3.1 VTE risk assessments. BE explained that CDU do not use the primary system that the rest of the Trust uses to capture the data. The Trust is required to report the aggregate performance, the target is 95%. The performance is varied and relies on validation. JP reported that the Thrombosis Committee reformed 3 months ago and is reviewing this. They will report to the Clinical Effectiveness Committee.

1.2.2 Highlights from CQRM The last meeting was held on 20th January. PS reported back to the CCGs on the A&E issues faced by the Trust over Christmas to provide assurance. The update from the CCGs on the CQC action plan was brief; VD had written to the Trust Board (as discussed at Trust Board). Surrey provided an update on RAPSID the “discharge to assess” project group which is chaired by the Trust. PS also reported to the CCGs that the Trust is now classified within the SNAP audit as a category B Trust. He informed them that the two items which are preventing the Trust from achieving level A status is timely access to the ward (because of emergency demand) and the lack of early supported discharge, particularly on the Surrey side. Nothing has been escalated from that meeting to the Single Performance Conversation. At the single performance conversation the Chief Officers discussed the marginal rate emergency tariff and early supported discharge for stroke. The Trust had agreed to provide information to cost the stroke pathway, to demonstrate the cost of the service. The costings were compared with the tariff and on an average basis the tariff does not cover the cost. The Trust declined to share


Page 4 of 10

this information with the CCGs at this point because work on this appears to have taken a different direction - East Surrey CCG has written to the Trust to advise that they will stop purchasing community beds and will stop early supported discharge for stroke, trauma and orthopedics (for financial reasons). The Trust will review this position and continues working with Sussex CCGs on their work around the stroke pathway. .

1.3 Quality Summit update from CCG

2 QUALITY PERFORMANCE

2.1 Quality Report PL commented on the excellent quality of the report. PB reported that the A&E target has been delivered for the last 3 weeks, the Trust is in the top 20% nationally. The expectation is that the standard will be delivered this week, but the Trust remains vulnerable to spikes in activity which takes time to recover from. PB feels that the Trust will struggle to meet the target for the quarter because the first week was so bad. YR commented on the Patient Experience report which she felt to be very hospital centric focusing on the FFT figures. Patient Opinion and Your Care Matters is not included, needs to be more patient centric. FA agreed and explained that it had already been identified that there needed to be some PALS and Complaints information within the report. The FFT information is included to inform the board because there is income associated with the targets. FA provided assurance that triangulation of data does take place in the sub-committees. ED patient survey will come to SQC next month. PL asked whether organ donation information could be captured somewhere. JP replied that this information is reported to the Clinical Effectiveness Committee.

2.2 SQC Dashboard PS noted the number of reds around crude mortality and that this has been discussed at the Clinical Effectiveness Group. There has been an increase in deaths this year 7,000 more than the same period last year. The HSMR figure is not available yet but will adjust for seasonal variation.


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2.3 Update on the impact of the Cabinet Committee initiative on delayed discharges This was announced at the Trust Board in January 2015. PB explained that there are two ways in which delayed transfers are measured. There are those patients who are “officially” delayed, all aspects of funding has been agreed and yet they are still within the Trust. These numbers are relatively low. There are also patients who are medically fit for discharge (MFFD). These are patients who may not have finished the absolute process of having social services funding agreed but there is no medical reason for them to be in an acute hospital bed. MW has lobbied hard nationally to get this cohort of patients recognised nationally. Twenty-five hospitals have been identified as having patient flow issues which relate to high numbers of MFFD patients. SASH has now been added to the list as number 26 because of the high number of MFFD patients. As of yesterday there were 113 MFFD patients within the Trust, which is a high proportion of the 550 beds within the Trust. The cabinet office has now instructed the Health Economies around the 26 hospitals to reduce the number by 50% by the end of February. The target for SASH is a reduction to 56 MFFD patients by 28th February. The target sits with the CCG but the Trust will support them. PB reported that there is an increased level of activity which is already resulting in an improvement in the number of long stay patients. The average time that a patient stays within the Trust with the status of MFFD is now 15 days; PB reported that this was 20 days 7 days ago. The numbers reduction has not yet happened. There has been a national drive to procure more private sector residential and nursing home capacity. The context is that additional beds are being procured in private nursing homes however there is a funding shortfall; social care funding equates to £600pw, continuing care funding is £800pw, however self-funding is £1,200pw, which makes self-funders the more attractive option. For the private sector to make beds available they will require a “top up”. PB confirmed that Sussex have committed to find another 10 beds, it is not currently clear what Surry’s plan is, but PB reported that there is an positive will to find long term solutions to the problem. PB confirmed that there are three types of patients within this cohort; those who are looking for a permanent placement; those for whom this is respite care or who need rehab who will eventually go home and finally those who are waiting for a package of care to be set up or equipment installed or adaptions made to their homes. PS confirmed that this initiative has been discussed at the Chief Officers meeting who have agreed to support and maintain the target. PB will give a verbal update at the next meeting and progress will be recorded in the performance report.

