the meeting of the board of directors to be held on …...2018/03/27 · the meeting of the board...

The meeting of the Board of Directors

To be held on Tuesday, 27 March 2018 at 9.00am

in the Boardroom, Montagu Hospital

AGENDA Part I

Enclosures

1. Apologies for absence

(Verbal)

2. Declarations of Interest

(Verbal)

3. Actions from the previous meeting

Enclosure A

4. Achieving Reliable Care Cindy Storer – Head of Nursing (MSK & Frailty) Becky McCombe – Senior Sister, Gresley Ward

Presentation

Reports for decision 5. Fundraising Strategy

Adam Tingle –Acting Head of Communications

Enclosure B

6. Amendments to Committee Membership Matthew Kane – Trust Board Secretary

Enclosure C

Reports for assurance

7. Chairs Assurance Logs for Board Committees held 23 and 26 March 2018 Philippe Serna – Chair of Audit & Non-Clinical Risk Committee Neil Rhodes – Chair of Finance & Performance Committee

To Follow

8. Finance Report as at February 2018 Jon Sargeant – Director of Finance

Enclosure D

9. Performance Report – February 2018 Led by David Purdue – Chief Operating Officer

Enclosure E

Reports for information

10. Chair and NEDs’ Report Suzy Brain England OBE – Chair

Enclosure F

11. Chief Executive’s Report Richard Parker –Chief Executive

Enclosure G

12. Minutes of Management Board, 12 February 2018 Richard Parker – Chief Executive

Enclosure H

13. WTP Briefing Richard Parker –Chief Executive

Enclosure I

14. To note: Board of Directors Agenda Calendar Matthew Kane – Trust Board Secretary

Enclosure J

Minutes

15. To approve the minutes of the previous meeting held 27 February 2018 Enclosure K

16. Any other business (to be agreed with the Chair prior to the meeting)

17. Governor questions regarding the business of the meeting

18. Date and time of next meeting

Date: 30 April 2018 Time: 9.00am Venue: Boardroom, DRI

19. Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Suzy Brain England OBE Chair of the Board

NOTICE FOR THE PUBLIC

DBTH is committed to ensuring its Part 1 Board meetings are open and accessible. If any adjustments need to be made in

order for you to access this meeting, please contact us.

If you are Deaf and need a BSL interpreter, or would like to request information in Braille, you can contact us at

[email protected] or text 0799 9924276.

Action Notes

Meeting: Board of Directors

Date of meeting: 27 February 2018

Location: Boardroom, BDGH

Attendees: SBE, RP, KB, MH, DP, SS, AA, LP, JP, NR, JS, PS

Apologies: PS, RA

No. Minute No Action Responsibility Target Date Update

1. 17/01/13 Director of Education to share the Teaching Hospital phase two development plan at a future Board.

MK Following discussions at

QEC

Partially complete. Research and development discussions at QEC complete. Phase 2 subject to discussions on where research sits within management.

2. 17/05/30 Once the Emergency Planning Officer had considered the existing business continuity plans, a presentation would be brought to Board and the plans would be tested by internal audit.

DP April 2018 Policy review in final stages with assurance report to come to Board in April.

3. 17/06/34 Board to meet with care group directors regarding EEPs.

MK January 2018 Complete. Meeting to take place 16 April.

No. Minute No Action Responsibility Target Date Update

4. 17/12/21 To provide assurance that risks relating to the IM&T Strategy are being managed appropriately.

SM April 2018 Risks in process of being assimilated on to Datix.

5. 18/2/13 Trust solicitors to do workshop to Board.

KB Spring/Summer To be made part of board development programme 2018/19.

Date of next meeting: 27 March 2018 Action notes prepared by: M Kane Circulation: SBE, AA, NR, KB, DJ, MH, RA, DP, JS, SS, JP, RP, LP, PS

Title DBTH Fundraising Strategy

Report to Board of Directors Date 27.03.2018

Author Adam Tingle, Acting Head of Communications

Purpose

Tick one as appropriate

Decision

Assurance

Information

Executive summary containing key messages and issues

Doncaster and Bassetlaw Teaching Hospitals NHS FT has a registered charity that raises, manages and distributes funds to enhance patient care and experience above and beyond what is provided by the NHS on the behalf of Doncaster and Bassetlaw Hospitals NHS FT. This strategy has been developed to establish:

appropriate fundraising priorities and infrastructure to support fundraisers (including branding and promotional materials as well as dedicated fundraising resources employed by the Trust);

to establish a process to engage with staff in both applying for and raising charitable funds for the Care Group/ward/department;

to explore new revenue streams and opportunities.

Key questions posed by the report

Does the strategy contain all the elements the committee would expect to see in a fundraising strategy? Is it ambitious enough with a limited resources approach?

How this report contributes to the delivery of the strategic objectives

We will develop high quality and responsive services ‘above and beyond’ NHS core care. We will work in partnership with our local communities to improve care and treatment for local people.

How this report impacts on current risks or highlights new risks

N/A

Recommendation(s) and next steps

To approve the Strategy.

DBTH Draft Fundraising Strategy 2018 – 2020

Introduction Doncaster and Bassetlaw Teaching Hospitals NHS FT has a registered charity that raises, manages and distributes funds to enhance patient care and experience above and beyond what is provided by the NHS on the behalf of Doncaster and Bassetlaw Hospitals NHS FT. This strategy has been developed to establish appropriate fundraising priorities and infrastructure to support fundraisers including branding and promotional materials as well as dedicated fundraising resources employed by the Trust; to establish a process to engage with staff in both applying for and raising charitable funds for the Care Group/ward/department; and to explore new revenue streams and opportunities.

Background With no specific branding, communications campaign or dedicated resource the awareness of the Doncaster and Bassetlaw Teaching Hospitals Charity is low and therefore fundraising activities that contribute to the general fund is minimal, as are bids to use the funds from across the Trust.

Historic commitment to fundraising at the Trust has seen targets set for a specific capital appeals achieved (for example The Breast Care Appeal at Bassetlaw). However with minimal capital appeals in more recent years income targets have remained static. Incoming resources generated specifically through fundraising activities over the last four years have fluctuated, however we are unable to provide insight as to why that may be the case due to how the charitable funds have previously been owned and distributed. The charitable fund has been made up of 200 smaller funds. The small funds within the main charitable fund have been set up by a wide variety of sources ranging from individual clinicians through to whole department funds. This disparate approach has led to some duplication, and funds not being used to their full potential to make the greatest impact on patient care. It also means that specific areas of the Trust attract more donations, whilst other areas are neglected. The Trust is dependent on fund holders to share information about how they plan to/ spend the fund as well as the activities they are undergoing in order to raise funds, the success of activities and who has supported the fundraising activities. This means we currently have no official insight into why fundraising activities are fluctuating and no database of previous supporters or active fundraisers for the Trust. This approach had been identified as potentially damaging for the Trust’s reputation, impacting on any future fundraising for the Trust as there is no consistent approach from fund holders regarding engagement and appreciation with those making donations. The Charitable Funds Committee identified that the Trust could enhance thousands of lives of patients every year by providing enhanced care and experience with the provision of charitable funds through this streamlined, strategic approach to fundraising. The benefits to a centralised approach include:

Greater governance on how charitable funds are spent meeting the need, ensuring they are used to enhance patient care above and beyond NHS funding

Increasing equity and appropriateness of how funds are distributed and currently used across the Trust

Expert support and advice provided for each fundraising endeavour, creating a standardised approach, ensuring all fundraisers for the Trust have the same, positive experience, impacting positively on reputation and future fundraising

Over the past year we have sought to limit the opening of new restricted or designated funds wherever possible as these clearly restrict how the funds can then be used. The intention is also to close down small and inactive funds, streamlining the funds to an overall charity fund which can be bid for, and disseminated according to the greatest need of the organisation, through a transparent, governed process. Historically the Trust had employed a Fundraiser for the Trust, based at Bassetlaw on a part time

basis (35 hours) at band 4 (paid for from the charitable funds). That position became vacant in

August 2016 providing the opportunity to rethink our approach to fundraising and the resource

needed to achieve more.

