northern care alliance nhs group salford royal nhs ... papers/2020/committee… · the group board...

Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT)

Group Board (Committees in Common) The Group Board operates as a Committees in Common and conducts shared meeting of:

Group Board (Salford) – established by Salford Royal NHS Foundation Trust; andGroup Board (Oldham, Bury and Rochdale) – established by Pennine Acute Hospitals NHS Trust

Summary Minutes – Non-Confidential Mattersfrom the meeting held on: Tuesday 26th May 2020

from 10.30am, via video-conferencing facility

Present:Mr Jim Potter, ChairmanMr Raj Jain, Chief Executive Officer Mrs Judith Adams, Chief Delivery Officer Mr Chris Brookes, Chief Medical OfficerMs Nicky Clarke, Chief People OfficerMr Kieran Charleson, Non-Executive DirectorMr Tim Crowley, Non-Executive DirectorMrs Carmen Drinkwater, Non-Executive DirectorMr Simon Featherstone, DirectorMrs Nicola Firth, Director of Nursing/Chief Officer Oldham Care Organisation Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer Mrs Christine Mayer CBE, Non-Executive Director/Vice ChairmanMr Ian Moston, Chief Finance OfficerProfessor Chris Reilly, Senior Independent Director Mr Jack Sharp, Chief Strategy OfficerDr Hamish Stedman, Non-Executive Director Mr Peter Turkington, Medical Director/Chief Officer Salford Care Organisation Mr Steve Taylor, Director of Operations/Chief Officer Bury & Rochdale Care Organisation Mrs Jane Burns, Director of Corporate Services and Group SecretaryMrs Rebecca McCarthy, Deputy Group Secretary

ApologiesNo apologies

No. Item Action

1 Apologies for AbsenceSee above.

2 Declarations of InterestThe Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as members of the Group Committees in Common (Group Board) and in particular to any matter being discussed at the meeting. There were no interests declared.

3 Chairman’s Opening RemarksNo further opening remarks.

4 Minutes of the Previous Meeting (held on 27th April 2020)4.1 Group Board (Salford)Subject to revision to Item 4.6 for accuracy, the minutes from the previous meeting of the Group Board (Salford) were approved as a true record.

4.2 Group Board (Oldham, Bury & Rochdale)The minutes from the previous meeting of the Group Board (Oldham, Bury & Rochdale) were approved as a true record.

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No. Item Action

5 Matters Arising:No matters arising.

6 Board Assurance Framework/ Corporate Risk RegisterThe Chief Executive Officer presented the Group Board Assurance Framework (BAF) to the Group Board. He confirmed that high-level interim principal objectives had been identified and enabled the development of an Interim Group BAF, with both operational and strategic risks to the delivery of the interim principal objectives identified by Group Directors. The Chief Executive Officer confirmed that principal and operational risks, scored at 12 or above, on the Care Organisations’ Board Assurance Frameworks/Corporate Risk Registers had been referenced within the Group Board Assurance Framework, which included: 8 risks scoring 12 and above, relating to incident plans, non-COVID19 service, staff

experience, two finance risks, the transaction and 2 IT infrastructure risks. 3 risks scoring 13, one of which, relating to non-COVID 19, services, had been reduced to

13 from 14.

Group Board reviewed the Group Board Assurance Framework, and confirmed that risks were adequately identified and effective mitigating action plans were in place.

7 Board Performance Scorecard and Proposed 2020/21 ReviewThe Chief Delivery Officer confirmed that, at the beginning of the new year, there was opportunity to review the scorecard presented to the Group Board. She confirmed that the context of the Covid-19 pandemic meant that the review, and subsequent proposals, would be different from previous years as the organisation required oversight of both the existing pandemic, which was likely to be a feature of how the organisation worked for some time, and also the requirement to monitor the NCA’s reset and recovery.

The Chief Delivery Officer confirmed the NCA’s guiding principles for its organisational scorecards and also provided a refocus of how leading (signal) and lagging (retrospective) indicators would be reviewed in the context of recovery and the absence of formal planning trajectories for a number of areas.

In line with the Scorecard, the Care Organisation Chief Officers each provided a summary of performance, key achievements and challenges and focus areas for the months ahead.

The Group Board requested that: the existing Board Scorecard continue to be presented to Board alongside the

newly proposed scorecard, for a transition period where amendments and changes can be made during the development process;

that the above arrangement is for an agreed finite period at which point the scorecard would be considered final and would be locked down and production of the previous version ceased; and

opportunity for further review is arranged at the Strategy & Investment Committee meeting scheduled for 23rd July 2020.

8 SRFT Board Annual Self-Certifications 2019/20The Group Secretary advised that NHS foundation trusts were required to self-certify on an annual basis whether or not they have complied with the conditions of the NHS provider licence; whether or not they have complied with governance requirements; and that they have the required resources available if providing commissioner requested services. She highlighted the following declarations were required:

Condition G6 (3): Providers must certify that they have taken all precautions necessary to comply with the licence, NHS Act and NHS Constitution (Condition G6 (3))

Condition FT4 (8): Providers must certify compliance with required governance arrangements (including Training of Governors)

Condition CoS7 (3): Providers providing commissioner requested services (CRS) must certify that they have a reasonable expectation that required resources will be available to deliver the designated service.

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No. Item Action

The Group Secretary confirmed that this year’s annual self-certification review had been completed to encompass compliance for the Northern Care Alliance NHS Group (NCA) including the statutory body, Salford Royal NHS Foundation Trust (SRFT) during 2019/20.

In response to the Chairman querying action from the Board Capability and Capacity Review, the Group Secretary confirmed that the recommendations from this report would be returned to at the appropriate time. The Chief Executive Officer highlighted that an initial review had been undertaken with key actions identified and suggested that this was revisited towards at the end of summer.

Group Board approved the current year’s annual self-certifications as described within the paper, subject to review by the Audit Committee on the 19th June 2020.

9 Date and Time of Next MeetingThe Chairman confirmed the next meeting of Group Board would take place in private on Monday 29th June 2020, from 10.30am to 12.30pm

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Northern Care Alliance (NCA) NHS GroupSalford Royal NHS Foundation Trust (SRFT)

Meeting Group Board (Committees in Common)

Author (s) Jane Burns, Director of Corporate Services and Group Secretary

Presented by Jim Potter, Chairman and Chair of NRTS Committee

Date 29th June 2020

Executive Summary

At the NRTS (Nominations, Remuneration and Terms of Service) Committee in January 2020, it was confirmed that SRFT’s Executive Nurse Director and the NCA’s Chief Nurse, Mrs Elaine Inglesby-Burke CBE, would retire at the end of June 2020. The recruitment process for this position was subsequently agreed.

Further to extensive national search and preliminary assessment of all applicants, a formal selection process was scheduled to take place on 27th March 2020. Due to the escalating covid-19 pandemic and national major incident response, the selection process did not go ahead.

At the NRTS Committee in May 2020, the Chief Executive confirmed that Mrs Inglesby-Burke had offered and agreed to continue in post until the end of the calendar year. NRTS Committee confirmed its appreciation of the Chief Nurse’s continued commitment.

The selection process for the new Chief Nurse was resumed at the end of May 2020, with provisional dates in the first instance in view of the uncertain pandemic circumstances. Candidates who had been shortlisted in the initial stages were contacted and a formal selection process was rescheduled.

The formal selection process took place on 15th June 2020, with strict social distancing measures in place. The selection panel comprised: Chairman; Chief Executive; Vice Chairman; Non-Executive Director; NHSI NW Regional Nurse; and Chief Nurse from Royal Free London NHS FT (Group Model). The panel received feedback from internal stakeholder focus groups.

Libby McManus was selected for appointment to the position of Executive Nurse Director and Chief Nurse. Libby is currently the Chief Nurse at The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust, having worked previously in senior roles across Nursing, Transformation and a period as an Acting Chief Executive with significant experience of working in a Group model.

All Fit and Proper Person requirement checks are underway and outcome will be reported in full to the Chairman.

This is an Executive Director appointment and as such is to be approved by the Chairman, Chief Executive and all Non-Executive Directors.

Recommendations The Group Board is asked request approval from the Chairman, Chief Executive and all Non-Executive Directors to appoint Libby McManus as Executive Nurse Director (SRFT Board of Directors) and Chief Nurse (Northern Care Alliance NHS Group), subject to positive outcome of all Fit and Proper Person requirement checks.

Title of Report Appointment of SRFT Executive Nurse Director/NCA Chief Nurse

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Equality Does this paper relate to a matter where equality issues may arise? N

This document does not contain confidential information and can be made available to the public.

This document contains some confidential information that would need to be redacted before the document was made available to the public.

Freedom of Information Please ‘cross’ one of the boxes

This document is entirely confidential, as the redaction of confidential information would render the document meaningless.

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Meeting Group Board (Committees in Common)

Author (s) Jane Burns, Director of Corporate Services and Group Secretary

Presented by Raj Jain, Chief Executive

Date 29th June 2020

Executive Summary

The Group Board Assurance Framework (BAF) is presented to this June Group Board meeting. All Risks have been reviewed be their relevant risk owners. Principal and operational risks, scored at 12 or above, on the Care

Organisations’ Board Assurance Frameworks/Corporate Risk Registers have been referenced within the Group Board Assurance Framework

5 risks score 12, relating to staff experience, two finance risks, the transaction and delay to single integrated IT infrastructure due to on-going COVID incident.

4 of the risks score 13, relating to major incident plans, critical non-COVID 19 services, maintain safe and reliable infection prevention and control (new risk) and up to date IT infrastructure, applications and end-user devices.

Recommendations The Group Board is asked: review the Group Board Assurance Framework, confirm that risks

are adequately identified and effective mitigating action plans are in place.

Equality Does this paper relate to a matter where equality issues may arise? N





Title of Report Interim Board Assurance Framework 2020/21

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Northern Care Alliance NHS GroupInterim Board Assurance Framework 2020/21: – High-level interim principal objectives and significant principal risks relating to COVID 19 pandemic response and recovery

Page 1 of 17

Summary

Risk Subject: Risk Score1.1 IF robust major incident plans are not in place and fully enacted 13

2.1 IF demand for critical non-COVID 19 services is not met whilst capacity is diverted to COVID response 13

2.2 IF we do not maintain safe and reliable infection prevention and control THEN patients and staff may come to harm 13

3.1 IF we fail to have in place a process to improve experience of our staff 12

4.1 IF we do not develop an effective productivity improvement and cost reduction strategy 12

4.2 IF the planned activity and income levels and/or expenditure controls are exceeded 12

5.1 IF we fail to secure the transaction and associated investment 12

7.1 If the NCA’s IT Infrastructure, applications and end-user devices are not brought up to date and replaced or upgraded when they reach end of life

13

7.2 If plans and business case funding to develop an Single Integrated IT infrastructure are delayed by on-going COVID Incident management and move of transaction timeline

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High-level Interim Principal Objective 1. Effective management of major incident and safe provision of critical services for COVID 19 patients through into recovery phase

Significant Principal Risks

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& Responsible Committee

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1.1 IF robust major incident plans are not in place and fully enacted in response to the COVID 19 pandemic THEN the NCA may be unable to maintain staff, patient and public safety and effectively manage demand for services, equipment and supplies.