1:18 2.4 Update on the progress of the CQUIN programme


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JP presented a summary table of the current position. He reported that the CCGs and CSUs were happy and have signed off the progress to date. JP took the opportunity to highlight a number of initiatives which have resulted in improvements in care for patients: • Steve Adams, the Dementia Nurse Specialist has successfully trained

1,000 members of staff.

• EOL training team 40/50 staff have been through that training programme

• COPD now have a self management plan in place which is reducing the number of admissions.

RS noted the good progress that has been with CQUINs. PS noted that the CCGs have not yet agreed the CQUINs for 15/16, there will be different CQUINs from NHS England, Surrey, Sussex and the MSK contract.

3 PATIENT EXPERIENCE

4 SAFETY

4.1 Update from Execs regarding evaluation of the impact of localised ward rounds The issue identified at a previous SQC meeting was that if a patient was moved from the ward specialising in the condition for which they had been admitted, for example cardiology, to a gastro ward, they would be reviewed and managed by a gastroenterologist. The question is whether this is the best model of care. This has not yet been evaluated at Execs; however PB explained that it is proposed that job planning within Medicine will change to manage ward rounds on a seven day basis. PB agreed that the admitting to patients to the correct ward first time is still a problem that needs to be solved, it is expected that the additional ward capacity will facilitate this. Action: PB will get an update from Medicine for the next meeting.

PB

4.2 Infection control update AF presented her report. There have been 0 cases MRSA against a target of 0. There have been 18 Trust acquired cases of CDiff, 3 where antibiotic prescribing has not been in line with Trust Policy and only 2 cases of cross infection; this has been declared an SI. So only 5 cases which would be classed as a “lapse in care”, which is where a failure to follow policy has resulted in the infection. The CCGs are able to fine £10,000 per lapse in care over the trajectory. This is also at the discretion of the CCG. The CCGs have not yet established a consistent approach to applying fines where a lapse of care has been identified, nor what evidence will be required. The Trust has a trajectory of 15 for 2015/16 (14/15 was


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29); the trajectories vary across the region. The Trust will need to be very clear when each case is investigated that every aspect of care has been appropriate and record the evidence. 3 recent ward closures due to Norovirus; Nutfield, Chaldon and Meadvale, in Q3. The proximity of bed spaces as a result of escalation in Meadvale and the high occupancy putting pressure on the ability to clean may have contributed to this. The infection control team undertook a snapshot audit of side rooms in use in January; they found 34 patients with an infection control issue, 30 of which were successfully isolated in single rooms as per policy. Three MRSAs were being nursed together in a bay; the final patient (group A strep) was being nursed in HDU. There were 37 patients with a biohazard alert on Cerner (patient has ESBL, CDiff or MRSA) which the staff were not aware of. There is a need to increase staff awareness of the biohazard alert and to ask ED administrators to make the admitting wards aware of the alert where it exists. YR asked whether it was an IT fix or a process issue (stickers). BS felt that this was an action for the Cerner user group to take forward. BS also made the point that there aren’t enough side rooms to isolate all the patients with a biohazard alert and that a traffic light system has to be applied. AF will report back to SQC on

• the biohazard alert options with ED

• the management of CDiff

BS drew the committee’s attention to the excellent orthopaedic infection rates which is a real turnaround. RS also congratulated the Infection Control team on the zero MRSA BSI rate.