The fundraising function sits within the communications and engagement team at DBTH ensuring

support is provided by the leadership of the communications team, and that the communications

team are sighted on, and able to support, fundraising activities.

A SWOT analysis of Doncaster and Bassetlaw Teaching Hospitals Charity fundraising approach

STRENGTHS WEAKNESSES

Strong donations from communities

Historic achievements for capital appeals

Proud, supportive local community and staff

Low administrative costs

Established community engagement positions within communications team with established contacts/relationships

Support from Charitable Funds Committee

Low brand awareness of charity

No strategic objectives, operational plans or performance metrics in place for fundraising

No systems or databases in place for historical giving/ information on donors

No alignment to corporate business plan/ strategy

Multiple fundraising pots

No established dedicated resource/ fundraising expertise

OPPORTUNITIES THREATS

Branding launch and communications of opportunities and achievements can enhance fundraising and giving

Supporting existing community, staff and partner fundraisers will enable them to achieve more

Major scope for improvements through all fund raising avenues

Strong competition for funding for healthcare charities including the hospice and cancer detection trust

Disengagement from individual staff owning previous funding pots may create barriers for collective efforts

Constantly moving/ changing fundraising environment

Poor record keeping in the past

Changes to legislation

Mission and aims The mission of the charity is:

To raise funds which will be used to enhance thousands of lives of patients every year by providing excellent care, treatment, experience and research, above and beyond that which the NHS can provide*. * Above and beyond that which the NHS can provide refers to anything above and beyond the core services and facilities

funded by the government.

The over-arching aims of the fundraising strategy are:

1. To develop and implement corporate fundraising priorities that are aligned with the Trust’s strategic objectives, identifying major capital appeals

2. To launch and embed the Doncaster and Bassetlaw Teaching Hospitals Charity brand, integrating fundraising and communication throughout the Trust to raise awareness

3. To raise funds through charitable means to help meet the increasing demand for new, innovative medical equipment and experiential support for patient care by understanding and maximising existing funding streams and identifying new ones

4. To actively engage with a range of stakeholders, contributing to the local community as well as seeking support.

5. To develop a sustainable resource (fundraising team) to meet the current and future funding environment, providing expert support to charitable partners, developing a proactive approach to fundraising and establishing fit and proper process’ for collection and disbursement of fund.

It is anticipated that the majority of fundraising income will come from patients, families, staff and

members of the public supporting Doncaster and Bassetlaw Teaching Hospitals. However the wide

range of stakeholders should not be overlooked:

Stakeholder analysis

Influence on activity/ resources

Keep satisfied Key players

Partner organisations Local councils

Patients, service users and their families Trust staff Media partners Current major donors and patrons including DCDT, Bassetlaw Hospital League of Friends, Montagu Comforts Funds

Monitor Keep informed

General public Charity commission

Local community Grant makers MPs

Interest in DBTH/ DBTH charity

Achieving our strategic aims The approach to achieving our strategic aims, taking into consideration our SWOT analysis and

stakeholder analysis will be:

1. To develop corporate fundraising priorities that are aligned with the Trust’s strategic objectives, identifying major capital appeals

We will establish strategic objectives, operational plans or performance metrics for fundraising

asking the question ‘what will add the most value to patients, service users and families in

Doncaster, Bassetlaw and beyond?’ We will identify a concise list of major capital appeals, and a

more substantial list of fundraising priorities.

These priorities and capital appeals will be reviewed in line with the business planning cycle to

ensure they are aligned to the strategic objectives of the Trust, health and care place plans, and

regional care plans.

Operational fundraising plans aligned to the identified Trust priorities will be developed on an annual basis and reviewed against the performance metrics in order to ensure that the plans are sustainable and reflective of the changing funding environment.

2. To launch and embed the Doncaster and Bassetlaw Teaching Hospitals Charity brand, integrating fundraising and communication throughout the Trust to raise awareness

Branding is integral to the set-up of the fundraising function. It has to have the values of the charity

at its core, and must be embraced by key stakeholders (especially staff) if they are to truly engage

and be an ambassador for the charity. It also has to resonate with local communities. DBTH covers

different geographic locations and communities and this needs to be considered and reflected in

the branding.

The branding and its values will create the narrative for the charity, addressing and explaining the

case for support including, the need for the charity, our proposition, the difference it will make and

why we are best placed to deliver it.

A charity logo (see appendix a) and supporting promotional collateral will be produced to support

the launch, roll out and promotional activities to increase the awareness of the official DBTH charity.

This includes (and is not exclusive of):

- DBH Charity posters for distributing across hospital sites - DBH Charity stationery (letterhead and compliment slips) - Charitable fund fundraising collateral - Website presence

3. To raise funds through charitable means to help meet the increasing demand for new, innovative medical equipment and experiential support for patient care by understanding and maximising existing funding streams and identifying new ones

Funds raised may be achieved through two strategic approaches to donations – corporate and private. A range of avenues for corporate donations include:

Grants from statutory sources and grant making trusts including the National Lottery

Corporate sponsorship and company matches by supporting events, projects, equipment and or publications, choosing the charity as the named corporate charity and Give-As-You-Earn opportunities

A range of avenues for private donations include:

Individual donations made through face to face donations, online fundraising, direct mail and legacies

Corporate and individual events including high value specifically created donor events, community events and supporting individuals to take part in a wide range of sponsored events such as marathons

Crowdfunding and digital media

Sale of goods and services (trading and gaming) including raffles and cake stands etc. In the first year the focus for private donations, primarily from patients, families, staff and members of the public will be:

o Recruiting new donors and increasing their gift size - this will be addressed through the establishment of the charity brand and promotional materials. It may also require some organisational process changes which are outlined in the operational plan.

o Increasing the frequency of the gift. This will require the establishment of marketing databases of current and recent donors

This approach will also seek to provide support to individuals taking part in a range of events, already established/ organised within the community. Creating corporate and high value events are resource intensive and in order to maintain a low cost fundraising function in the first year it is not a recommended focus. In the first year the focus for corporate donations will be on mapping and applying for grants, in order to understand the funding landscape to be incorporated into a strategic approach to grant applications. It will also be to map stakeholder relationships across the communities to corporate sponsorship and company match opportunities. For both strategic approaches it is important in the first year to ensure that measurement is established in order to identify who our current donors are and how they are raising the funds. This will create a benchmark and an understanding of what is achievable, allowing for the development of SMART fundraising objectives in proceeding years for each of the finding streams.

4. To actively engage with a range of stakeholders, contributing to the local community as well as seeking support.

Whilst the essential aim of the fundraising strategy is to ‘raise funds’, a hospital fundraising function can also support and contribute to the local communities it engages with. In line with the Trust’s strategic direction it can help with preventative messaging, providing advice and signposting to health and wellbeing initiatives. Providing fundraising opportunities within communities can also help to instil a sense of pride, coming together for a common cause.

Within the communications and engagement team DBTH has an established community engagement function as part of the NHS England Screening programmes promotion. Whilst the contract for this work is across South Yorkshire and Bassetlaw relationships have been developed in Bassetlaw and Doncaster with community organisations, schools, large employers, local shops and voluntary groups. We will formalise current and potential community contacts in Doncaster and Bassetlaw, creating a database mapping engagement and fundraising potential.

5. Develop a sustainable resource (fundraising team) to meet the current and future funding environment, providing expert support to charitable partners, developing a proactive approach to fundraising and establishing fit and proper process’ for collection and disbursement of fund.

Research into the fundraising approach of surrounding hospital trusts identified how each approach requires a different level of resource support. This resource has also altered over time to reflect the changing funding environment. This reinforces the need to ensure that any developed resource is sustainable and future proofed. Our current resource is made up of the following:

The Charitable Funds Committee governs the charitable funds, headed up by The Chair

The Trust does not currently have any fundraising staff so all administration for fundraising is done by the finance team.

Promotion of the charitable funds is delivered by the DBTH communications team. The approach is currently reactive in nature, aiming to maximise media coverage of donations and fundraising activities, as well as support for existing donors. Additional resource would be needed to support the focus on charitable funds

In the first year of establishing the charity the approach should be to ensure that there is significant resource to establish a proactive approach to fundraising and fit and proper process, whilst maintaining a low cost/ low level of expenditure.