Chief Executive

Exec Gold Command

BRCO13 - Clinical standards for IPC 12 – Reduction in workforce

OCO 12 – Service remodelling

SCO13 – Care Act easement12 - Provision of PPE12 – Impact of Covid-19 demand on safety

D&P12 – Server availability

5 5 -Major incident and BCP processes in place-Head of Emergency Preparedness in place working across the NCA to ensure emergency preparedness for all NHS Categorised Major Incident Plans-Emergency Preparedness Group in place across the NCA-Gold, Silver and Bronze commands in place and understood by the CO leaders. -Precedent set from other country's responses/ lessons learned - Gold command in

-National instructions changing frequently-Unquantifiable impact on all services-Alignment across localities of EPRR and business continuity plans- National supply chain gap in delivery of timely PPE in adequate quantities-Consistency of communication outside of Gold command- oxygen delivery systems not yet stressed tested to the degree required by a pandemic

3 - Exec Gold COVID 19 Dashboard- Safety and Staff Feedback Surveillance Report- GOLD actions mapped back to national asks- Daily staffing review through the central deployment hub

-Appropriate and timely communication in response to changing situation and national instruction - Continuation of BCP activities and Gold command structures- Source alternative PPE items, risk assess and train staff adequately as part of PPE business continuity planning - development of a comprehensive IPC and staff testing strategies- Process to be e finalised for rapid deployment of staff through silver

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High-level Interim Principal Objective 1. Effective management of major incident and safe provision of critical services for COVID 19 patients through into recovery phase


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for POCT

place for all people aspects of COVID supported by a Silver People group- local and national modelling on rate of infection and peak- recovery cell established-establishment of medical gases triggers and monitoring

command centres

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High-level Interim Principal Objective2. Safe provision of critical services for non-COVID-19 patients through into recovery phase of major incident


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2.1 IF demand for critical non-COVID 19 services is not met whilst capacity is diverted to COVID response THEN there is increased likelihood of patient safety harm and mortality incidents arising

Chief Delivery Officer

Exec Gold Command

OCO12 – Service provision and continuity12 – SHMI/HSMR12 – Service provision: Endoscopy

SCO13 – Capacity to meet non-Covid demand

D&P12 – Shortage of critical medicines12 – Sufficient medical capacity for IR

4 5 - Established capacity for non-COVID activities on Rochdale, Oldham and Salford sites - Business continuity plans in place reviewed daily-Gold command and silver control in place-Staff briefings and communication- pathways and mutual aid arrangements in place with Independent Sector - Review and implementation of new national clinical criteria for pathway/condition management -Planning taking place daily- all out patients risk stratified

- potential lack of workforce to deliver on COVID and non-COVID activities- Supply chain response not rapid enough to meet demand in critical equipment- as yet unknown and unquantified future health impacts from cessation of core activities- current national mandates to cease core non-COVID activities

4 - Local and GM assurance system for tracking of all new and urgent cancers - Monitoring of live data from Datix (incidents, complaints etc) for trends and analysis

- National supply chain response

- Continuation of BCP activities, including workforce planning- Deliver on national discharge guidance and virtual hospital - Develop Home First Strategy- Re-configure out-patient, cancer and urgent activities to optimise resources and deliver on national priorities- Develop estates strategy to separate covid from non covid work creating low risk covid areas thereby supporting IPC objectives-Track national modelling and develop local modelling and

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recovery plans that deal with backlog and changes in disease prevalence.- develop safety siren work and mortality indicators acting on findings- development of comprehensive IPC staff testing strategies

High-level Interim Principal Objective 1. Effective management of major incident and safe provision of critical services for COVID 19 patients through into recovery phase2. Safe provision of critical services for non-COVID-19 patients through into recovery phase of major incident

2.2 IF we do not maintain safe and reliable infection prevention and control THEN patients and staff may come to harm

Chris Brookes, Chief Medical Officer

Elaine Inglesby-Burke, Chief Nursing Officer

4 5 Comprehensive suite of measures established covering: Leadership &

Culture Hygiene Distancing and

Environment Screening &

Testing Masks & PPE

Detailed IPC Programme Plan and Action Log in place

Leadership establishedin each Care Organisation

Quality and IPC

Comprehensive utilisation of the quality improvement method

PPE Officers not yet in place

Space Programme to be fully implemented

Workforce Policy to be fully implemented re home working and utilisation of workforce (non-clinical)

GDE symptom checker for daily

4 Daily hospital acquired infection reports

Board Scorecard including HAI data

Assurances to confirm reliability in minimising nosocomial transmission

Detailed Action Plan developed and actively monitored via IPC Committee, reporting directly to Exec Quality Committee.

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Committees established

screening

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High-level Interim Principal Objective3. Safety and well-being of staff


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3.1 IF we fail to have in place a process to improve the experience our staff THEN we may not achieve a reliable and resilient workforce and our operational performance and service developments will not be delivered

Chief People Officer

Exec People Committee(EPPLC)

B&RCO12 – Action to support health and well-being of workforce

OCO14 - Provision of PPE13 – Staff availability due to COVID 1912 – Mandatory Training

4 4CO People Committees in place

People Gold Sub Group established

Recovery plans in development

Staff side engagement and consultation structures in place

Approved Health and Well Being Strategy and plan. Specific additional support during COVID also in place.

Additional mental health support being provided

Recruitment plans in place

Retention Strategy under development

Resource to lead staff experience currently seconded to MFT

Employee branding and careers website not yet formally launched

Full national people plan launch delayed

Clarity on reasons for COVID impact on certain staff groups

Identification of work for large group of shielding staff to be established

Implications of any service

4Quarterly People Report to Group Board including turnover, sickness absence, staffing levels, staff engagement. Equality & Diversity

Analysis of reasons for absence

Trajectories for improvement for recruitment and retention agreed for each CO (including agency spend).Reviewed monthly via

Impact of Employee Branding to be measured through conversion rates in first 12 months

Staff Experience Strategy to be developed in line with national People Plan

Careers website development to be completed

Quarterly staff survey to be revamped to understand staff COVID experience

Set up permanent wellbeing rooms

Wellbeing support for post COVID to be defined and implemented, including mental health support

Implement

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Employer Brand agreed and careers website under development

National people plan website launched with health and wellbeing content

Staff testing in place

Enhanced risk assessment process in place

Mechanism for staff to feed in celebration ideas

Daily monitoring of staff absence levels

Non clinical redeployment model in place to enable staff to work who need to be at home or where work has stopped

Recruitment of returners and students

Leadership support and advice in place

reconfiguration not yet fully understood

Full understanding of longer term staff testing implications

Full understanding of the risks faced by BAME staff

Group Board Dashboard.

Quarterly Pulse and National Staff Survey Result reviewed at CO and NCA level.

Recruitment tracking of returners and students

Risk assessment completion trajectories being reported weekly

Analysis of staff survey by ethnic group

celebration ideas

Review of all staff self isolating and shielding to enable a return to work in some form

Modelling of staffing requirements based on new models of care post June

Developing accessible virtual learning for all staff

Develop accessible form of leadership development programme

Complete recovery plans

Longer term sustainable staff testing plans

BAME Leadership Council to be established

Health MOTs to be set up

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Page 9 of 17

Clinical workforce strategy developed in draft

Additional measures in place for support to BAME staff – Leadership Council and active involvement of Staff Networks

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High-level Interim Principal Objective4. Financial governance


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4.1 IF we do not develop an effective productivity improvement and cost reduction strategy that identifies key cost drivers and solutions for improvement THEN we may not deliver financial sustainability or achieve an Outstanding UoR / VFM opinion

Chief Financial Officer

Exec Strategic Finance & Information Committee(ESFI)

D&P12 - Financial impact of COVID 19

4 5QPID – eHub established. All PIDs recorded on eHUB.

Delivery Management Office (DMO) established

CO/GBU SoA includes Financial Analysis

CO Finance & Information Committee established.

Executive Strategic Finance & Information established

BCLC programme of change monitored via DMO and Executive Portfolio Committee (EPC)

20/21 BCLC Plan to achieve 5.4% target at SRFT

20/21 BCLC split between two interim management agreements

3Monthly BCLC Month End Dashboard reviewed via ESF&I including: Scheme Development, Progress on PIDs (Transacted/Identified/Unidentified) and Movement of Schemes.

Monthly Group Board PAVE Report (Including above metrics)

Monthly ESF&I and Group Board Finance Report including

20/21 BCLC Plans to May ESF&I

Interim Management Agreement Schedule 5/6 to Transaction Oversight Group

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Summary Financial Performance

Benchmark Data sets e.g. Model Hospital

MIAA Internal Audit Cost Efficiency Programme 2019/20 – Moderate Assurance

4.2 IF the planned activity and income levels and/or expenditure controls are exceeded leading to NHSI Use of Resources rating lower than planned THEN this will increase


Executive Strategic Finance and Information Committee(ESFI)

4 5 SRFT and PAT Financial Plan 2020/21 in place.

CO/GBU SoA includes Financial analysis

CO Finance & Information Committee established.

PAHT Interim Management Agreement Schedule 5/6

M1-M4 Income set to COVID rules and needs to be confirmedTop up guidance expected Apr 20.

3 - Monthly Finance & Activity Report including: Financial Performance- Monthly PAVE Report including Scheme Development, Progress on

Interim Management Agreement Schedules to be produced May 2020 ESFI

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regulatory investigation & intervention and put at risk Provider Sustainability Funding

Exec Strategic Finance & Information Committee established

Audit Committee Mid-Year Financial Review established

SRFT/PAHT Drivers of the Deficit Report

PIDs and movement - Audit Comm. Mid Year Detailed Financial review / Going Concern Reports- Monthly monitoring via NHSI escalation meeting (CFO, CEO & Chair)

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High-level Interim Principal Objective5. Commercial Transaction (Acquisition of Oldham, Bury and Rochdale services, currently provided by PAHT)


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5.1 IF we fail to secure the acquisition of Oldham, Bury & Rochdale services and associated investment THEN we will be unable to ensure a safe and sustainable future for the Northern Care Alliance.


SRFT Acquisition Committee(SRFT AC)

3 5SRFT Acquisition Committee

Transaction Programme Management office

PAT Board in place Committee 3 – SRFT/MFT/PAT/NHSIEtransaction and disaggregation committee

Support from NHSIE regional directors and PAT Board for completion by April 2021

Capital funding for ORB & system solution

Interim team diversion to Covid-19 programmes

Financial positions in light of Covid-19.

4Full participation in on-going programme with PAT

Integration with IBP

Ongoing engagement and fortnightly meetings with NHSIE dedicated to SRFT transaction

NHSI/LA /CCG support for financial plan

Disaggregation planning and funding.

Third party engagement driven by Covid-19

Confirmation of future programme funding

Submission of Business Case to NHSIE inc LTFM [Post Jun 20]

Disaggregation plans to be finalised and strategy reconsidered with PAT[Acquisition Committee, On-going]

Engage in NHSI review Process [NHSI, completed by Q3 2020]

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High-level Interim Principal Objective6. Progress key strategic service developments (outside of major incident management)


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6.1 IF key strategic service developments are adversely impacted by the COVID response THEN this may impact upon the NCA’s recovery and the delivery of long term strategic objectives.