4.3 Incident report FA presented the incident report. The data shows an increasing trend in reporting across the Trust, particularly from medical staff, of no harm or near miss incidents. But the incidence of falls with harm remains similar. There has been an increase in patients who have fallen from bed, stretcher or trolley and a significant increase in delayed/inadequate care. However, the numbers are small and all these incidents are low harm. FA gave assurance that there is nothing of particular concern. There is an improvement in the timeliness of reporting to the NPSA. Serious incidents are down on Q2 which is encouraging. FA confirmed that the Trust is still dealing with a backlog of falls SI’s. There are 41 SI’s open with the CCGs. 9 are within date, 14 have been submitted to


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the CCG for closure, 14 have breached but the Trust is in dialogue with the CCGs about completion dates. YR asked whether the increase in some of the subcategories is due to the pressure that the Trust has been under. It was agreed that it is difficult to know. FA asked the committee to take assurance from the fact that the Trust had not seen an increase in incidents with harm. The data is a snapshot in time and a number of these incidents will be reviewed and the severity amended. BS felt that a system under pressure would expect the majors and extremes to go up and that it is reassuring that even though staff are under pressure they are still taking the time to report incidents. The increase in no harm and near misses would indicate that this is improved reporting and a better understanding of safety. Action: To include in the next quarterly report: • Variation between reporting severity and assessed severity

• Review the profile of incident severity over 2 years.

FA

4.4 Update on Patient Safety Committee Task and Finish Group DN updated the committee on the work of the Task and Finish Group which had been commissioned by the PSC to look at under-reporting culture within the Trust. In November 44 members of staff (including domestics, porters, Bands 2-7 and some SHOs) were asked a number of set questions around incident reporting. There was a lack of robust knowledge of the incidents that require a Datix report; they aligned their reporting to KPI’s such as falls, medicines management and pressure damage. Despite that, all of the staff were able to articulate what a near miss was. Staff were not aware of a trigger list or guidance of what to report within their areas. The T&F identified a big emphasis on the lack of time to complete Datixweb. 63% had a problem accessing Datix or had a problem with the complexity of the form. The majority of staff confirmed that they had received training and education in risk management at induction but that the training was very specific to general incident reporting and all felt that specialty specific training would be beneficial. There was a lack of awareness of the total process and a perception that the responsibility for managing incident resolution lies with the Ward Manager and senior managers. It was clear that the Trust could improve the feedback mechanisms to reporters. DP reported that only a third of managers are feeding back to their staff. 60% of staff have limited or no access to e-mails. One ward had a clear process for feeding back incidents at handover and also had information on team notice boards.


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DN reported that the different structures within departments makes a single solution difficult, she suggested champions within each area. MC reinforced the benefit of trigger lists. FA suggested that the recommendations are discussed with the Division risk leads. There are a number of work streams currently looking at aspects of this; the patient safety collaborative and the Virginia Mason project, so this needs to be planned carefully. The committee commended DN for the work she has done on this subject. Action: FA to give a verbal update in two months time.

FA

5 QUALITY

5.1 NICE compliance update Internal audit are satisfied with progress on actions, a report has gone to AAC regarding this. NICE compliance is now on the agenda of each Divisional Meeting, clinicians are aware of what is being assessed within their Divisions and ensuring that baseline assessments are being filled out for all clinical guidelines. The process of reviewing the 46 guidelines where the Trust was partially compliant or non-compliant started in July 2014. Nine of the first ten to be reviewed were updated, six of the guidelines were updated in October and in January the next ten to be reviewed were identified, so the Trust now has an up to date position on three-quarters of the guidelines. All the responses came through the clinical effectiveness committee and the actions that are required to move the Trust to full compliance In December the Divisions were asked to consider the NICE Quality Standards, Medicine has responded and believe that they can make progress on two; COPD and lung cancer. JP confirmed that progress is being made and stronger systems to manage compliance are in place. PS asked whether Internal Audit should be invited to review the progress that has been made, JP agreed that this would be a good idea. Action: JP to make contact with Internal Audit to arrange a review.