Measuring performance and governance As outlined in the objectives above it is important to establish performance measurement metrics in the first year in order to identify who our current donors are and how they are raising the funds, enabling the development of SMART fundraising objectives for the following year. Research suggests that a realistic income target is £5 income: £1 expenditure. However by maintaining a low cost approach to expenditure (fundraising team resource) the income vs expenditure position can be significantly stronger. An income target of £75,000 is a realistic, but stretching target in the first year, based on the key aims of the strategy, and the historic income generated through fundraising activities. A developed operational plan will identify performance measures and delivery timelines for years one and two of the strategy, with specific actions and measures of performance for year one activity. The plan will be monitored through the Charitable Funds Committee, which reports into the Board of Directors.

The Fred and Anne Green Advisory Committee reports in to the Charitable Funds Committee and advises on how the Fred and Ann Green legacy is best spent to support enhanced patient care.

Appendix A

Board of Directors

Charitable Funds

Committee

Fred and Ann Green

Advisory Group

Title Changes to Committee Membership

Report to Board of Directors Date 27 March 2018

Author Matthew Kane, Trust Board Secretary

Purpose Tick one as appropriate

Decision X

Assurance

Information


With changes to the Board of Directors to take effect from 1 April 2018, Board is asked to approve amendments to the membership of its board committees. In summary these are:

On Audit and Non-clinical Risk, Kath Smart to replace John Parker

On Finance and Performance, Pat Drake to fill vacancy

On Quality and Effectiveness, Pat Drake to fill vacancy

On Charitable Funds, Kath Smart to replace John Parker as Chair

On Charitable Funds, Pat Drake to fill vacancy

On Nominations and Remuneration, Pat Drake and Kath Smart to replace John Parker and fill vacancy

A complete list of members for all board committees is attached as an appendix. Please note that for the purposes of this report, observers and other attendees are not listed in the appendix.


N/A


The committees provide a method through which the Board obtains assurance.


N/A


That Board approves the membership of its committees attached as an appendix.

March 2018

Membership of the Board of Directors Committees

Audit & Non-clinical Risk

Finance & Performance

Quality & Effectiveness

Charitable Funds Nominations & Remuneration

Committee in Common

Frequency: Quarterly Monthly Every other month

Every other month Ad hoc Monthly

Chair: Philippe Serna Neil Rhodes Linn Phipps Kath Smart Suzy Brain England Suzy Brain England

Non-executives Linn Phipps Kath Smart

Pat Drake Philippe Serna

Alan Armstrong Pat Drake

Alan Armstrong Pat Drake Suzy Brain England Linn Phipps Neil Rhodes Philippe Serna

Alan Armstrong Pat Drake Linn Phipps Neil Rhodes Philippe Serna Kath Smart

N/A

Executives N/A Chief Operating Officer Director of Finance Director of People & Organisational Development

Director of Nursing, Midwifery & Allied Health Professionals Medical Director Director of People & Organisational Development

Chief Executive Director of Finance Medical Director

Chief Executive Chief Executive

Chair’s Log – Audit & Non-clinical Risk Committee – 23 March 2018

This was the final meeting of the financial year and also John Parker’s last meeting whom I thanked at the beginning for his invaluable contribution to the Committee over the last eight years. Internal audit There were seven audits completed in the quarter:

We reviewed the cyber maturity audit and made suggestions around how actions could be brought into line with what you would expect in a proper action plan. We also asked for confirmation that all outstanding actions were addressed and received. On another item, we recognised the improvements to the audit recommendations tracker but it was apparent that it contained some high priority recommendations which were overdue. We asked that staff leads for each of the audits provide ‘intermediate remediation’ measures where they are not able to fully remediate the recommendation in a timely manner. We also looked at trialling QEC’s assurance questions in relation to the actions to give some assurance that action was being taken. Finally, we agreed the internal audit plan for next year subject to additional audits around business continuity and some key corporate risks as well as requesting a redistribution of days from admin to audit. External audit The audit arrangements were noted and the Committee agreed the levels of materiality that would be applied. Key issues around the quality accounts, ‘going concern’ status and the new ledger were discussed. BAF and Risk Register

Key risks around finance had been de-escalated as we approached the year end but are likely to rise again as next year’s challenges begin. In total, two new risks had been added to the register and four risks had seen alterations in ratings. Security management We received a full report on security management. Following some recent localised thefts, it was pleasing to see some good work around training so that staff knew how to mitigate future incidences of theft. Local Counter Fraud Mark Bishop presented the report in addition to the operational plan. Some recent cases were explained. We also took assurance from Mark’s self-review tool which showed the extent to which the Trust was managing its anti-fraud obligations:

The Committee also commended Mark on his approach to counter fraud training compliance which is an exemplar across the Trust. Health and Safety Last year the Board received training on health and safety and it was recognised at that point that, although the Trust had a functioning Health and Safety Committee (which reported into ANCR), more work was required around assuring ANCR on health and safety issues. This was the first of the assurance reports. A further meeting involving the Committee, Directors of Finance and Estates and Trust Board Secretary will take place after Board on 27 March. This will look at how and when we receive reports, with a focus on performance, risk, assurance and putting learning into action. Other items Suspensions and exclusions, losses and compensations, and tender waivers were all noted.

Philippe Serna Chair – Audit & Non-clinical Risk Committee

Chair’s Log - Finance and Performance Committee – 26 March 2018

The timing of the Committee did not allow for an extensive written report, however, in summary we considered the following business:

There was a full and fulsome debate on the recent issues and challenges relating to the catering contract along with the remedial actions taken to date.

David Pratt, new Efficiency Director, provided an update against how the Trust was progressing recommendations against Carter/Model Hospital review and future planned actions.

We considered the financial plan and budget setting proposals for 2018-19 including the risks against delivery. The challenge for next year is significant and will be subject to some final refinement. The key is to ensure it is agreed now so that work on the ground can begin immediately.

Following on from the previous item, David provided full details of next year’s cost improvement plans.

James Nicholls of BDO provided a final roundup of the work he and his team have been doing to support the Trust’s efforts.

These were in addition to the usual suite of finance, performance and workforce items. I am happy to update the Committee verbally on all the above items. Matters escalated to the Board A copy of the Budget Setting paper is attached and the Committee recommended to Board that it: (1) Approves the draft income and expenditure plan/budgets, capital plans and cost

improvement programme, including contracts with commissioners. (2) Delegates to Finance and Performance Committee power to approve the final

version of the budget and annual/operational plan.

Neil Rhodes Chair – Finance and Performance Committee

Title Financial Performance – February 2018

Report to Trust Board Date

Author Jon Sargeant - Director of Finance

Purpose To update the Board on the financial position for the month of February 2018.

Tick one as appropriate

Decision

Assurance

Information


The Trust’s deficit for month 11 (Feb 2018) was £832k, which is an adverse variance against plan of £48k, however this is a favorable variance of £244k against forecast. The year to date I&E position at month 11 is a £16,336k deficit which is (£437k) adverse to plan. In month 11 elective and day case income was £606k less than plan, however emergency income continued to mitigate this position with a favorable variance of £976k, with clinical income overall £1,322k favorable against plan. The Trust continues to forecast it will meet its control total, however this is on the basis of receiving winter pressure funding of £1.2m linked to delivery of the trajectory set for A&E performance standards and that this can be counted towards achieving the Trust’s control total.


Are the Board assured by actions taken to bring the financial position back in line with

plan?


Identify the most effective care possible

Assist in the control and reduction of the cost of healthcare

Aid focus on innovation for improvement

Assist in developing responsibly and delivering the right services with the right staff


Update on risk relating to delivery of 2017/18 financial plan.


The Board is asked to note:

That the in-month I&E position was slightly behind plan (£48k);

The year to date I&E position at month 11 of £16,336k deficit which is (£437k) adverse

to plan;

While there is still a significant improvement on run rate (excluding winter pressure

costs) it is likely that the Trust will need to earn the winter pressures funding in order

to deliver the control total. It is therefore imperative the Trusts cost base is minimised

and income maximised in the final weeks of the financial year to support this

outcome.