Chief of Strategy

Group Executive Team / EDC

D&P12 – Fail to deliver the transformation agenda

3 4 Existing work programme reviewed by the Exec Team and prioritised, with each development classified (‘stop for now’, ‘paused – but prepare’, ‘continue to support recover’, or ‘fast forward’) Work streams classed as ‘continue to support recover’ or ‘fast forward’ continue to be tracked through the Exec Team

Recovery planning governance

Impact of changing organisational demands, due to Covid-19, on organisational capacity to progress key workstreams

Strategy team diverted to support Covid-19 programmes

3 Work streams classed as ‘continue to support recover’ or ‘fast forward’ continue to be tracked through the Exec Team

Review will align with COVID changes in relation to IPC, capacity and estates planning

[EDC currently suspended during Covid-19]

[Strategy & Investment Committee currently suspended during Covid-19]

Suspension of GM ISC programme

Review of work programme and prioritisation to be undertaken at least quarterly

[Exec Team]

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Page 15 of 17

High-level Interim Principal Objective7. Critical digital solutions (outside of major incident management).


Responsible Officer



Risks Like

lihoo

dIm

pact



Cont

rols


Action plan summary

Ope

ning

pos

ition

20

20/2

1Q

1 20

20/2

1 po

sitio

n

Q2

2020

/21

posi

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Q3

2020

/21

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Targ

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e

7.1 IF the NCA’s IT Infrastructure, applications and end-user devices are not brought up to date and replaced or upgraded when they reach end of life THEN access to key clinical systems will be disrupted, slowed down or lost completely causing clinical risk and disruption to care.

CFO

Exec Digital Health & Enterprise Committee(EDHEC)

OCO13 – IM&T – Unsupported and out of date systems

4 4 Approval of IT Emergency Capital Loan (PAT) by Group Board (Dec 19)

Stabilisation Programme for PAT infrastructure established and underway

Risk-based capital programme defined for SRFT & PAHT

Digital Representation CO Silver Commands and Corporate Silver.

NCA wide IS/IG team established and monitoring systems and Cyber Vulnerabilities

Emergency loan only dealt with 201920 pressures. Further significant investment needed for 2020/21

In April 2021 current PAHT primary data centre is due to be demolished as per MFT Estates plan.

Stabilisation Programme timeline is delayed by limited access to clinical stakeholders for system developments and reduce on site access for contractors.

Core digital workforce focussed on Digital response to COVID deflects

5 Daily monitoring of system performance

Capital investment under consideration at GCC

Group Digital Board meeting bi-monthly to review KPIs and programme performance

Updates on key KPI’s and programme status through Digital & Informatics Gold

Work on-going to fully define the Digital Risk Management Approach

Delayed funding for Post transaction integration planning

Implement a costed imminent replacement programme that reflects the NCA aims of a single instance EPR, cloud, interoperability, citizen facing and wearable technology

Development of plans for additional DC provision to support the NCA.

Continue to progress Stabilisation Phase 1 As fast as COVID incident allows

Develop NCA wide strategy for Digital Integrated Care

Risk assesses programme delays

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Page 16 of 17



Responsible Officer



Risks Like

lihoo

dIm

pact



Cont

rols


Action plan summary

Ope

ning

pos

ition

20

20/2

1Q

1 20

20/2

1 po

sitio

n

Q2

2020

/21

posi

tion

Q3

2020

/21

posi

tion

Q4

/ Cl

osin

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020/

21

posi

tion

Targ

et R

isk

Scor

e

from normal replacement programme

2021 Capital refresh funds not allocated (need 11.5m for PAT yr. 2 stabilisation)

Devices procured for stabilisation programme redirected at COVID remote working solutions.

Complexity of digital disaggregation of NMGH as part of the transaction

Delayed implementation of NES EPR due to clinical focus on incident.

Command

Audit Committee deep dive of digital risk and overview of the digital portfolio (Nov 19)

and feedback into Gold command.

Establish a route to additional digital capital funding

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Page 17 of 17



Responsible Officer



Risks Like

lihoo

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Cont

rols


Action plan summary

Ope

ning

pos

ition

20

20/2

1Q

1 20

20/2

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n

Q2

2020

/21

posi

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Q3

2020

/21

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020/

21

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Targ

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isk

Scor

e

7.2 IF plans and business case funding to develop an Single Integrated IT infrastructure are delayed by ongoing COVID Incident management and move of transaction timeline THEN significant investment will be required at PAHT to maintain Existing and obsolete applications which would have been replaced by an NCA EPR and disaggregation timeline will be extended.


EDHEC

4 4 Daily Monitoring of system performance

When possible and appropriate upgrade existing systems

Develop and Enterprise Architecture for NCA Future Solution

Capital allocation not clear for 2020/21.

Detail planning delayed due to staff focus on COVID response

4 Reporting through Digital & Informatics Gold Command

GGC

Acquisition Committee

Pennine Transactions and Disaggregation Committee

EDHEC review

Planning Discussions with MFT Digital on hold due to Covid

Develop a proposal and engagement plan for external support through NHS England Digital

Develop an EPR/System strategy and business case (to de-couple from Transaction FBC to minimise the delay in receiving funds to start to disaggregate and move to an enterprise solution.

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

A&E Performance

Target: Local Trajectories

A&E Performance - Non Admitted

Target: 95% Standard

Ambulance Turnaround

(Waits over 60 minutes)

12hour+ Wait for Admission

Target: Zero Tolerance

KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)

Average (Mean) Waiting Times

(Minutes)

A&E Attendances

(Attendances)

Self-Referrals per 1,000

(Rate per 1,000 Population)

Aggregated Admitted Patient Delay

(Minutes per 100 Admitted Attendances)

Score Score Score

13

Le

ad

ing

& S

ign

al

Me

tric

s

Oldham

Care Organisation

Salford

Care Organisation

Commentary

Average waiting times are one of the proposed new

indicators for A&E following the NHS England review of

performance targets.

This measures the number of A&E attendances as an

indicator of demand on the service.

This indicator measures the number of self-referrals to

A&E per 1,000 of the population within the locality. This

measure has been proposed as part of the NHS

England review of performance targets

This measures the amount of time patients who are

admitted spend in Type 1 A&E department per 100

attendances. This is an indicator of the average time

spent waiting for admission beyond 4hrs within A&E and

is used in the Model Hospital benchmarking set.

Significant decreases in the number of patients attending our A&E departments have been seen over the last three months although increases

have been seen again in May '20. Delays for admitted patients have reduced to very low levels and average waiting times overall have seen

significant reductions as a result of the reduced attendances.

Ke

y M

etr

ics

Commentary

Bury & Rochdale

Care Organisation

Attendances across our A&E departments in May remained low and waiting times for patients have been significantly reduced, with no 12hr

waits for admission.

Salford did not achieve the 4hr A&E standard of 95% that the other Care Organisation did and issues with bed availability due to zoning of

beds for infection prevention and control has impacted on flow.

Principal Risk

BA

F

Associated Principal Risks

Principal Risk Principal Risk

3000

5000

7000

9000

11000

13000

15000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual (exc WiC) Mean UCL LCL

7000

9000

11000

Committee in CommonIntegrated Performance Scorecard

Urgent Care

0

5

10

15

20

25

30

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

10

20

30

0

50

100

150

200

250

300

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

200

400

0

200

400

600

800

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual NHSE Mean UCL LCL

500

1000

3000

5000

7000

9000

11000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual (exc WiC) Mean UCL LCL

0

5

10

15

20

25

30

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

50

100

150

200

250

300

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

100

200

300

400

500

600

700

800

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL NHSE

3000

5000

7000

9000

11000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

5

10

15

20

25

30

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

50

100

150

200

250

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

200

400

600

800

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


These scorecards are designed to be reviewed on-screen. For printed copies, consider A3.1/8

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Stranded Patients (7 days+)

Super-Stranded Patients (21 days+)


Delayed Transfers of Care

Target: 3.5%


Bed Occupancy

(% of beds occupied at midnight)

Same Day Emergency Care

(% of total emergency admissions)

Length of Stay (Locality)

(Days)

Note differing scales on charts

Length of Stay (Out of Locality)

(Days)

Note differing scales on charts

Score Score ScorePrincipal Risk

BA

F



Oldham

Care Organisation

Salford

Care Organisation

The number of delayed and long-stay patients continues to remain low across all Care Organisations. Care Organisations are reviewing all

patients on a daily basis to ensure there is a clinical need for them to remain within our hospitals.

Occupancy remain low across all Care Organisations but difficulties remain with flow from urgent care departments. Part of this is due to the

zoning of beds to ensure patients are kept safe and although occupancy is low, available beds depend on the COVID status of patient

requiring admission.

Ke

y M

etr

ics

Commentary

Bury & Rochdale

Care Organisation

Le

ad

ing

& S

ign

al

Me

tric

s

Commentary

Bed occupancy is a signal indicator of flow within the

hospital. Lower occupancy levels support improved flow.

NHS England's aim is for bed occupancy levels to be 92%

or below.

Same day emergency care (SDEC also known as

ambulatory care) aims to minimise delays for patients and

avoid admission to hospital. This indicator measure the

proportion of patients managed in SDEC facilities out of

the total number emergency admissions.

This signal indicator measure the average length of stay for

emergency admissions for patients registered with a GP in

the locality of the Care Organisation. This measure

excludes zero length of stay, paediatric and obstetric

services.

This signal indicator measure the average length of stay for

emergency admissions for patients not registered with a

GP in the locality of the Care Organisation. This measure

excludes zero length of stay, paediatric and obstetric

services.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL


Urgent Care - Flow

5.0

5.5

6.0

6.5

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

6.4

6.9

7.4

7.9

8.4

8.9

9.4

9.9

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

4.0

4.5

5.0

5.5

6.0

6.5

7.0

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

4.3

4.4

4.5

4.6

4.7

4.8

4.9

5.0

5.1

5.2

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

6

7

8

9

10

11

12

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

10.0

10.2

10.4

10.6

10.8

11.0

11.2

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

These scorecards are designed to be reviewed on screen. For printing,

consider A3.2/8

NCA #

274

090

06/2

9/20

20 09:

32:5

3

25/74


52 Week Breaches

Target: Zero Tolerance

RTT List Size


RTT Performance


6wk Diagnostic Wait

Target: 99% - Data still to be validated

KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation

Median Wait in Weeks (RTT)

(Weeks)

NHS England Average: 7.5 weeks

45wk+ RTT Waiters

(Number of Patients Waiting)

Outpatient Referrals

(Number of Referrals - GP and Other)

Theatre Utilisation

(% of available session time utilised)

Score Score Score

13

Principal Risk

Le

ad

ing

& S

ign

al

Me

tric

sB

AF



Commentary

The median waiting time indicates that half of

patients wait less than this time. This is used rather

than the mean which can be skewed by very short or

very long waiting times and is a measure used by

NHS England.

This is the number of patients currently waiting more

than 45 weeks without treatment. This is a signal

indicator for potential 52 week waits.