JP

6 ANY OTHER BUSINESS BS provided an update from AF on the financial sanctions that can be applied in the event of CDiff as follows:


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2015/16 the financial sanction that can be applied to each CDI within

an acute setting will remain £10k. For each case where the provider

assessment indicates that the acquisition is not linked to a provider lapse in care, the coordinating commissioner will determine whether they accept this argument and inform the provider accordingly. If it accepts that there has been no lapse then the case should not count towards the total number of CDI cases on which any sanction will be based. This decision is for the coordinating commissioner to make at its discretion and is not subject to change through contract dispute resolution procedures. For example a single provider may have a target of 25 cases for 2015/16, it may report 30 actual cases in total, but its subsequent assessment may conclude that only 20 of the 30 cases were linked with lapses of care by the provider. In this situation and at its discretion the commissioner may choose to use the second number (20) as the basis for whether any contractual sanction may be applied. If it does so, as this number falls below 25, no sanction will apply. BS confirmed that the sanction will only be applied for cases in excess of the target for the organisation. YR asked why the Trust had abandoned Symbiotics. FA responded to confirm that Symbiotics had been a real time tool for ward based teams to look at their safety information. The organisation did not buy enough modules do this comprehensively. The system only allowed users to see one month at a time so comparisons could not be made. Web access was not good. The company was not felt to be responsive. The Trusts that are using Symbiotics well have had to purchase 20-30 modules; the Trust did not have a plan to do that. There are other mechanisms for collecting the same data and the Trust is in the process of designing a ward based at a glance safety scorecard that pulls from existing data sources that will allow Ward Managers to look at information real time. Symbiotics cost £30k for 8 modules; additional modules were not felt to be cost effective. There will be a trial in March using February data.

DATE OF NEXT MEETING 5th March 2015 14.00 – 16.00 AD77

Audit & Assurance Committee Page 1 of 8 Minutes 13th January 2015 An Associated University Hospital of


AUDIT & ASSURANCE COMMITTEE

Meeting held on Tuesday 13th January 2015, 09:30 – 12:00pm

Venue: Room AD77, Trust HQ, East Surrey Hospital

Present: Paul Biddle PB Committee Chair / Non-Executive Director Richard Durban RS Non Executive Director Richard Shaw RS Non-Executive Director Yvette Robbins YR Non-Executive Director In attendance: Alan McCarthy AM Chairman Michael Wilson MW Chief Executive officer Paul Simpson PS Chief Finance Officer Fiona Allsop FA Chief Nurse (Item 3.3) Gillian Francis-Musanu GFM Director of Corporate Affairs (from 11.00am) Yvonne Parker YP Director of HR (Item 4.1) Darren Wells DW Grant Thornton (External Audit) Nick Atkinson NA Baker Tilly (Head of Internal Audit) Stuart Doyle SD Local Counter Fraud Specialist (LCFS) (Item 4.3.1) Djafer Erdogan DE Head of Financial Accounts Colin Pink CP Corporate Governance Manager

Action by

1 1.0 Welcome and Apologies for absence

PB welcomed members to the meeting. No apologies for absence had been received.

1.1

1.2

Minutes of last meeting The minutes of 11th November 2014 meeting were reviewed and agreed as a true record. Actions from previous meetings: PB introduced the action log and requested updates from the action owners present. CP apologised for the delay in review of risk management key lines of enquiry. The action remains open. SD reported on the initial review of timesheet fraud. SD highlighted that a sample of 44 timesheets had identified a case of fraud and



highlighted improvements that could be made to the system of control. The committee expressed concern that the first sample review had identified a case of fraud. PS and SD re-assured the committee that although issues had been identified there was no evidence that time sheet fraud was rampant within the Trust and that the issues identified were being resolved. NA agreed that the review was not cause for serious concern and that the IA were looking into similar issues in other Trust’s. The committee noted that the remaining actions on the tracker had either been actioned and closed or were on the agenda for discussion.

1.3 Annual review of effectiveness of the committee PB introduced the review of committee effectiveness which would be used to form the annual report from the committee to the Board. CP went on to describe the content of the review.