1

FINANCIAL PERFORMANCE

P11 February 2018

14th March 2018

2

Performance Indicator Performance Indicator Annual Forecast

Actual

Variance to

Forecast Actual Actual Actual Plan

£'000 £'000 £'000 £'000 £'000 £'000

I&E Perf Exc Impairments 832 48 A (244) F 16,030 (235) F 16,489 16,070 Employee Expenses 1,035 1,050 A 7 A 6,299 873 A 9265 7,510

Income (30,299) (1,435) F (1,014) F (336,847) (5,629) F (361,811) (367,541) Drugs 2 (0) F 2 35 (6) F 30 38

STF Incentive (1,347) 0 0 (10,200) 0 (11,547) (11,547) Clinical Supplies 78 5 A 8 F 602 11 A 947 680

STF Adjustment 16/17 0 0 0 (419) (419) F 0 (419) Non Clinical Supplies 0 25 A 0 0 75 A 100 0

Donated Asset Income 0 0 0 83 (253) F Non Pay Operating Expenses 110 75 A (3) F 737 279 A 1340 1,027

Operating Expenditure 31,424 1,551 A 792 A 351,593 5,960 A 377,010 382,646 Income 138 (66) F 113 A 910 (414) F 724 1,042

Pay 20,966 233 A (752) F 236,612 4,818 A 252,593 257,974

Non Pay 10,458 1,318 A 1,544 A 114,981 1,142 A 124,417 124,672

I&E Perf Exc 16/17 STF

and Donated Asset

Income

832 48 A (244) F 16,366 437 A 16,489 16,489 Total 1,364 1,089 A 127 A 8,583 818 A 12,406 10,296

Financial Sustainability Risk Rating Plan Actual

UOR 4 3 Performance Indicator Annual Forecast

CoSRR 1 2 Plan Plan Actual Plan

£'000 £'000 £'000 £'000

Cash Balance 1,900 6,320 1,900 6,320 1,900 7,707

Capital Expenditure 635 992 5,846 4,101 6,481 7,615

Non Current Assets 196,907 193,076 (3,831) Funded Bank Total in Under /

Current Assets 33,612 38,196 4,584 WTE WTE Post WTE (over)

Current Liabilities (31,967) (41,266) (9,299)

Non Current liabilities (79,348) (86,085) (6,737) Current Month 6,037 5,572 145 129 5,846 191

Total Assets Employed 119,204 103,921 (15,283) Previous Month 6,041 5,612 217 113 5,942 99

Total Tax Payers Equity 119,204 103,921 (15,283) Movement 4 40 0 72 (16) 0 96 92

WTE WTE

F = Favourable A = Adverse

4. Other

Opening

Monthly Performance YTD Performance

Balance

Actual

01.04.17

£'000 £'000

Variance

£'000

Movement

in

year

3. Statement of Financial Position

All figures £m

DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

P11 February 2018

1. Income and Expenditure vs. Forecast 2. CIPs

5. Workforce

Actual Agency

YTD Performance YTD PerformanceAnnual

£'000 £'000 £'000

Plan

£'000

Forecast

£'000

Current

Balance

30.11.17

Monthly Performance

Variance to

Forecast

£'000

Variance to

budget Variance

Variance to

budget

Monthly Performance

3

The year to date month 11 position is a deficit of £16,030k. After removal of the 2016/17 STF adjustment and the

variance relating to donated assets, this is restated to a deficit of £16,366k.

The Trust’s deficit for month 11 (Feb 2018) was £832k, which is an adverse variance against plan of £48k, however

this is a favourable variance of £244k against forecast. Year to date, the Trust has an adverse variance of £437k

against plan.

In month 11 elective and day case income was £606k less than plan, however emergency income continued to

mitigate this position with a favourable variance of £976k, with clinical income overall £1,322k favourable against

plan.

At Month 11 the Trust has included £1.3m of non-recurrent funding for winter pressures in its position (£671k in

month). A further £1.2m of winter funding is assumed to be received in month 12 (yet to be included in the position)

however this is linked to delivery of the trajectory set for A&E performance standards. The Trust continues to

forecast it will meet its control total, however this is on the basis of receiving the winter pressure funding outlined

and that this can be counted towards achieving the Trust’s control total.

The cumulative income position at the end of Month 11 is £6,301k favourable to plan (this includes £1.3m of non-

recurrent winter funding as outlined above).

The expenditure position to the end of February was £5,960k higher than budgeted levels, with a £1,551k adverse

variance in month. This mainly relates to unachieved CIPs on non-pay.

Capital expenditure YTD is £4.101m against the YTD plan of £5.846m. Although the actual expenditure is £1.488m

behind the plan, the Trust is still expected to spend to its revised Capital Programme of £7.615m.

The cash balance at the end of February was £6.3m against a plan of £1.9m. The closing balance was higher than

plan due to; NHS organisations settling a number of outstanding balances, lower than expected payroll costs and

delays to the capital programme.

Income GroupAnnual Budget

In Month

Budget

In Month

Actual

In Month

VarianceYTD Budget YTD Actual

Commissioner Income -302,532 -24,227 -25,229 -1,002 F -276,578 -279,773 -3,194 F

Drugs -22,601 -1,713 -2,033 -320 F -20,553 -21,855 -1,302 F

STF -11,547 -1,347 -1,347 0 F -10,200 -10,619 -419 F

Trading Income -36,677 -2,924 -3,037 -113 F -33,750 -35,136 -1,386 F

Grand Total -373,358 -30,211 -31,646 -1,435 F -341,082 -347,383 -6,301 F

YTD Variance

Subjective Code In Month

Budget

In Month

Actual

In Month

Forecast

YTD Budget YTD Actual Annual

Budget

Forecast

1. Pay 20,733 20,966 233 A 21,498 -752 F 231,794 236,612 4,818 A 252,593 260,930

2. Non-Pay 8,919 10,568 1,649 A 9,135 1,544 A 105,994 119,574 13,546 A 115,635 122,466

3. Reserves 221 -110 -331 F 743 - A 7,812 -4,592 -12,405 F 8,783 -750

Total Expenditure Position 29,873 31,424 1,551 A 31,376 792 A 345,600 351,593 5,959 A 377,010 382,646

In Month

Variance

In Month

Variance to

forecast

YTD Variance

1. Context/Background

2. Executive Summary

4

The Trust’s year to date financial position at Month 11 is £437k adverse to plan, however it continues to forecast

that it will deliver its year end control total. This is due to the continuing work on the recovery programme to

delivery better financial and operational grip and control. However, there are still significant risks to delivery of the

forecast and the financial control total, including:

Achievement of tranche two of winter funding of £1.2m.

Delivery of CIP which has always been back loaded and significant savings still need to be achieved in the

next month.

The Trust has failed to deliver its activity targets, especially in elective over several months and significant

changes to doctor’s timetables compounded by some sickness are the main reason for this.

Control of agency spend, especially in medical which increased in February.

3. Conclusion

Title Business Intelligence Report

Report to Board of Directors Date 27th March 2018

Author David Purdue, Chief Operating Officer

Sewa Singh, Medical Director

Moira Hardy, Acting Director of Nursing, Midwifery and Quality

Karen Barnard, Director of People and Organisational Development


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the 3 main performance area for NHSi compliance: Cancer 62 day classic, measured on average quarterly performance 4hr Access, measured on average quarterly performance 18 weeks measured on monthly performance against active waiters, performance measured

on the worst performing month in the quarter Diagnostics performance against 14 key tests Infection control measures, CDiff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The Workforce report identifies vacancy levels, agency spend and usage, sickness rates, appraisals and SET training.


Is the Trust maintaining performance against agreed trajectories with NHSi? Is the Trust providing a quality service for the patients? Are Governors assured by the actions being taken to maintain quality and performance standards for patients?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


The corporate risks supported by this report are related to NHSi single oversight framework, especially in line with quality, patient experience, performance and workforce.


That the report be noted.