This is the number of referrals received for outpatient

appointments and is an indicator of demand into

services.

This is a measure of the efficient use of theatre time

and an indicator of productivity.

2.1 IF demand for critical non-COVID 19

services is not met whilst capacity is

diverted to COVID response THEN there is

increased likelihood of patient safety harm

and mortality incidents arising

Demand from primary care has significantly reduced but due to reduced capacity, our average waiting times have increased significantly and the

number of patients we have waiting more than 45wks have also seen a significant increase.

Oldham

Care Organisation

Salford

Care Organisation

The size of the waiting list across all Care Organisations has reduced through limited demand from primary care. However, the significant

reduction in capacity is leading to an increase in long waiters and there at the end of May 2020, almost 500 patients had waited longer than 52

weeks and are still yet to receive their treatment.

Capacity in our diagnostic services has also significantly reduced and only the most urgent patients are currently able to access diagnostic tests

due to capacity constraints. This will have an impact on overall waiting times as the amount of time that our patients will wait in the diagnostic

phase of their pathway will also significantly increase.

Ke

y M

etr

ics

Commentary

Bury & Rochdale

Care Organisation

0

100

200

300

400

500

600

700

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL


Planned Care

0

2000

4000

6000

8000

10000

12000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

4.00

6.00

8.00

10.00

12.00

14.00

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Ambition Mean UCL LCL

0

100

200

300

400

500

600

700

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

1000

2000

3000

4000

5000

6000

7000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

4.00

6.00

8.00

10.00

12.00

14.00

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL Ambition

0

100

200

300

400

500

600

700

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

2000

4000

6000

8000

10000

12000

14000

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

4.00

6.00

8.00

10.00

12.00

14.00

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


These scorecards are designed to be reviewed on screen. For printing, consider A3.

3/8

NCA #

274

090

06/2

9/20

20 09:

32:5

3

26/74

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

62 Day Referral to Treatment

Target: 85%

31 Day Treatment

Target: 96% Standard

2 Week Referral

Target: 93%

28 Day Faster Diagnosis

New indicator due for live monitoring in April 2020

KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Deteriorating (No Target), Improving (No Target) , Stable (No Target)

Total Size of 62 Day List

(Number of patients)

62 Day Backlog - Diagnosed


62 Day Backlog - Undiagnosed


Referral Conversion Rates

(Number of urgent cancer referrals )

(Conversion from urgent referral to cancer treatment)

Score Score Score

13

Principal Risk

BA

F








This shows the number of urgent (2 week wait)

cancer referrals received from primary care, an

indicator of demand. The conversion rate is the

percentage of these referrals that go in to have

treatment for cancer.

Although the numbers of patients on the 62 day waiting list remain stable, there has been an increase in the number of patients who have

already waited beyond 62 days and are still to be diagnosed. This increase is a result of significantly reduced access to diagnostic services,

in particular endoscopy services where capacity has been significantly reduced.

Ke

y M

etr

ics

Commentary

Bury & Rochdale

Care Organisation

Oldham

Care Organisation

The latest cancer performance is based on April 2020. Both the Bury & Rochdale and the Oldham Care Organisation failed to deliver the 62

day standard, but performance was within normal variation with improvement in Oldham. Bury & Rochdale delivered the two week wait

standard and Salford's position has improved in month, just 0.6% below the target. However Oldham's performance has declined

significantly in month.

All Care Organisations achieved the 31 day standard. This means that once cancer is diagnosed, 96% of our patients receive their first

treatment within 31 days.

Timeliness of diagnosis, represented by the 28 day Faster Diagnosis standard, is deteriorating at Salford as diagnostic capacity continues to

be impacted.

Salford

Care Organisation

Le

ad

ing

& S

ign

al

Me

tric

s

Commentary

This shows the total number of patients currently on a

62 day urgent cancer pathway. Not all patients on

these pathways will be diagnosed with cancer. An

increase in the size of the waiting list can indicate

potential capacity issues for the future.

This shows the total number of patients who have

already waited more than 62 days on an urgent

cancer pathways and have had a cancer diagnosis

confirmed and a decision to treat has been made.

This is indicative of future breaches of the standard.

This shows the total number of patients who have

already waited more than 62 days but have not yet

had a diagnosis of cancer confirmed. These patients

may or may not be confirmed as cancer. This is

indicative of the potential risk of breaches for the

future.

0

10

20

30

40

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL


Cancer

0

50

100

150

200

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

2500

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

0%

5%

10%

15%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Conversion % Total 2ww ReferralsLinear (Total 2ww Referrals)

0

10

20

30

40

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

100

200

300

400

500

600

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

2500

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

0%

5%

10%

15%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0

5

10

15

20

25

30

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

100

200

300

400

500

600

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

2500

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

500

1000

1500

2000

0%

5%

10%

15%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


These scorecards are designed to be reviewed on-screen. For printed copies,

consider A3.4/8

NCA #

274

090

06/2

9/20

20 09:

32:5

3

27/74

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

Pre-Term Birth Rates

(Babies born between 24 and 36 weeks)

Still Birth Rate

(Still births per 1,000 deliveries)

Term Admission to NICU

(Babies born at 37weeks+ )

Non-Clinical Paed Transfers

(Transfers for bed capacity reasons)

Smoking in Pregnancy

(At Delivery)

NHS England Ambition: 6% or less

Emergency C-Section Rates

NHS England Average: 16%

3rd/4th Degree Tears

NHS England Average: 4%

1:1 Care in Established Labour

Score

BA

F

Associated Principal RisksPrincipal Risk

No Current BAF Level Risks

Ke

y M

etr

ics

Commentary

Commentary All indicators are within normal variation.

KEY: Normal Variation, Special Cause Improving, Special Cause Getting Worse

Smoking during pregnancy can lead to

complications during labour and an increased risk of

miscarriage, premature birth, still birth, low birth-

weight and sudden unexpected death in infancy

Significant increases in the rates of caesarean

sections across the NHS have been seen over the

last decade and this increase in rate is not

accompanied by significant benefits to either mother

or baby.

Third and fourth degree tears are a type of trauma

that can occur during birth. This type of trauma can

have a long-term impact. High levels of birth trauma

can be indicative of variation in care and poor

experience.

NICE recommends one to one care for women in

established labour. One-to-one care aims to ensure

that the woman has a good experience of care and

reduces the likelihood of problems for her and her

baby.

All indicators remain within normal variation.

Oldham

Care Organisation

Lea

din

g &

Sig

na

l M

etr

ics

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21



Maternity & Children's Services

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%



0.00%

5.00%

10.00%

15.00%

20.00%

25.00%



92.0%

94.0%

96.0%

98.0%

100.0%


Actual Mean UCL LCL


5/8

NCA #

274

090

06/2

9/20

20 09:

32:5

3

28/74

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

Admissions to Permanent Care

(65yrs+ - Nursing and Residential 811.5 per 100,000)

Successful Reablement

(65yrs+ at 91 days - 80%)

Delayed Transfers of Care

(Attributed to Social Care - 3.5%)

Preventing Admissions: Equipment

(Delivery of Equipment within 1 day - 90%)

(Some Social Care metrics are a month in arrears) KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation,

Timeliness of Assessment

(Delivered within 14 days)

Ambition: 85%

Timeliness of Package

(Delivered within 14 days)

Ambition: 50%

Emergency Admissions

(65yrs+)

Emergency Readmissions

(65yrs+)

Score

Salford

Care Organisation

Commentary Data has not been provided by Salford City Council for March, April or May 2020 due to COVID-19 pressures.

This signal indicator provides the percentage of contact

assessments completed within 14 days of request.

This signal indicator provides the percentage of packages

of care implemented within 14 days of assessment.

This signal indicator provides the number of emergency

admissions for over 65yrs.

(Salford CCG population only)

This signal indicator provides the rate of emergency

readmissions within 28 days for over 65yrs.

(Salford CCG population only)

Ke

y M

etr

ics

Commentary Data has not been provided by Salford City Council for March, April or May 2020 due to COVID-19 pressures.

BA

F


Le

ad

ing

& S

ign

al M

etr

ics

Principal Risk

No Current NCA-Level BAF Risks

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%


Actual Target Mean UCL LCL


Social Care

9800

10000

10200

10400

10600

10800

11000

11200

11400


Actual Mean UCL LCL

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Actual Target Mean UCL LCL

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%


Actual Mean UCL LCL


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

HSMR

(Hospital Standardised Mortality Ratio)

Weekend HSMR

(Hospital Standardised Mortality Ratio - Saturday & Sunday)

SHMI

(Summary Hospital-Level Mortality Indicator - Quarterly)

KEY: Better than Expected, Worse than Expected, As Expected

Clostridium Difficile

(Occurrences)

Pressure Ulcers

(Grade 2+ Occurrences)

Falls

(Moderate Harm and above)

Score Score Score

13

Principal Risk






Le

ad

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ign

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Me

tric

sB

AF



Commentary

Description

Description

Description

Quality and Safety indicators are within normal variation across Bury & Rochdale and the Oldham Care Organisations.

Salford has seen an increase in levels of C.Dif and root cause analysis is underway.

The latest position for HSMR is the 12 month rolling position

from August 2018 to July 2019. HSMR currently stands at

105 and weekend HSMR is 108.6 This is statistically as

expected.

The latest position for SHMI is the 12 month rolling position

from April 2018 to March 2019 and is statistically as

expected at 104.34.

Clinical teams continue to prioritise mortality review and

review of high HSMR basket groups through the Care

Organisation Mortality Oversight Group (COMOG). The Care

Organisation is also prioritising improvement of the number

of structured judgement reviews completed.

Due to data issues with the Hospital Episodes Statistics

(HES) extract used for SHMI, the data will not be updated

and refreshed until May '20. Local early indicator data will be

supplied to COMOGs to compensate.

The latest position for HSMR is the 12 month rolling position

from July 2018 to August 2019. HSMR currently stands at

83 and weekend HSMR is 84. This is statistically better than

expected.


from August 2018 to September 2019 and is statistically

better than expected at 94.9

The Salford Care Organisation has been unaffected by the

Hospital Episodes Statistics data issues.

Oldham

Care Organisation

Salford

Care Organisation

Ke

y M

etr

ics

Commentary

The latest position for HSMR is the 12 month rolling

position from August 2018 to July 2019. HSMR currently

stands at 102 and weekend HSMR is 105. This is

statistically as a expected.


from April 2018 to March 2019 and is statistically as

expected at 109.18



and refreshed until May '20. Local early indicator data will

be supplied to Care Organisation Mortality Oversight

Groups to compensate.

Bury & Rochdale Care Organisation

Fairfield Rochdale

The latest position for HSMR is the 12 month rolling

position from August 2018 to July 2019. HSMR currently

stands at 84 and weekend HSMR is 56.7. This is

statistically as expected.

The latest position for SHMI is the 12 month rolling

position from April 2018 to March 2019 and is statistically

as expected at 66.68



and refreshed until May '20. Local early indicator data will

be supplied to Care Organisation Mortality Oversight

Groups to compensate.