The committee considered the report and agreed with the review of effectiveness, noting the initial delays in progress to review internal control systems. It reflected on the need to continue to focus on financial control as the national and local position became ever challenging. PB and PS discussed how the report could be enhanced to include the detail of the committee’s previous conversations relating to national financial pressures. The committee agreed with this update and requested that it was included prior to presentation to board. Action CP to update committee annual report for public board. YR stated that the report lacked detail on the assurances that had been gained by the committee throughout the year and the actions taken by the committee to address issues. The committee discussed this issued but agreed that this detail was visible in minutes of the meetings, summary reports and would be included in the annual governance statement. The committee noted the assurances that had been provided by internal and external audit throughout the year and the actions taken to complete recommendation’s that had seen significant improvements in the internal audit action tracker. The committee accepted the annual review of effectiveness and agreed

CP



the annual report to Board which would be presented on 29th January.

2 2.1 Review of BAF PS introduced the latest revision of the BAF to the committee highlighting changes since the last iteration. The Committee reviewed the previous iteration. PB asked for an update on how assured management was regarding the nursing recruitment and retention risks. MW described the trusts recruitment and retention strategy and the plans to start international recruitment drives. He went on to highlight the size of the local nursing vacancy stating that the nation could not train nurses at a rate that matches attrition. MW went onto remind the committee that the recent introduction of mandatory staffing levels had had a significant effect on national nurse recruitment and retention issues. RD highlighted the business cases that are being reviewed by the finance and workforce committee and PS highlighted the ongoing issues in emergency demand and elective pressures which have a significant impact on agency and bank use. AM reflected on recent discussions at the safety and quality committee (SQC) reflecting on the balance of risk across the local health economy. The emergency risk was defaulting to acute services rather than a balance with primary care. MW agreed stating that risk based decisions are being made regularly relating to the balance of emergency care and the delay in planned treatment. PB summarised the conversation and requested that the executive team consider adding detail on the current position to the staff related risks. The Committee accepted the report.

2.2 Review of SRR

PS presented the latest revision of the SRR to the committee, ahead of its submission to the board. RS highlighted the drop off in appraisal rates over the year and requested that this be considered for the SRR. The committee noted the remaining elements of the SRR and the conversations linked to BAF risks with no further comment.



3 3.1 Corporate Governance Manual Review PS presented the annual review of the Corporate Governance Manual, which includes the Trust’s SFIs, defines accountability and the scheme of delegation. The committee noted the minor changes throughout and discussed the proposed changes to Section G, which aimed to modernise the tendering processes. This would reduce administration and improve capability to audit activity. The committee agreed this change and asked whether similar systems could be applied to the waver processes. PS highlighted that the procurement policy and managers guides for budgetary control had been updated to reflect the current SFIs. The committee accepted the review and proposed that the manual be referred to public board for acceptance with minor changes. Action PS and GFM to present the Corporate Governance Manual for ratification at Public Board on 29th January.

3.2 Internal Control systems; Financial Systems PS presented an updated review of the Trust’s financial controls. This highlighted changes to risk assessment of controls relating to assessment for revenue budget setting and cost improvement planning.

The committee discussed this change in detail and acknowledge that the proposal would need to recognise significant forecast revisions to the activity assumptions used as the basis for the annual plan. PB stated that it is important to maintain variance reporting against the approved plan. PS noted that these changes are based on need to adjust the financial position to reflect revenue budgets and activity. The changes are based on sound forecasting systems and regular meetings with the divisions. NA stated that budget holders would clearly need to be held to account for budget management and as such the system would need to demonstrate any changes in position and why. PS agreed stating that this would be the case and was being put in place to support mangers during periods of significant unexpected changes in activity or income. The committee noted the proposed changes and asked for further information on how this element of budget control is managed when the system had embedded and the detail could be discussed. Action: PS AM went on to describe that the Trust continued to align its plans with the CCG where possible and this was under regular negotiation. RD reflected

PS



on the 2% assumption included in the long term financial model. The committee agreed that this was reasonable and based on assumptions relating to emergency activity noting the ongoing external discussions relating to tariff and CCG plans. RS asked what steps need to be taken to ensure that CIPs where well governed. PS stated that DH and FA are reviewing this process and the individual quality impact of cost improvement plans. This will be reported to Board. RD asked that future iterations of the assessment would include the management of joint ventures and controls relating to commercial activity. PB asked what consideration was given to the assessment of quality benefits from finished projects. PS stated that this is work in progress and that the Trust would need to develop a system for identifying and assessing the quality benefit profile of a project and whether these had been met. PB and RD agreed with this process and suggested that appropriate post project implementation could be reviewed at FWC. The committee accepted the assessment of financial control systems.