Performance Executive Summary Board of Directors March 2018

The performance report is against operational delivery in December 2017, January and February

2018.

Provide the safest, most effective care possible

Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to

Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored

quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is

monitored each month of the quarter and must be achieved each month.

The report also highlights key local targets which ensure care is being provided effectively and safely

by the Trust.

Referral to Treatment

The Referral to Treatment Target, active waiters below 18 weeks set at 92%, is the target which is

causing the most significant issues for the Trust.

Though performing above the National average, the Trust position remains below the target at 90%

in February, which is the same as the January position.

Weekly PTL meetings continue to take place with Care Groups where Delivery Plans are

discussed to bring performance levels back in line with commissioned activity and meeting

RTT.

Management of the key areas takes place through fortnightly advanced performance

meetings with Ophthalmology, General Surgery, ENT and Orthopaedics.

NHSI are aware of the current capacity shortfalls and performance is planned to achieve in March

2019.

Key to performance is the need to be maintaining contracted activity. February saw an improvement

in theatre utilisation in GI, ENT and T&O.

The Elective Steering Board is reviewing theatre lists on all 3 sites to ensure that all lists are utilised

effectively. The Elective Development Programme is looking at 3 specialties, Cardiology, ENT and

Urology to maximise the efficient use of out-patients.

Diagnostics

The diagnostic target was achieved at 99.35%

4hr Access

The target is based on the number of patients who are treated within 4hrs of arrival into the

emergency department and set at 95% and reported quarterly as an average figure. This target is for

all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at

BDGH and DRI and 1 type 3 facility at MMH.

February Performance

Trust 88.8%, including alternative pathways 90.2%.

Year to date 91.51%, excluding alternative pathways

The key issues for breaches remains internal ED waits to see or be reviewed by a doctor. Potential

improvements are expected after reviewing a number of processes within the dept.

The identification of the EPIC (Emergency Physician in Charge) and standardised operating protocols

for escalation and shop floor management.

Measure Feb 2017 Feb 2018 Difference %Difference

4 hour performance 88.7% 88.8% 0.1%

Attendance numbers 12045 12579 534 4.4%

4 hour bed waits

4 hour bed waits - BDGH

4 hour bed waits - DRI

18.4% of all of DRI discharges take place at a weekend and 15.2% at BDGH

If the rest of the week was at the same level as Mondays then we would see an extra 159 patients a

week at DRI and an extra 107 patients at BDGH

A&E attendances on a Monday at DRI account for 15.5% of weekly activity rising to 15.9% at BDGH

Non Elective Admissions on a weekday that GP admissions account for is 20.5% of all Emergency

Admissions on a weekday at DRI but only 8.6% at BDGH.

When we move into the weekend this drops to 11.3% at DRI and 2.5% at BDGH

Cancer Performance

January Performance

62 day performance 85.6%, TWW performance 87.2%

The 62 day target was achieved by the Trust in January 85.6%.

Across the Cancer Alliance the Cancer Services Managers continue to review all shared pathways at Day 38. The Trust needs to achieve and maintain a 7 day access either to diagnostics or 1st consultation and achieve discussion at Central MDT by Day 24 to allow for a smoother transition to Day 38. The 2 week-wait pathway is being process mapped to understand the issues with inconsistent performance. Stroke Performance

Performance in December Performance against the scan within 1 hour standard continues to be maintained above 48% at 62.5%. This is the best performance in the past 2 years The 4 Hour Direct Admissions standard is still not being achieved by the Trust however December saw performance being maintained as the previous 3 months improved position at 64.3%.

David Purdue Chief Operating Officer March 2018

PERFORMANCE REPORT – February 2018

RB/DP 19/03/18

1

Cancer Performance The following information relates to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust performance in January. January Performance

62 day Cancer performance 62 day performance nationally has failed for the past 3 years and is not achieving for the SYB ACS. A National 8 high impact intervention plan has been shared which DBTH has responded to. Cancer performance is monitored locally through the Cancer alliance. The 62 day target was achieved again by the Trust in January at 85.6%. The key issue remains in Urology, due to the number of patients requiring treatment. There were a number of delays in complex pathways within Head and Neck, Lower GI and lung. As part of the Cancer Alliance Work Programme, a series of deep dive meetings around cancer waiting times standards have taken place. The Doncaster and Bassetlaw place based meeting occurred on 12 February.


RB/DP 19/03/18

2

The graphs below compare 62 day performance in January at Doncaster and Bassetlaw with National performance.

Two Week Wait Performance

The December position for two week wait was 87.2% which was not compliant with the national target of 93%.


RB/DP 19/03/18

3

The reasons for breaches in relation to two week wait appointments can be seen in the table below.

Patient choice continues to be a key reason for patients not being seen within two weeks. In relation to ERS, Primary Care is promoting the use of direct booking for patients referred for two week wait appointments and continues to encourage discussion with patients regarding the reason for referral and the importance of attendance. Patients who choose to be seen outside of two weeks are contacted by nurse specialists to ask why they do not wish to attend. The Capacity and Demand tool continues to be developed, providing a planning tool based on previous referral, activity and capacity. Care groups will begin to use the tool to proactively plan two week wait capacity. Meetings have taken place with individual specialties to ensure appropriate capacity planning for the Easter period has taken place. Daily communication with Care Groups will also be trialed to promote early escalation of issues. The cancer management team meets regularly with the CCGs to review the information given in primary care which supports the two week wait position.


RB/DP 19/03/18

4

4hr Access Target The Trust achieved 88.8% in February 2018, 90.2% with alternative pathways, against the 4hr

access standard of 95%. Nationally the Trust remained within the top third of Trusts.

The graphs below compare 4 hour access performance at Doncaster and Bassetlaw with

National performance

In February, 1407 patients failed to be treated in 4hrs, with a total of 12579 patients attending ED. The main breach reason was wait to see ED doctor/ ED review which accounted for 603 of the 1407 breaches. 175 breaches were due to bed pressures. Performance overall compared to January 2017 saw with a 0.1% improvement but there was a 4.4% increase in attendances. System Perfect commenced on 27 February until 5 March, with a focus on supporting the ED and assessment areas as well as planning discharges ahead and understanding why patients don’t always leave as planned. Outcome measures are being reviewed


RB/DP 19/03/18

5

Streaming Doncaster FDASS The number of patients streamed directly from the front door increased again in February. The graph below shows the percentage of patients streamed each month.

13.612.1 11.6 11.6 12 12.5

16.1 15.813.9 15.2 13.9

16.413.6

16.1

0

5

10

15

20

25

DRI FDASS Streaming Percentage

Bassetlaw Streaming commenced at Bassetlaw on 1 October 2017. The % streamed has consistently been between 6-12%.


RB/DP 19/03/18

6

Referral to Treatment (RTT) Incomplete pathways for February ended in an improved position at 90.0% against the 92% standard. The graphs on the following page show Doncaster and Bassetlaw’s performance in relation to the National picture.