0

2

4

6

8

10

12

14

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL


Quality & Safety

0

2

4

6

8

10

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

3

6

9

12

15

18

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Trajectory Mean UCL LCL

0

2

4

6

8

10

12

14

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

2

4

6

8

10

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

3

6

9

12

15

18

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0

2

4

6

8

10

12

14

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

2

4

6

8

10

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL

0

3

6

9

12

15

18

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Trajectory UCL LCL

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Agency Spend: Nursing & Midwifery

Local Trajectories

Agency Spend: Medical & Dental

Local Trajectories

Stability Index: Nursing & Midwifery

Target:

Stability Index: Medical & Dental

Target:


Sickness Absence

Target: NES COs 5% | SCO 3.6%

Vacancy Rate: Nursing & Midwifery

(%)

Vacancy Rate: Medical & Dental

(%)

Nursing Fill Rates

(%)

Le

ad

ing

& S

ign

al

Me

tric

sK

ey

Me

tric

s

Commentary

Bury & Rochdale

Care Organisation

Oldham

Care Organisation

Salford

Care Organisation

Commentary

Sickness absence has increased significantly across all Care Organisations as a result of COVID-19, including requirements for self-

isolation.

Vacancy rates across all staff groups remain stable and fill rates are in line with trend.

All key metrics workforce indicators remain within normal variation across our Care Organisations.

0.00%

5.00%

10.00%

15.00%

20.00%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL Trajectory

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


Pennine Acute Hospitals NHS TrustIntegrated Performance Scorecard

Workforce

0%

10%

20%

30%

40%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


-10%

0%

10%

20%

30%

40%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0%

2%

4%

6%

8%

10%

12%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Mean UCL LCL Target

0%

2%

4%

6%

8%

10%

12%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


75%

85%

95%

105%

115%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21

Actual Day Actual Night

75%

80%

85%

90%

95%

100%

105%

110%

115%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0.00%

5.00%

10.00%

15.00%

20.00%

Ap

r-19

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-20

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0%

10%

20%

30%

40%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


0%

2%

4%

6%

8%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


75%

80%

85%

90%

95%

100%

105%

110%

115%

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

Dec

-19

Jan

-20

Feb

-20

Mar

-20

Ap

r-2

0

May

-20

Jun

-20

Jul-

20

Au

g-2

0

Sep

-20

Oct

-20

No

v-2

0

Dec

-20

Jan

-21

Feb

-21

Mar

-21


These scorecards are designed to be reviewed on-screen. For printed copies, please consider A3.

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Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT) & Pennine Acute Hospitals NHS Trust (PAT)

Meeting Group Committees in CommonAuthor Care Organisations Finance ManagementPresented by Ian Moston, Chief Finance OfficerDate 29th June 2020Executive Summary SRFT : The year to date position before the retrospective top up payment is

a deficit of (£3.6m). This is an improvement of £4.3m compared to the (£7.9m) deficit at month 1 which for month 2 represents a negative top up or repayment of funding to NHSE of £4.3m. After including the retrospective top up the SRFT adjusted financial positon is break even.PAT : The year to date position before the retrospective top up payment is a deficit of £10.7m. After including the retrospective top up the PAT adjusted financial positon is break even.

Annual Plan Objective We will work with partners to ensure financial plans are sustainable and deliver on our annual income and expenditure budgets

Principal Associated Risks

3.2.1 IF we do not generate sufficient cash over a 3 year period THEN we may not be able to support the planned investment and meet operational costs3.2.2 IF the planned activity and income levels and/or expenditure controls are exceeded leading to NHSI Use of Resources rating lower than planned THEN this will increase regulatory investigation & intervention and put at risk Provider Sustainability Funding

Recommendations Group Committees in Common is asked to review and approve the reported financial position of each Trust.

Equality N/A





Under the Data Sharing Agreement, the NCA may be required to share this paper with MFT. This is distinct from information disclosed under the FOIA. As MFT will acquire part of PAT they will need to understand a range of matters which may otherwise be exempt under FOI e.g. contracts to be split and specific workforce-related issues.

Please consider the statements below and indicate which applies in relation to this paper:

Data Sharing Agreement with Manchester University NHS FT (MFT) in relation to the Transaction

a) This paper relates solely to PAT and can be released

Title of Report Finance Report as at 31st May 2020 (Month 2)

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b) This paper relates solely to SRFT and is therefore not eligible for release

c) This paper contains information relating to both PAT and SRFT. All information other than that relating to PAT will be fully redacted.

d) This paper contains reference to both PAT and SRFT but

contains no quality, finance or operational performance data relating to PAT which could be relevant to the transaction and is therefore not eligible for release.

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Contents Page

Group Performance Summary as at 31st May 2020 4

1. PAT : Summary Dashboard as at 31st May 2020 10

2. SRFT : Summary Dashboard as at 31st May 2020 11

Appendix A PAT Income and Expenditure Position as at 31st May 2020 12

Appendix B PAT Income and Expenditure Run Rate 13

Appendix C PAT Balance Sheet as at 31st May 2020 14

Appendix D PAT Cash Flow as at 31st May 2020 15

Appendix E PAT Capital Expenditure as at 31st May 2020 16

Appendix F PAT COVID-19 Capital Expenditure as at 31st May 2020 17

Appendix G SRFT Income and Expenditure Position as at 31st May 2020 18

Appendix H SRFT Income and Expenditure Run Rate 19

Appendix I SRFT Balance Sheet as at 31st May 2020 20

Appendix J SRFT Cash Flow as at 31st May 2020 21

Appendix K SRFT Capital Expenditure as at 31st May 2020 22

Appendix L SRFT COVID-19 Capital Expenditure as at 31st May 2020 23

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Group Performance Summary as at 31st May 2020

Bury and Rochdale

£000

North Manchester (Managed by MFT)

£000

Oldham

£000

Group Functions

£000

PAT

£000

Salford

£000

Group Functions

£000

SRFTHosted

£000

SRFT(Including Hosted)

£000

Group

£000Income 32,821 30,526 38,206 31,152 132,705 108,128 29,846 18,670 156,644 289,349Expenditure (27,274) (26,339) (30,026) (44,252) (127,891) (104,434) (28,756) (19,266) (152,456) (280,347)EBITDA 5,547 4,187 8,180 (13,100) 4,814 3,694 1,090 (596) 4,188 9,002Depreciation and Amortisation

(3,795) (3,795) (2,481) 0 0 (2,481) (6,276)

Financing Costs (1,019) (1,019) 0 (1,755) 0 (1,755) (2,774)

Surplus / (Deficit) 5,547 4,187 8,180 (17,914) 0 1,212 (665) (596) (48) (48)

Cash Balance £89.1m £174.1m £263.2m

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Group Financial Commentary as at 31st May 2020

Post COVID-19 arrangements

In response to the exceptional circumstances arising from the impact of the COVID-19 pandemic, NHSE/I issued a new financial framework for all NHS foundation and non foundation trusts for the period 1 April to 31 July. The temporary revision to the financial regime was one of the actions taken to remove routine NHS burdens to devote maximum operational effort to COVID-19 readiness and response for the duration of the crisis, and to ensure that NHS organisations have sufficient funding to respond to the crisis. The framework has the following key features:-

• Payment by results (PBR) and the associated contracting and commissioning have been temporarily suspended and replaced with a new financial model comprising of a block contract between each commissioner and the Trust, alongside centrally paid top ups.

• Financial Recovery Funding (FRF), Provider Sustainability Funding (PSF) and Marginal Rate on Emergency Tariffs (MRET) funding have all also been temporarily suspended.

• The block contract values have been calculated centrally using source data from the national month 9 2019/20 Agreement of Balances exercise.

• The block contract values have been adjusted to fund providers gross i.e. no efficiency factor has been applied.

• In addition to the monthly block contract an initial central top up will be paid each month to bring each Trust up to its underlying cost position based on an average of costs and non commissioner income during months 8-10 in 2019/20.

• Where a Trust’s monthly expenditure exceeds income from all sources including the monthly block and central top up, and these costs are reasonable, a final top up will be paid to bring the Trust to a break even position.

• Incremental costs associated with responding to COVID-19 are included in the above block and top up model in terms of reimbursement, but are identified and reported separately to NHSE\I.

• The nationally calculated budgets and NHSE\I financial performance measures for months 1 - 4 are based on the above methodology, replacing the plan submitted by each Trust in early March with its accompanying BCLC requirement.

• The monitoring of the BCLC programme is currently paused although divisions are encouraged to continue to add new schemes to e-Hub as usual.

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SRFT Position

The year to date position before the retrospective top up payment is a deficit of (£3.6m). This is an improvement of £4.3m compared to the (£7.9m) deficit at month 1 which for month 2 represents a negative top up or repayment of funding to NHSE of £4.3m. After recognising the net retrospective top up for month 1 and repayment for month 2 the adjusted financial position is break even (actual position is a £48k deficit due to donated asset depreciation which is excluded from the above block / top up model).

£m £m £m M1 M2 YTDNHSI Assumed Position Post Block & Top Up 0 0 0 Note COVID-19 Additional cost 5.5 11.3 16.8 1Mitigating Underspends (1.7) (2.7) (4.4) 2Reference Period Issues 0.9 0.5 1.4 3Non Clinical Commissioner Income 1.2 (14.5) (13.3) 4Loss Of Commercial Income 0.5 0.6 1.1 5Additional 20/21 Costs 1.5 0.5 2 6Deficit Pre Final COVID-19 Top Up 7.9 (4.3) 3.6

The key drivers behind the £3.6m difference to the block / top up calculation are:-

1. COVID-19 expenditure (£16.8m) YTD. The in-month COVID-19 expenditure includes provisions totalling £5.8m for contracts / services that may no longer be viable post-COVID-19, plus a further £2.0m accrual for stakeholder repayment to GMH&SCP which is recorded as a COVID-19 related expense as it becomes a cost pressure due to the current financial regime suspending our 2020/21 financial plan. There is a risk that NHSE&I will not accept these financial transactions as COVID-19 related expenditure and may dispute these as expenses for which additional top-up income is allowed; however, the regional NHSE&I were alerted to our plans to include provisions in our month 2 results before we submitted our financial returns for May and are aware of and understand our rationale for inclusion. The balance of the year to date COVID-19 costs relate to increased pay costs (£4.1m) which are driven by a combination of increased additional shifts (£0.5m), backfill for sickness (£1.7m) and expansion of workforce (£1.3m). Non pay COVID-19 expenditure also includes a further £1.8m for procurement of PPE, Hitachi costs of the Digital Control Centre of £0.5m originally to be funded via benefits, and stranded costs as a result of COVID-19 in NES Community Services and AQuA of £0.5m.

2. There has been a £4.4m reduction in the run rate due to the suspension of the Trust’s planned elective programme as part of the COVID-19 response. The majority of the savings are on medical and surgical purchases within theatres and ICD linked to the reduction in activity. There has been a reduction in bank and agency spend on nursing and medical staff in non COVID-19 areas also linked to a reduction in clinical activity.