3.3 Internal Control systems: Clinical Governance Systems RS presented a review of controls that supported the Trust’s clinical governance systems. Stating that the review had been completed by management and reviewed by SQC prior to presentation to the committee. The risk assessments included presented the risk of the system failing and the level of harm to the Trust that each would cause. PB asked what needed to be done to reduce the risks score for incident management. FA stated that the system was in place but that there was work to do to ensure the timely closure of incidents and that the Trust was implementing new processes to increase shared learning. NA agreed that the system had improved and had the right direction of travel. YR asked whether the committee accepted the green rating for clinical audit, reflecting on the value gained from the process and the delivery of action plans following completion. PS stated that this assessment was agreed by the SQC and was underpinned on improvements since previous review. RS highlighted the agreed actions to improve the quality of the output of the divisions clinical audit programs. CP highlighted the quality account and the Trust’s engagement in national audits and linkages to the local clinical science networks. YR noted the point but highlighted that the



output of the Trust’s involvement in national audit is not shared and as such does not provide assurance. FA stated that the assessment is not fixed and could be reconsidered should the actions agreed at SQC not be delivered appropriately. AM stated that the challenge was appropriate and agreed that SQC should review the situation if actions are not delivered. The committee accepted the assessment of internal controls and asked that the SQC reconsider the assessment of clinical audit system once proposed actions had been completed.

4 4.1 Internal Audit Progress Report NA provided a summary of Internal Audit activity carried out since the last meeting. The committee focussed on the review of Trust Whistleblowing systems which had identified possible improvements in policy and recommendations on shared leaning of incidents. YP assured the committee that the policy changes had already been effected and that there are plans to produce regular whistleblowing reports. GFM noted the plans for bringing whistleblowing reports to the board when available. NA went on to highlight the financial feeder system audit which had provided strong assurance. The committee went on to discuss how SBS managed cases of fraud that affected the Trust. DE highlighted the monthly check for new providers and the dual responsibility required to amendments that effect payments. NA agreed that it was good to carry out these checks monthly. NA stated that the Trust had effective systems in place to manage the contract with SBS. The committee reviewed the Internal audit progress report and gained assurance from the maintained progress in closing actions highlighted by audit.

4.2 External Audit Letter to the Chair of the Committee DW introduced the annual external audit letter which requests details of financial governance and assurances that support end of year review and audit. PB noted the letter. PS confirmed that management would provide an initial response for the chair of the committee to consider. Action: PS

PS



4.3 LCFS Progress report

SD introduced the report which gives specific progress of activity to prevent and minimise the impact of Fraud on the Trust. This focused on the proactive review of systems in radiology and possible timesheet fraud. SD highlighted the recent successful fraud investigation which had resulted in a custodial suspended sentence. PB requested a summary of counter fraud awareness activities. SSD highlighted the face to face training that occurs and the linkages to other incident management systems such as whistleblowing. RS indicated that there was a similarity of issues in recent cases of identified fraud and asked how the team prioritises activity. SD stated that each new case is reviewed to see if any reactionary work is required. SD went to highlight that the majority of work was risk based using local benchmarking and the focus to mitigate against trends. RS asked if the number of cases of fraud should be on the decline due to the amount of publicity and training. SD highlighted that it was a multifactorial issue similar to incident reporting; as you improve awareness you increase the chance of cases being identified and alerted. SD also highlighted that fraud was linked to the national economic situation, reflecting that fraud trends tend to be higher in times of low economic growth. PS highlighted the risk of fraud recorded on the risk register that is reviewed regularly. PS updated the committee on the case of an illegal worker who had been deported prior the planned court appearance, stating that the Home Office had apologised for the error and where considering refunding the costs incurred in preparation for the court case.

5 5.1 AOB and summary of meeting PB summarised that the meeting highlighting the quality and value of financial risk and budget management conversations.AM agreed with PB comments noting the ongoing issues regarding alignment of plans with activity and difficulties associated with the national tariff conversations.PS indicated the internal controls conversations had been particularly useful. No AOB was raised. PB brought the meeting to a close.



6 6.1 Date of Next Meeting: 17th March 2015, 09:30 pre-meet, 10:00

meeting start.