At the end of February 2018 there were three Incomplete Pathway over 52 Weeks. These pathways have been validated and were all found through the escalation report over the last few weeks. Specialties which failed to meet 92% in December:

Specialty Group Percentage

General Surgery 85.4%

Urology 92.1%

T&O 87.3%

ENT 89.4%

Ophthalmology 89.0%

Oral Surgery 94.8%

General Medicine 92.1%

Cardiology 89.9%

Dermatology 91.1%


RB/DP 19/03/18

7

Thoracic Medicine 94.6%

Rheumatology 74.8%

Geriatric Medicine 97.6%

Gynaecology 94.5%

Others 93.9%

Trust Total 90.0%

Weekly PTL meetings take place with all Care Groups where Delivery Plans are discussed to bring performance levels back in line with commissioned activity and meeting RTT. Advanced fortnightly monitoring meetings are in place with a number of specialty areas; Orthopaedics, ENT, Ophthalmology and General Surgery. Ongoing challenges remain with accommodating elective patients due to beds across the two main sites, workforce and capacity to meet demand. Mitigations are identified short and long term to manage patient care. There was one 52wk breach reported at the end of February in ENT. TCI 07/03/20118. No clinical harm to patient. Ophthalmology - New Timetable agreed across the service to support delivery of activity. - Successful in recruitment to, expand middle grade tier by 3. This is in support of a long term

realistic workforce model for the service. ENT - Cancelled patients due to lack of beds - A number of consultants have agreed to increase clinic times to accommodate patients + 18

weeks. - Requirement to increase theatre productivity to support waiting list reduction – monitored

daily - New Clinical Lead of ENT no win place

General Surgery - Key issue with operating capacity due to theatre availability - Cleansing of PTL completed - Pre-Op capacity issues resolved - Confirm long term operational capacity and delivery plan for General Surgery Trauma and Orthopaedics - Planning and population of theatre list demonstrates improvement - Service placed in advanced weekly monitoring chaired by the COO with Care Group Director

attendance


RB/DP 19/03/18

8

Rheumatology - Loss of workforce has impacted on ability to meet demand. Locum to commence from 19th

March - Increase in referrals by 8% in 2017/18 has applied further strain on service ability to flex

capacity - Awaiting contracted activity agreement for 2018/19 to support new consultant post Future planning and delivery To provide a more sustainable delivery model, the Trust is working in partnership with the CCG to agree a planning and delivery model for Waiting List Management including RTT. The team has invested in a tool called ‘Gooroo’. The tool aim is to support the determination, of achieving an ideal waiting list size based on ideal pathway delivery at a specialty level that in return delivers 92% patient care within 18 weeks. Strategic contract meetings are taking place to confirm activity for 2018/19 based on National Planning Guidance and Local population needs. Diagnostics The Trust has achieved the Diagnostic performance standard of 99% in Febuary at 99.35%. In Febuary there were 41 breaches overall compared with 64 breaches in January. Audiology diagnostic performance improved significantly in February with 23 breaches (from 581 waiters) compared with 27 breaches (from 559 waiters) in January. Medical Imaging overall performance was 99.9% in January with 6 breaches out of 4712 waiters.


RB/DP 19/03/18

9

Stroke Performance in December Performance against the scan within 1 hour standard continues to be maintained above 48% at an improved position of 62.5% compared with October. The 4 Hour Direct Admissions standard is still not being achieved by the Trust however December saw a maintained position compared with the previous months at 64.3%. Validation of the breaches by the Stroke Nurse Practitioner team indicate that there were several Bassetlaw patients experiencing transport delays which affected their time to admission, as well as some who were admitted onto Bassetlaw wards before being transferred. There were increased bed pressures on the stroke unit and instances where CT scans were requested in good time but the patient was delayed on their arrival at CT. Direct admissions within 4hrs, target 90%

Category Sub Category Total

Direct Admission within

4 Hours Bassetlaw Doncaster Other Total Organisational Beds 1

Yes 8 23 5 36 Pathway 9

No 4 15 1 20 Staff Availability 2

Grand Total 12 38 6 56 Clinical

Patient

Presentation 4

Performance 66.7% 60.5% 83.3% 64.3% Patient Needs 3

Patient Choice Declined 1

Awaiting further validation

CCG


RB/DP 19/03/18

10

Scan within 1hr, target 48%

Category Sub Category Total

Scan 1 hr Bassetlaw Doncaster Other Total Organisational Scanner

Yes 7 24 4 35 Pathway 11

No 5 14 2 21 Staff Availability 2

Grand Total 12 38 6 56 Clinical Criteria

Performance 58.3% 63.2% 66.7% 62.5% Patient Needs 1

Patient

Presentation 7

Patient Choice Declined

Awaiting further validation

CCG

Cancelled Operations In February, 1.36% of Trust operations were cancelled. This demonstrates reduced performance compared with the previous month with 61 patients cancelled out of a total of 4489. 56 patients were cancelled for theatre reasons and 5 for non theatre reasons. Out of these overall cancellations, 12 patients were cancelled at Doncaster, 12 at Bassetlaw and 9 at Mexborough. 1 patient was cancelled on the day of admission and waited over the 28 day standard for their surgery to be rearranged. The reasons for the non-clinical cancellations are displayed in the graph below:

Indicator Standard

Dec-17

Jan-18

Feb-18

Cancelled Operations (Total) 0.8% 1.51% 0.87% 1.36%

Cancelled Operations (Theatre)

1.17% 0.77% 1.25%

Cancelled Operations (Non Theatre) 0.34% 0.10% 0.11%

Cancelled Operations-28 Day Standard 0 2 5 1


RB/DP 19/03/18

11

Insufficient Time, 14

Urgent Case, 9

Equipment, 6Beds, 11

Staff, 21

Theatre Cancellations Non Clinical Reasons Febuary 2018

Insufficient Time

Urgent Case

Equipment

Beds

Staff

DNA and CNA Rates In February, the overall DNA rate across the Trust maintained the previous month’s position at 9.38%. It is recognised that the overall Trust DNA rate is higher in some specialties than the National picture. A focused piece of work is being undertaken to improve attendance within those specialties with the highest DNA rates.

Indicator Dec-17

Jan 18

Feb 18

Outpatients: DNA Rate Total 9.73% 9.85% 9.38%

Outpatients: Hospital cancellation Rate 5.78% 5.2% 5.96% 201

Page Indicator Standard Current Month Month Actual

RAG Rating

against

National &

Peer

NHS England

%DBTHFT Month Peer Groups % DBTHFT Month Page Current Month

Month

Actual

(TRUST)

Month

Actual (DRI)

Month Actual

(BDGH)

Data Quality RAG

Rating

31 day wait for second or subsequent treatment: surgery 94.00% 100.00% 93.60% 93.70% % of patients achieving Best Practice Tariff Criteria Feb-18 61.0% 62.0% 59.0%

31 day wait for second or subsequent treatment: anti cancer drug

treatments98.00% 100.00% 99.00% 99.70%

31 day wait for second or subsequent treatment: radiotherapy 94.00% 100.00% 96.20% Not Available 36 hours to surgery Performance 66.0% 62.0% 75.0%

62 day wait for first treatment from urgent GP referral to treatment 85.00% 85.60% 81.20% 80.10% 72 hours to geriatrician assessment Performance 94.0% 100.0% 75.0%

62 day wait for first treatment from consultant screening service

referral90.00% 96.20% 87.70% 89.40% % of patients who underwent a falls assessment 100.0% 100.0% 100.0%

31 day wait for diagnosis to first treatment- all cancers 96.00% 98.50% 96.50% 97.40% % of patients receiving a bone protection medication assessment 98.0% 100.0% 92.0%

Two week wait from referral to date first seen: all urgent cancer

referrals (cancer suspected)93.00% 87.20% 93.80% 89.70%

Two week wait from referral to date first seen: symptomatic breast

patients (cancer not initially suspected)93.00% 93.90% 91.90% 93.80%

10 Infection Control C.Diff4 Per Month -

45 full yearM

Infection Control MRSA 0 L

7 HSMR (rolling 12 Months) 100 N Dec-17

Never Events 0 L Feb-18

VTE 95.0% N Jan-18

Pressure Ulcers12 Per Month

144 full YearL

Ambulance Handovers Breaches -Number waited over 15 & Under 30

Minutes914 Falls that result in a serious Fracture

2 Per Month 23

full YearL

Ambulance Handovers Breaches-Number waited over 30 & under 60

Minutes112

Ambulance Handovers Breaches -Number waited over 60 Minutes 26

Proportion of patients scanned within 1 hour of clock start (Trust) 48.00% 62.50%

Proportion of patients directly admitted to a stroke unit within 4 hours

of clock start (Trust)90.00% 64.30%

Percentage of eligible patients (according to the RCP guideline

minimum threshold) given thrombolysis (Trust)20.00% 3.60%

Percentage of patients treated by a stroke skilled Early Supported

Discharge team (Trust)40.00% 65.40%

Percentage of those patients who are discharged alive who are given a

named person to contact after discharge (Trust)95.00% 88.50%

Implementation of Stroke Strategy - TIA Patients Assessed and Treated

within 24 Hours60.00% February 28.00%

Cancelled Operations 0.80% 1.36%

Cancelled Operations-28 Day Standard 0 1

Out Patients: DNA Rate 9.38%

18

17

Peer Groups: Trusts Used are: Bradford Teaching Hospitals NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Northern Lincolnshire and Goole NHS Foundation Trust, Hull and East Yorkshire Hospitals NHS Trust, The Rotherham NHS Foundation Trust,