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3. The timing of the reference period in 2019/20 for the temporary block and top up calculation has resulted in various non recurrent adjustments in this period reducing the value of the initial top up paid to SRFT. The month 8-10 2019/20 reference spend was suppressed due to non recurrent actions taken to deliver the quarter 3 financial position totalling £1.8m and also excludes stakeholder repayments which were paid as an annual amount at year end outside the reference period. The impact of this and other smaller timing differences has the effect of undervaluing the monthly top up payment to SRFT by £1.4m.

4. The block and top up model excludes commissioner income in the reference period which was unrelated to clinical activity and cannot therefore continue to be earned over and above the block contract. The impact of this is to undervalue the initial monthly top up payment required by £2.2m however this is offset by £15.4m of additional ASC income which continues to be received despite being excluded from the reference period top up calculation. This has resulted in the overall monthly top up figure being overstated by a total of £13.3m year to date.

5. The value of commercial income received by the Trust outside the block and top up model has fallen by £1.1m. The majority of this is lost car park income of £0.4m and a reduction in income from private patients and overseas visitors of £0.6m.

6. There are new costs which have been incurred by SRFT in 2020/21 which are over and above those included in the reference period and therefore not included in the initial top up. The most significant of these is an increase to depreciation and PDC dividends of £0.8m and CEA payments made year to date of £0.6m.

Cash: The cash position at the end of May is higher than usual at £174.1m. This is due, in the main, to commissioners making accelerated block contract payments under the temporary financial framework to ensure that no provider should require any emergency loan funding due to insufficient cash.

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PAT Position

The month 2 position is a deficit of £5.2m and year to date £10.7m. After including the retrospective top up the PAT adjusted financial positon is break even.

The monthly block contract values from commissioners have been set at £53.3m, alongside a monthly top up derived from the underlying cost base in 2019/20 of £4.1m. Prior to the final top up being taken into account the financial position for month 2 was a £5.2m deficit. After including the final top up, the adjusted financial positon is break even (actual position is a £38k deficit due to donated asset depreciation which is excluded from the above block / top up model)

M1£m

M2£m

YTD£m

NHSI Assumed Position Post Block & Top Up 0.0 0.0 0.0 Note COVID-19 Additional cost 3.7 4.8 8.5 1Mitigating Underspends (3.8) (4.9) (8.7) 2Reference Period Issues 2.5 2.5 5.0 3Non Clinical Commissioner Income 0.3 0.2 0.5 4Loss Of Commercial Income 1.0 0.8 1.8 5Additional 2020/21 Costs 1.8 1.8 3.6 6Deficit Pre Final COVID-19 Top Up 5.5 5.2 10.7

The key drivers behind the £5.2m difference to the block / top up calculation are:-

1. COVID-19 related expenditure in May of £4.8m. This is made up of £0.9m B&R CO, £1.3m NMCO, £1.5m OCO and £1.1m from Group functions. The biggest areas of COVID-19 spend are the backfill of staff due to sickness /self-isolation and an expansion of the workforce to support the Trust’s response to the pandemic. Local PPE expenditure was £0.3m. The majority of PPE has been supplied and paid for nationally alongside mutual aid from SRFT.

7. There has been a £4.9m reduction in the run rate due to the suspension of the Trust’s planned elective programme as part of the COVID-19 response. The majority of the savings are on medical and surgical purchases in theatres and across ward areas linked to the reduction in activity. There has been a reduction in bank and agency spend on nursing and medical staff in non COVID-19 areas also linked to a reduction in clinical activity.

2. The timing of the reference period in 2019/20 for the temporary block and top up calculation has resulted in various non recurrent adjustments in this period reducing the value of the initial top up paid. The month 8-10 2019/20 reference spend was suppressed due to non recurrent actions taken to deliver the quarter 3 financial position totalling £5.7m.The impact of this and other smaller timing differences has the effect of undervaluing the monthly top up payment by £2.5m.

3. The block and top up model excludes commissioner income in the reference period which was unrelated to clinical activity and cannot therefore continue to be earned over and above the block contract. The impact of this is to further undervalue the initial monthly top up payment required by £0.2m.

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4. The value of commercial income received by the Trust outside the block and top up model has fallen by £0.8m. The majority of this is lost car park income of £0.3m, catering income of £0.2m and a reduction in income from CRU income of £0.2m.

5. There are new costs which have been incurred in 2020/21 which are over and above those included in the reference period and therefore not included in the initial top up. The most significant areas are due diligence (FYE impact), the impact of the pay awards and inflation above the uplift included in the block and top up payment of £0.5m. In addition repayments of stakeholder support and other minor FYE impacts have added a further £0.5m to the cost base.

Cash: The cash position at the end of May is higher than usual at £89.1m. This is due, in the main, to commissioners making accelerated block contract payments under the temporary financial framework to ensure that no provider should require any emergency loan funding due to insufficient cash.

Retrospective Top Up Payments

SRFT received £5.9m and PAT £4.5m in respect of the retrospective April top up on the 15th June. The payments were £2.0m (SRFT) and £1.0m (PAT) less than expected.

NHSI are analysing our month 1 positions before payments are released in full.

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1. PAT : Summary Dashboard as at 31st May 2020

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4. SRFT : Summary Dashboard as at 31st May 2020

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Appendices

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A. PAT Income and Expenditure Position as at 31st May 2020

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B. PAT Income and Expenditure Run Rate as at 31st May 2020

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C. PAT Balance Sheet as at 31st May 2020

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D. PAT Cash flow as at 31st May 2020

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E. PAT Capital Expenditure as at 31st May 2020

Planned funding method Capital scheme Submitted

plan Adjust Proposed

plan

Actual to 31st May

2020 £000s £000s £000s £000s

PDC MFT: HIP2 NMGH 21,100 21,100 -GM Healthier Together 16,592 16,592 -IT GDE 2,500 2,500 622NEEF 2,251 2,251 -

PDC Total 42,443 - 42,443 622Internally Funded Equipment/other schemes 10,601 2,986- 7,615 1,664

Trafford Orthopaedic schemes 5,995 12 6,007 4Stabilising Technology Infrastructure 2,300 1,140 3,440 2,821UEC 1,980 65- 1,915 -Energy schemes (NMGH/ROH) internally funded 427 351 778 613GM Healthier Together (internally funded) - - 189

Internally Funded Total 21,303 1,548- 19,755 5,291

Loans (Interim)- approved IT urgent remediation 3,000 3,000 -Loans (Interim)- approved Total 3,000 - 3,000 -

Loans other (e.g. Salix) Energy schemes (NMGH/ROH) SALIX funded 3,423 3,423 -Loans other (e.g. Salix) Total 3,423 - 3,423 -

Loans (Interim)- to be approved ROH ward refurbs/ED/Wave 4 extra 21,398 21,398- -IT due diligence 17,845 5,845- 12,000Equipment 13,300 2,651- 10,649Estates/Facilities (aggregated no item > del limit) 13,100 13,100IT stabilisation 8,700 7,200 15,900IT preparation for acquisition 7,200 7,200- -EPR 5,300 5,300- -Estates 3,200 3,200- -

Loans (Interim)- to be approved Total 90,043 38,394- 51,649 -Grand Total (excluding Covid) 160,212 39,942- 120,270 5,913

PDC COVID schemes 4,398 4,398 1,273Grand Total (Including Covid) 160,212 35,544- 124,668 7,186

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F. PAT COVID-19 Capital Expenditure as at 31st May 2020

PAT Covid-19 Capital Spend TotalKetone Meters 12,018Laryngoscopes 42,934Pre-Owned Pneupac Ventipac Ventilators 2,070Resmed CPAP *100 34,800Ventmed 5 PEEP Oxygen Max consumables 50,400Training / Test Lungs - Adult 4,766Beds For Critical Care 65,400Blood Gas Testing System 420,000Ceiling Hood 43,888Vocera Platform For Clinical Communications 92,700Mechanical Chest Compression Device *7 70,107Blood Pressure Monitors 3,140Laerdal Suction Unit 11,981Glidescope Core 10 20,160Personal Oxygen Enrichment Monitors 65,486Cytokine Absorber 44,348Nebuliser 1,715Medmix Mini 6,840Ketone Meters 6,018Video Glidescopes X 2 19,200Ventmed 5 PEEP Oxyen Max Consumables 29,400Vocera Hardware 9,198Professional Services - Matthew Barker 2,280Duracell sync / charge cables 1,906COVID19 - IPADS *400 151,882Dialysis machine (COVID-19) 14,400Rochdale Mortuary 31,259Dialysis machine (COVID-19) 14,400

1,272,697

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G. SRFT Income and Expenditure Position as at 31st May 2020

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H. SRFT Income and Expenditure Run Rate as at 31st May 2020

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I. SRFT Balance Sheet as at 31st May 2020

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J. SRFT Cash flow as at 31st May 2020

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K. SRFT Capital Expenditure as at 31st May 2020

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L. SRFT COVID-19 Capital Expenditure as at 31st May 2020

SRFT Covid-19 Capital Spend TotalExtension cable and Finger sensors 2,480iStat 2,319iStat (8 additional for CC) 59,117Syringe Pumps 38,064GE ECG accessories 9,095Cough Assist 21,600Medtronic assesories 9,953Vital signs and BP hose 899Personal Oxygen enrichment monitors 6,660Non connected nano glucometers 377Fisher and Paykal Ventilator accessories 10,487Drip Stands 1,782Lockers for Oaklands 3,917CMAC - Consumables 1,536Nurse chart trolleys 2,540Glucose & Ketone meters 858Accu check blood test meters 3,600Infusion Pumps 15,600Difficult Airway Trolleys 2,351Oxygen Cylinder holders 163IV Poles 161Drawer insert labels 204

193,761

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Meeting Committees in Common Board

Author (s) Stephanie Woodward, Senior Planning ManagerJude Adams, Chief Delivery Officer

Presented by Jude Adams, Chief Delivery Officer

Date 29th June 2020

Executive Summary

This interim Single Oversight Framework (SOF) has been developed to cover the remainder of the financial year 2020/21, recognising the changes in focus and challenges that have arisen from the COVID-19 pandemic.

For quarter 1 of 2020/21, interim arrangements were put in place through Group Strategic Gold Command which in line with our Major Incident Policy ensured oversight of all Group business and operations throughout the peak wave of the pandemic management. As we move from Level 4 incident status nationally and transition into the restoration and recovery phases of incident management we must safely move to new organisational governance and oversight arrangements of our annual plans and objectives.

This interim Single Oversight Framework (SOF) supersedes all previous versions of the Single Oversight Framework and should be reviewed prior to expiry in March 2021.

It is recognised that the usual NCA process of annual business and operational planning has taken a different approach this year; it has instead been replaced by 3 phases of organisational planning aligned to a revised national and regional planning framework in response to the Covid pandemic.

The current version of the Single Oversight Framework describes the accountability of Care Organisations (COs) and the Diagnostics and Pharmacy (D&P) Group Business Units and the process by which CO and D&P oversight takes place resulting in a segmentation rating and associated actions for improvement .

This version of the SOF focuses oversight for the recovery period on the effectiveness of action plans to mitigate significant risks, with additional focus on those risks related to COVID recovery and statutory requirements. It also extends to include Group E&F functions.

Assurance of progress and oversight of these matters will be evidenced and reviewed via Statements of Assurance (SoA) presented to the Group Risk and Assurance Committee.