Mid Yorkshire Hospitals NHS Trust, Calderdale and Huddersfield NHS Foundation Trust

January98.91%95.18%January

90.00%

98.91%97.70%

Still looking @ data sources for obtaining this information

No Benchmarking available

90.00%

3

See Month

Actual

See Month

ActualJanuaryJanuary

FebruarySee Month

Actual83.32%February

See Month

Actual85.00%

January90.00%83.27%January

Mo

nit

or

Co

mp

lian

ce F

ram

ewo

rk

A&E: Maximum waiting time of four hours from arrival / admission /

transfer / discharge (Trust)95.00% February 88.80%

Feb-18

1

95.1%

0

87.42

0

0

Direction of

travel

compared to

previous

Month

January





February

SET Training

3

5

Effe

ctiv

e

Emergency Readmissions within 30 days (PbR Methodology) 6.30%December

Thea

tres

& O

utp

atie

nts

February

Out Patients: Hospital Cancellation Rate 5.96%

Stro

ke

December

Am

bu

lan

ce H

and

ove

r

Tim

es

January

Data Quality RAG

Rating

Complaints received (12 Month Rolling) 470

Concerns Received (12 Month Rolling) 671

Complaints Performance 82.0%

Clinical Negligence Scheme for Trusts (CNST)

Liabilities to Third Parties Scheme (LTPS)

Claims per 1000 occupied bed days

5

0

Indicator Current Month Month Actual

Feb-18

Snap shot auditCatheter UTI 0.41%

Feb-18

8

Appraisals

Data Quality RAG

Rating

78.03%

66.48%Feb-18

0.23

Wo

rkfo

rce Indicator Current Month YTD (Cumulative)

Co

mp

lain

ts &

Cla

ims

At a Glance -February 2018 (Month 11)

Indicator Current MonthStandard (Local,

National Or Monitor)Month Actual

Data Quality RAG

Rating

8

Frac

ture

d N

eck

of

Fem

ur

Indicator

Best Practice Criteria

0.00%11.80%8.70%

Feb-18

Mortality-Deaths within 30 days of procedure

2

Page

Safe

9

NHS England

BenchmarkingPeer Group Benchmarking

Page

Page

Current position

Maximum time of 18 weeks from point of referral to treatment-

incomplete pathway92.00% 88.20%

4

% of Patients waiting less than 6 weeks from referral for a diagnostics

test99.00% 99.35%

February

13

Monitor Compliance Framework: Cancer - Graphs - January 2018 (Month 10)

Monitor Compliance Framework: A&E - Graphs - February (Month 11)

Monitor Compliance Framework: 18 Weeks & Diagnostics - February (Month 11)

Stroke - Graphs December 2017 (Month 9)

Executive Summary - Safety & Quality - February 2018 (Month 11)

HSMR: The Trust's rolling 12 month HSMR remins better than expected at 87.4 Despite a rise in crude mortality, in December, HSMR wa s 95

Fractured Neck of Femur: An improvement in acheievement of BPT to 60%. Risk adjusted mortality continues to improve . Serious Incidents: The increase in SI's seen over the last three months have meant that we have now exceeded the number of SIs reported in the previous financial year . This has been due to an increase in HAPUs reported .

Executive Lead: Mr S Singh C-Diff We are slighly above our internal trajectory, although on trajectory to achieve the nationally set target. Fall resulting in significant harm: The rate remains slightly above the trajectory for the year Hospital Acquired Pressure Ulcers: There is a reduction in the rate, improving on last years performance Complaints and concerns: Complaints reply timeliness remains the same aslast month, with a slight reduction in the rate over recent months Friends & Family Test: The response rate for A&E is improved from last month but remains lower than peers. The Inpatient response rate is improved from a reduction in January 2018, The positivity rate is better than peers. Executive Lead: Mrs M Hardy

2014 2015 2016 2017

January 115.45 116.80 99.21 94.86

February 99.11 99.94 97.73 105.44March 102.91 90.54 97.37 82.66April 110.49 105.91 88.50 81.05May 90.93 101.15 96.60 77.82June 113.74 80.27 93.67 84.56July 109.94 92.56 97.73 90.30August 120.18 100.27 87.52 70.91September 110.10 90.26 95.34 82.88October 106.58 90.29 88.66 91.81November 106.84 88.98 82.30 85.75

December 115.87 82.30 93.52 95.01

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

Trust 1.29% 1.38% 1.22% 1.25% 1.33% 1.01% 1.22% 1.45% 1.46% 1.99% 2.11% 1.52%

Doncaster 1.43% 1.33% 1.13% 1.32% 1.46% 1.01% 1.28% 1.41% 1.42% 2.13% 2.29% 1.63%

Bassetlaw 1.11% 1.82% 1.74% 1.34% 1.09% 1.27% 1.31% 1.95% 1.90% 1.94% 1.86% 1.45%

HSMR Trend (monthly) Crude Mortality (monthly) - February 2018 (Month 11)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) - December 2017 (Month 9)

Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months)

87.42

86

88

90

92

94

96

98

Feb

16

- J

an 1

7

Mar

16

- F

eb 1

7

Ap

r 1

6 -

Mar

17

May

16

- A

pr

17

Jun

16

- M

ay 1

7

Jul 1

6 -

Ju

n 1

7

Au

g 1

6 -

Ju

ly 1

7

Sep

16

- A

ug

17

Oct

16

- S

ep 1

7

No

v-1

6 -

Oct

-17

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

87.53

86

88

90

92

94

96

98

Feb

16

- J

an 1

7

Mar

16

- F

eb 1

7

Ap

r 1

6 -

Mar

17

May

16

- A

pr

17

Jun

16

- M

ay 1

7

Jul 1

6 -

Ju

n 1

7

Au

g 1

6 -

Ju

ly 1

7

Sep

16

- A

ug

17

Oct

16

- S

ep 1

7

No

v-1

6 O

ct-1

7

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

79.03

40

50

60

70

80

90

100

Feb

16

- J

an 1

7

Mar

16

- F

eb 1

7

Ap

r 1

6 -

Mar

17

May

16

- A

pr

17

Jun

16

- M

ay 1

7

Jul 1

6 -

Ju

n 1

7

Au

g 1

6 -

Ju

ly 1

7

Sep

16

- A

ug

17

Oct

16

- S

ep 1

7

No

v-1

6 O

ct-1

7

Dec

16

- N

ov

17

Jan

17

- D

ec 1

7

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Crude Mortality (Trust)

0.5%

1.5%

2.5%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Crude Mortality (BDGH)

1.0%1.3%1.6%1.9%2.2%2.5%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Crude Mortality (DRI)

NHFD Best Practice Pathway Performance - February 2018 (Month 11)

Best Practice Criteria Performance 36 Hours to Surgery Performance 72 hours to Geriatrician Assessment Performance

Bone Protection Medication Assessment Falls Assessment Performance

Relative Risk Mortality (HSMR) - Fractured Neck of Femur

Rolling 12 month

0%

20%

40%

60%

80%

100%

120%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

% achieving best practice tariff criteria (Trust) % achieving best practice tariff criteria (DRI)

% achieving best practice tariff criteria (BDGH)

40%

60%

80%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Trust DRI BDGH

40%

60%

80%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Trust DRI BDGH

80%

90%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Trust DRI BDGH

80%

90%

100%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Trust DRI BDGH

53.93

46.14

93.3

40

50

60

70

80

90

100

110

120

130

140

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Trust DRI BDGH

Current YTD reported SI's (Apr 17-Feb 18) 72 56

Current YTD delogged SI's (Apr 17-Feb 18) 24 13

Serious Incidents - February 2018 (Month 11)(Data accurate as at 12/03/2018)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr 16-Feb 17)

Number delogged SI's (Apr 16-Feb 17)