Annual Plan Objective

All planning objectives

Title of Report Interim Group Single Oversight Framework

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Associated Risks All BAF risks

Recommendations The committees in common are asked to:

1. Note the changes in oversight from Gold Command structures which were in place for Quarter 1 of 20-21 at the peak of the COVID Pandemic and which were in line with Group Major Incident Policy.

2. Approve the Interim Single Oversight Framework for 2020/21

Equality Does this paper relate to a matter where equality issues may arise? Y/NIf so, has due regard been given to equality analysis of any adverse impactsThis document does not contain confidential information and can be made available to the public.




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Northern Care AllianceInterim Single Oversight Framework

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1. SOF Approach

For the remainder of 20/21 the NCA Single Oversight Framework will focus on the delivery of recovery (including associated trajectories, targets and plans) through review of significant risk actions plans, key controls and assurances to achieve target risk levels by the end of the year.

Via their Statements of Assurance, COs, D&P and E&F, will be required to:

Identify the target risk profile for all principal and significant operational risks, profile the journey to this target over the rest of the year and track actual risk change against expected;

Assess the effectiveness of clearly identified controls and appropriate assurances, identifying remedial actions as necessary, to ensure actual risk change matches target profiling;

Describe actions that effectively address gaps in controls, update on progress to date and an evaluation of their impact on the current risk profile;

Identify timely remedial actions, where completed actions are not controlling the risk as expected, outlining clear plans monitored by COARC that set out the what, by whom and when.

A revised Statement of Assurance Template has been created, which will ensure the above information is adequately captured and evidenced.

Alongside the risk based approach, assessment will be made of leadership and improvement

capability (well-led). Care Organisation and Group Directors must demonstrate three main

characteristics – effective management of teams and governance, continuous improvement

capability and effective use of data.

Alongside evidence and risk management provided via the Statement of Assurance sources to assess

Director leadership includes:

information from Group Executive Risk & Performance Committees information from locality leaders and third parties staff/patient surveys/temperature checks organisational development metrics internal ‘well-led governance’ assessments application of the Learning Framework effective deployment of the Group Strategy and objectives Contribution to and effective delivery of major improvement programmes

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2. Care Organisation and D&P Assessment

This Interim Single Oversight Framework will be in place throughout the remainder of 2020/21, replacing the previous segmentation approach Care Organisation, Diagnostics & Pharmacy and Estates and Facilities will instead be rated as Effective, Requires Recovery, or Executive Support

EffectiveWhere the Statement of Assurance provides evidence that the risks are well articulated, plans are effectively implemented and significant risks are controlled, the Care Organisation/Group Diagnostics & Pharmacy and Estates and Facilities will be rated as Effective.

Requires Recovery Where the SoA does not provide evidence that meets the above criteria, and the plans are failing to progress the CO/ D&P/E&F will be rated as Requires Recovery. In this situation, the CO/ D&P/E&F will be asked to review their risk management processes along with their controls and action plans for current risk and submit an improvement plan within 4 weeks to the following Group Risk Committee. Support and additional capacity for this process will be provided via Corporate Directors and experts from across COs.

Executive SupportIn a situation where a Care Organisation or Group D&P or E&F are rated as Requires Recovery for one whole quarter and where the resubmitted SoA and plans continue to fail to meet the criteria to evidence adequate delivery, risk management and control, the Care Organisation/Group Diagnostics & Pharmacy and E&F will be rated Executive Support. In this instance Group Executive Directors will work alongside Care Organisation/Group Directors and their teams to help drive the necessary improvement.

Leadership assessment will be considered using the sources outlined above at the end of each quarter when Care Organisation and Group Business Units ratings are reviewed.

3. Completing the Statement of Assurance Template

The new SoA template has been created so that it is easy to identify if the above risk management criteria has been satisfied, and clearly evidence the logical and well thought out risk control that is being undertaken across the NCA. The SoA should be completed in line with the NCA Risk Management Strategy (RMS).

The majority of information for the SoA should be contained within the relevant BAF/Risk Register and should be able to be easily copied across, with the focus of the SoA to be to assess the effectiveness of the controls and actions identified as part of the BAF/Risk Register.

Completing your Risk Profile

The Initial and Target Risk Profile should be assessed in line with the RMS and should not change. The Target Risk Profile should show how you expect the impact of your actions to reduce the Risk Profile over time. The Actual Risk Profile should be updated on each submission of the SoA. Where this differs from the Target, this may indicate a failure in controls or proposed actions either haven’t been completed or have not had the

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intended impact and should be detailed in the actions sections below. The frequency of both the Target and Actual can be adjusted to monthly by adding additional columns.

Risk title IF xxxxx THEN xxxxxx Current Risk Profile

15

Initial Risk Profile Target Risk Profile Q1 Target Risk Profile Q2 Target Risk Profile Q3

Target Risk Profile Q4

15 14 13 12 11Actual Risk Profile ARP Q1 ARP Q2 ARP Q3 ARP Q4

15 15 15

Effectiveness of Controls

Appropriate controls to manage risks should be identified within the BAF/Risk Register, within the SoA you are asked to rate the effectiveness of these controls, provide detail behind your assessment and where controls are not deemed effective, identify remedial actions to rectify this.

Current controls Effectiveness Detail Remedial actionsControl requires improvement

Control having desired effect

Control failing

Action Plan Update

In each submission of the SoA, you will be asked to capture the actions taken and completed as per described Care Organisation plans within that period, including any actions that were due to take place but have not. It is essential that the actions identified within your plan are clearly related to the gaps in controls and can be tracked over a period of time. Each action should be assessed to identify whether it has had the desired impact on controlling the risk. Where the impact will take longer to identify, the actions should remain on the list until such point. If the desired impact has not been achieved, it should be understood why and remedial actions should be included and tracked over time.

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Adjusting the target risk profile

If all controls are effective and actions have the desired impact, then the risk should reduce in line with the Target Risk Profile. However, where controls and/or actions have deemed ineffective and associated remedial actions have also failed to control the risk, it may be appropriate to adjust the Target Risk Profile – acknowledging that the risk cannot be reduced. In such instances the Care Organisation/Group Diagnostics & Pharmacy and Estates and Facilities should propose any adjustment and ensure this is appropriately documented and described in the SoA.

Actions to date Status Impact Impact-Detail Remedial Actions/Next Steps

Update Training & Retrain Staff

Complete/ Delayed / Tracking

Some impact on risk, however not as fully expected – e.g. reduced errors by 50% but not the 70% target

Obtain feedback on training processConduct RCA on errors still occurring etc etc

Full impact achieved – e.g. hit target of 70% reduction of errors

Update Actual Risk Profile and close action

Impact not achieved – no reduction in errors Obtain feedback on training processConduct RCA on errors still occurring etc etcIdentify other causes of errors

Impact not expected to be seen until August Continue to track until assessment of impact can be made

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1. Area/Theme:

Risk title IF xxxxx THEN xxxxxx Current Risk Profile

Initial Risk Profile Target Risk Profile Q1 Target Risk Profile Q2 Target Risk Profile Q3 Target Risk Profile Q4

Actual Risk Profile ARP Q1 ARP Q2 ARP Q3 ARP Q4

Current controls Effectiveness Detail Remedial actions

Actions to date Status Impact Impact – Detail Remedial Actions/Next Steps

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The Northern Care Alliance NHS GroupSalford Royal NHS Foundation Trust (SRFT)

Meeting Group Board (Committees in Common)Author Rebecca McCarthy, Deputy Trust Secretary

Presented by Tim Crowley, Chairman of Audit Committee

Date 29th June 2020

Executive Summary

A summary is provided for the Group Board of the key matters and decisions from the Audit Committee meeting on 19th June 2020.

Annual Plan Objective

N/A

Principal Associated Risks

N/A

Recommendations The Group Board is asked to review the summary and the agreed actions from the meetings held on 19th June 2020

Equality Does this paper relate to a matter where equality issues may arise? NoThis document does not contain confidential information and can be made available to the public.




Title of Report Report from Group Audit Committee – 19th June 2020

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Summary of Group Audit Committee meeting held on 19th June 2020

Present: Mr Tim Crowley, Chairman of Audit Committee Mrs Carmen Drinkwater, Non-Executive Director Mrs Chris Mayer CBE, Vice-ChairmanProfessor Chris Reilly, Senior Independent DirectorDr Hamish Stedman, Non-Executive Director

Attendance: Mrs Jane Burns, Director of Corporate Services/Group SecretaryMr Darrell Davies, Assistant Director, MIAAMrs Sarah Dowbekin, Internal Audit Engagement Manager, MIAA Mr Mark Heap, Engagement Lead, External Auditor Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer (Item ??)Mrs Diane Morrison, Finance Director, Salford Care OrganisationMr Ian Moston, Chief Financial OfficerMr Stephen Nixon, Engagement Manager, External AuditorMr Stephen Ridgway, Group Head of Financial Control Mrs Nicky Tamanis, Deputy Chief Financial Officer

Apologies: Mr Chris Brookes, Chief Medical Officer Mr Kieran Charleson, Non-Executive Director

Year End Matters – Salford Royal NHS Foundation Trust (SRFT)

1. SRFT Annual Self-Certifications including:− General Condition 6− FT Condition 4− Training of Governors− Continuity of Services CoS7

Reviewed and approved including declarations required by General Condition 6 of the NHS Provider Licence, FT Condition 4, Training of Governors and Continuity of Services CoS7.

2. SRFT Annual Report (including Annual Governance Statement) 2019/20 – Reviewed and approved

3. SRFT Audited Annual Accounts 2019/20 – Reviewed and approved subject to resolution of outstanding items

4. External Auditor: SRFT Audit Findings Report (ISA 260) – Reviewed and confirmed subject to resolution of outstanding items

5. SRFT Letter of Representation: Financial Statements – Reviewed and confirmed subject to resolution of outstanding items

Year End Matters – Pennine Acute Hospitals NHS Trust (PAHT)

As part of the PAHT Interim Governance Arrangements it was agreed that the NCA Audit Committee would develop and receive the PAHT Annual Report and Accounts, including Annual Governance Statement, Letter of Representation, Response to Auditors, Annual Self-Certifications and Head of Internal Audit Opinion 2019/20.

The final PAHT Annual Report and Accounts and all year-end statements have been provided to PAHT Audit Committee, with a supporting Assurance Statement from NCA Audit Committee, ahead of the final submission date.

The External Auditor Opinion will be reported separately to PAHT Audit Committee, comprising of ‘Those Charged with Governance’ for PAHT ahead of the final submission date

6. PAHT Annual Self-Certifications including:- General Condition 6- FT Condition 4

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7. PAHT Annual Report (including Annual Governance Statement) 2019/20 – Reviewed and confirmed as presented

8. PAHT Audited Accounts 2019/20 – Reviewed and confirmed as presented noting outstanding items

9. External Auditor: PAHT Audit Findings Report (ISA 260) – Reviewed and confirmed as presented subject to clearance of outstanding items

10. PAHT Letter of Representation: Financial Statements – Reviewed and confirmed as presented subject to clearance of outstanding items

11. Assurance Statement from NCA Audit Committee to PAHT Audit Committee – Reviewed and approved subject to inclusion of an addendum confirming the comprehensive discussion with respect to the Audited Accounts 2019/20 and External Auditor Findings Report (ISA 260).

12. Group Reference Costs Assurance Process – Reviewed and approved.

13. Financial Governance including Covid-19 Expenditure – Reviewed and confirmed the effectiveness of the financial governance arrangements in place for the period of the major incident.

14. Declarations of Interest and Gifts & Hospitality – Reviewed and confirmed the processes in place for the management of interests and gifts and hospitality, including processes established in response to the Covid-19 pandemic.

15. Clinical Audit Progress Report and Work Programme 2020/21 – Reviewed and confirmed.

16. Internal Audit & Counter Fraud Proposal 2020-21 – Reviewed and approved, noting further iteration may be required in response to key risk areas emerging during recovery.

17. Outcome of Audit Committee Self-Assessment & Work Plan 2020/21 Re-set - Reviewed and approved.

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Audit Committee Terms of Reference

Author Jane Burns, Director of Corporate Services/ Group SecretaryContact email address

[email protected]

Date approved DRAFTApproval route Group Committees in CommonApplies to Northern Care Alliance GroupKeywords Audit, Audit Committee, ToR, Terms of ReferenceExpiry date 30th April 2021

1.0 Definition (Constitution)

1.1 The Group Committees in Common (Group CiC), established by the Boards of Salford Royal NHS Foundation Trust (SRFT) and Pennine Acute Hospitals NHS Trust (PAT), has delegated authority to appoint an Audit Committee.

To establish an Audit Committee to exercise relevant statutory functions for the two trusts (SRFT and PAT), the Group CiC hereby resolves to appoint an Audit Committees in Common (Audit Committee).

Audit Committee will meet at the same time, around one table, to make decisions in relation to SRFT and PAT. It will also review the establishment and maintenance of an effective system of integrated governance, risk management and internal control that support the achievement of Group objectives and its constituent Care Organisations.

Herein after, the Audit Committees in Common will be known as and referred to by its short title ‘Audit Committee’.

Audit Committee is a non-executive committee and has no executive powers, other than those specifically delegated in these Terms of Reference.

Audit Committee is authorised by the Group CiC to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Audit Committee. Audit Committee is authorised by the Group CiC to obtain outside legal advice or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

1.2 The main role and responsibilities of the Audit Committee are set out in these Terms of Reference and are publicly available on the internet.

1.3 The Council of Governors will be consulted on these terms of reference, which will be reviewed and refreshed regularly.

1.4 The Chairman of Audit Committee will provide report to the Council of Governors identifying any matters in respect of which it considers that action or improvement is needed and making recommendations as to the steps to be taken.

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2.0 Purpose and Powers (Duties: Governance, Risk Management and Internal Control)

2.1 Audit Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of Group, SRFT and PAT’s activities (both clinical and non-clinical), that support the achievement of the organisations’ objectives.

2.2 In particular, the Audit Committee will review the adequacy of:

2.2.1 All risk and control related disclosure statements (in particular the Annual Governance Statement), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances.

2.2.2 The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements

2.2.3 The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements

2.2.4 Review the policies and procedures for all work related to fraud, bribery and corruption as set out within NHS Standard Contract Service Condition 24 and as required by NHS Counter Fraud Authority’s Standards for Providers.

2.2.5 The system of risk management across the whole of the organisations’ activities (clinical and non-clinical) and receive regular monitoring information against the management of risks judged as ‘significant’ and provide verification to the Group Committees in Common on the systems in place for the management of risk across the Group.

2.2.6 The arrangements by which staff can raise issues in confidence about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters. Audit Committees objective will be to ensure arrangements are in place for the proportionate and independent investigation of such matters and appropriate follow-up action.

2.3 In carrying out this work, Audit Committee will primarily utilise the work of Internal Audit, External Audit, and Group Executive Committees but will not be limited to these. Audit Committee will work closely with the Group Executive Risk and Assurance Committee. The work of the two committees needs to be linked so that the Group CiC can be confident that there is an aligned independent and executive focus on strategic risk and assurance. This will be achieved through committee work plans underpinned by the Assurance Framework, agreed priorities, routine referral of issues between committees so that there is respective understanding of risk and assurance concerns. It will also seek reports and assurances from directors and managers as appropriate, concentrating on overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

2.4 This will be evidenced through Audit Committee’s use of the Group Board Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

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2.5 Audit Committee will have access to Assurance Groups within Care Organisations in order to seek assurances or explanations.

3.0 Purpose and Powers (Duties: Internal Audit)

3.1 Audit Committee shall ensure that there is an effective internal audit function established by management that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive, Group CiC, Care Organisations and the SRFT and PAT Boards. This will be achieved by:

3.1.1 Consideration of the provision of Internal Audit service, the cost of the audit and any questions of resignation and dismissal

3.1.2 Review, alignment and approval of the Internal Audit strategy, operational plans and more detailed programmes of work, ensuring that this is consistent with the audit needs of the organisations as identified in the respective Assurance Frameworks and delivers Group level efficiencies and outcomes.

3.1.3 Consideration of the major findings of internal audit work (and management response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources. This will include consideration of Care Organisation high risks and limited assurances that impact upon Group. It will also involve receiving progress reports and group-wide reviews together with an overview of follow up in respect of all recommendations

3.1.4 Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation

3.1.5 Receive all Head of Internal Audit Opinions (Group, statutory bodies and Care Organisations).

3.1.6 Annual review of the effectiveness of internal audit.

4.0 Purpose and Powers (Duties: External Audit)

4.1 Audit Committee shall review and monitor the external auditor’s independence and objectivity and the effectiveness of the audit process. In particular, Audit Committee shall review the work and findings of the External Auditor appointed by the SRFT Council of Governors and PAT Board and consider the implications and management's responses to their work. This will be achieved by:

4.1.1 Consideration of the appointment and performance of the External Auditor

Specific requirement for NHS Trusts, therefore applicable to PAHT:

4.1.2 Establishing an Auditor Panel to make recommendations to the Board on the appointment of an External Auditor.

4.1.3 Discussion and agreement with the External Auditors, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensure coordination, as appropriate, with other External Auditors in the local health economy

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4.1.4 Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee

4.1.5 Review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses

4.1.6 Ensuring that there is in place a clear policy for the engagement of external auditors to supply non audit services, with particular reference to the fee cap and prohibited services.

4.2. Audit Committee shall review the Annual Accounts on behalf of the Boards and approve the signing of the relevant annual accounts certificates (both Exchequer and Charitable Funds).

4.3 Audit Committee shall review that actions falling out from reports by external or internal auditors have been implemented.

4.4 Audit Committee shall review and agree the External Auditors Annual Letter, and management response to it.

4.5 Audit Committee shall consider any report issued involving the Trusts by the Public Accounts Committee or Comptroller and Auditor General and advise the Group CiC and Boards on the appropriate response.

4.6 Audit Committee shall review annually the Corporate Governance Framework documents and circumstances and instances when the Group Standing Orders (Board) are waived.

4.7 Audit Committee shall review Losses and Compensations paid and make any recommendations arising there from.

4.8 Audit Committee shall approve write-off of non-NHS debtors.

4.9 Audit Committee shall approve accounting policies.

4.10 Audit Committee shall monitor the implementation of policy of the Standards of Business Conduct and Codes of Conduct and Accountability on behalf of the Group CiC and Boards.

5.0 Purpose and Powers (Duties: Other Assurance Functions)

5.1 Audit Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation.

5.2 These will include, but will not be limited to any reviews by the Department of Health Arm’s Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Litigation Authority etc.), professional bodies with responsibility for performance of staff or functions (e.g. Royal Colleges, accreditation bodies etc.)

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5.3 In addition, Audit Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee's own scope of work. This will particularly include the Group Executive Risk and Assurance Committee.

5.4 The Audit Committee will wish to satisfy themselves on the assurances that can be gained from the clinical audit function and specifically the actions taken arising from individual clinical audits.

6.0 Purpose and Powers (Duties: Management)

6.1 Audit Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.

6.2 They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as they may be appropriate to the overall arrangements.

7.0 Purpose and Powers (Duties: Financial Reporting)

7.1 Audit Committee shall review the Annual Report and Financial Statements focusing particularly on:

7.1.1 The wording of the Annual Governance Statements and other disclosures relevant to the Terms of Reference of the Audit Committee

7.1.2 Changes in, and compliance with accounting policies and practices

7.1.3 Unadjusted mis-statement in the financial statements

7.1.4 Major judgmental areas

7.1.5 Significant adjustments resulting from audit

7.2 Audit Committee should also ensure that the systems for financial reporting to the Group CiC, including those of budgetary controls, are subject to review as to completeness and accuracy of the information provided to the Group CiC.

7.3 Audit Committee will monitor procurement and the management of non-pay spend, and specifically have oversight of the Procurement Work Plan.

8.0 Frequency of Meetings

8.1 The Committee will meet on at least five occasions throughout the year.

8.2 Meetings will be scheduled around key tasks such as consideration of the External Auditor’s Annual Letter, annual accounts and annual audit plans.

8.3 Other meetings may be called as duties require or at the request of External or Internal Auditors.

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8.4 Audit Committee will meet, on at least one occasion each year, with the External Auditors without any Executive Director or other officer present.

8.5 Similarly, the Head of Internal Audit may meet Audit Committee without Executive Director or External Auditor representatives present.

8.9 The Chief Executive and other Executive Directors should be invited to attend, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that director.

8.10 The Chief Executive should be invited to attend, at least annually, to discuss with the Audit Committee the process for assurance that supports the Annual Governance Statement.

9.0 Membership

9.1 Audit Committee appointed by the Group CiC will consist of all Non-Executive Directors, with the exception of the Chairman.

9.2 The Group’s Chief Financial Officer, Chief Nursing Officer, Chief Medical Officer, Director of Corporate Affairs (Group Secretary), Head of Internal Audit, and representatives of the External Auditors will normally attend meetings but are not members of Audit Committee. The Executive Director of Finance for SRFT and PAT (whichever is not the Group Chief Financial Officer) will have access to all papers and welcome to attend any meeting.

9.3 Other Executive Directors, Care Organisation Directors, or relevant members or staff may attend a meeting on request or by invitation of the Audit Committee Chairman.

10.0 Chairmanship

10.1 The Chair of the committee will be a Non-Executive Director. Another Non-Executive Director will Chair in the absence of the Chairman.

10.2 The Group Secretary shall be the Secretary to the Committee and will ensure appropriate minutes are recorded for each meeting. S/he will provide appropriate support to the Audit Committee Chairman and committee members.

11.0 Quorum

11.1 A Quorum will be two Non-Executive Directors.

12.0 Conduct of Meetings

12.1 The meeting will follow the following format:MinutesMatters arisingItems for discussions and decisionAny other business

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13.0 Reporting

13.1 The minutes of the Audit Committee meetings shall be formally recorded by the Group Secretary and submitted in summary to the Group CiC.

13.2 The Audit Committee Chairman shall draw to the attention of the Group CiC and Boards, any issues that require full disclosure to the Board, or require executive action.

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