Themes

0

0.05

0.1

0.15

0.2

0.25

0.3

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Pressure Ulcers - Category 3 & 4 (HAPU)

Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Care Issues

Care Issues per 1000 occupied bed days

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.1

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Serious Falls

Serious Falls per 1000 occupied bed days

0

0.1

0.2

0.3

0.4

0.5

0.6

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days - Previous years performance

0

2

4

6

8

10

12

14

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Number Serious Incidents Reported (Trust & Care Group)

Emergency Care Group MSK & Frailty Care Group Surgical Care Group

Children & Family Services Diagnostic & Pharmacy Speciality Services

Chief Operating Officer Number Reported SI's Number Reported SI's - Previous years performance

Standard Q1 Q2 Q3 Jan Feb YTD

2017-18 Infection Control - C-diff 40 Full Year 8 8 6 5 0 272016-17 Infection Control - C-diff 40 Full Year 7 7 8 2 1 24

2017-18 Trust Attributable 12 1 1 1 0 0 32016-17 Trust Attributable 12 0 0 3 1 0 4


2017-18 Serious Falls 10 Full Year 0 1 3 1 1 6

2016-17 Serious Falls 19 Full Year 0 2 2 0 0 4


2017-18 Pressure Ulcers 34 Full Year 5 7 7 6 6 31

2016-17 Pressure Ulcers 60 Full Year 7 6 8 8 6 35

Monitor Compliance Framework: Infection Control C.Diff - February 2018 (Month 11)

(Data accurate as at 06/03/2018)

Pressure Ulcers & Falls that result in a serious fracture - February 2018 (Month 11)

(Data accurate as at 09/02/2018)

Please note: At the time of producing this report the number of serious falls reported are

prior to the RCA process being completed.

Please note: At the time of producing this report the number of pressure ulcers reported

are prior to the RCA process being completed.

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

C-diff 2017-18

2017-18 C-diff Cumulative total 2016-17 C-diff Cumulative total Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Falls that result in a serious fracture

2017-18 Falls Cumulative Total 2016-17 Falls Cumulative Total Standard

0153045607590

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

2017-18 Pressure Ulcer Cumulative Total 2016-17 Pressure Ulcer Cumulative Total Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Trust Attributable C-diff 2017-18

2017-18 Trust Attributable Cumulative Total 2016-17 Trust Attributable Cumulative Total Standard

Safe Effective Caring Responsive Well Led

Care Group Matron Ward

No of

Funded

Beds

CHPPD Variance Total score Total score Total score Total scoreQM total

scoreWork-force Quality

NS B6 16 7.3 94% 2.5 0.0 0.0 2.0 4.5

NS 20 27 4.8 97% 1.5 1.0 2.0 1.5 6.0

NS 21 27 5.0 101% 0.5 1.0 1.0 1.5 4.0

LM S12 20 4.6 100% 4.5 0.0 1.0 2.5 8.0

RF SAW 21 6.5 97% 2.5 0.5 3.0 2.0 8.0

LC ITU DRI 20 24.8 95% 2.5 1.0 0.0 2.5 6.0

LC ITU BDGH 6 25.1 92% 2.0 0.0 0.0 1.5 3.5

96%

SS A4 24 5.6 99% 1.0 2.0 0.0 1.0 4.0

SS B5 30.7 6.7 99% 0.5 1.0 0.5 1.5 3.5

AH St Leger 35 6.0 100% 2.0 1.5 2.0 2.0 7.5

AH 1&3 23 8.3 101% 1.5 0.0 0.0 2.0 3.5

SS Mallard 16 8.5 103% 1.0 0.0 0.0 1.0 2.0

SS Gresley 32 5.7 98% 1.0 1.0 1.5 1.5 5.0

SS Stirling 16 7.7 100% 1.0 1.0 1.0 1.5 4.5

KM Rehab 2 19 5.5 103% 0.0 0.0 0.0 2.0 2.0

KM Rehab 1 29 4.1 101% 2.0 2.0 0.0 2.0 6.0

100%

JP 18 12 7.8 107% 2.5 1.0 0.0 1.5 5.0

JP 18 CCU 12 7.5 98% 0.0 0.0 0.0 1.5 1.5

AW 32 18 5.8 90% 2.0 2.0 0.0 1.5 5.5

AW 16 24 8.2 107% 2.5 2.5 0.0 0.5 5.5

RM 17 24 5.7 95% 1.0 1.0 0.0 0.5 2.5

JP CCU/C2 18 6.4 109% 2.0 0.5 3.0 1.5 7.0

RM S10 20 5.5 104% 2.5 0.0 1.0 1.5 5.0

RM S11 19 6.0 105% 2.5 0.0 0.0 1.5 4.0

102%

MH ATC 21 7.7 96% 2.0 0.5 1.0 2.0 5.5

SS AMU 40 7.9 103% 2.5 1.0 1.0 1.5 6.0

MH C1 16 5.6 98% 1.5 1.0 0.0 1.5 4.0

SC 24 24 5.7 99% 3.5 1.5 2.0 1.5 8.5

SC 25 16 7.4 103% 3.5 1.0 0.0 1.0 5.5

SC Respiratory unit 56 5.6 96% 4.5 1.5 3.0 1.5 10.5

99%

AB SCBU 8 23.5 100% 1.0 0.0 0.0 0.0 1.0

AB NNU 18 9.5 97% 2.0 0.0 0.0 1.0 3.0

AB CHW 18 13.0 97% 0.0 0.0 0.0 0.0 0.0

AB COU/CSU 21 7.0 98% 0.5 0.0 1.0 0.5 2.0

SS G5 24 6.2 92% 1.5 1.0 3.5 1.0 7.0

SS M1 26 8.0 85% 1.0 1.5 0.0 1.0 3.5

SS M2 18 9.0 81% 2.0 1.0 0.0 1.0 4.0

SS CDS 14 19.5 95% 1.0 0.0 2.0 0.5 3.5

SS A2 18 8.3 86% 0.0 0.5 1.0 1.5 3.0

SS A2L 6 21.8 96% 0.0 0.0 0.0 1.0 1.0

93%

Children and Families

Hard Truths -February 2018 (Month 11)(Data accurate as at 16/03/2018)

Planned v Actual ProfileThe workforce data submitted to UNIFY provides the actual hours

worked in February 2018 by registered nurses/midwives and health care

support workers compared to the planned hours.

The Trusts overall planned versus actual hours worked was 98% in

February 2018, similar to recent months.

The data for February 2018 demonstrates that the actual available hours

compared to planned hours were:

• Within 5% 30 ward (65%) 4 more than January

• Between 5-10% 7 Wards (20%) 1 less than January

• Surpluses over 10% 0 Wards (5%) 2 less than January

• Deficits over 10% 3 Wards (10%) 1 less than January

The wards where there were deficits in excess of 10% of the planned

hours in February 2018, are Wards M1, M2 and A2.

When there has been lower levels of bed occupancy these areas have

supported CDS and Labour Ward (Bassetlaw) with providing safe staffing

levels.

There has been an issue in Maternity services with leave management

over the year, while having more vacancies. This has been identified

through the weekly e-roster support and challenge meetings, which

impacts on February and March rosters, but is projected to be improved

on the rosters in coming weeks. Safe staffing has been achieved with

three periods where internal maternity diverts from Doncaster to

Bassetlaw were instigated during February

Quality and Safety Profile

The Quality Metrics data has highlighted that no wards have triggered

Red for quality in February 2018, leading to no occasions in 3 months.

Surgical

MSK and Frailty

Specialty Service

Emergency

Aim Objective

Ensure relevant staff have access

to Prevent training either face to

face or by eLearning.

85% of those identified within DBTH as

requiring WRAP training will have accessed

training by 31/03/2018

PREVENT Action Plan - February 2018 (Month 11)

As part of the UK’s Counter Terrorism Strategy, Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. The NHS intention is to achieve 85% of staff to be trained at the appropriate level. The Basic Prevent Awareness Training has been achieved at 85% by Q3

2017/18. The action plan below from NHS England has been populated for the Trust and illustrates the plan to reach the Workshop Raising Awareness of Prevent (WRAP) compliance rate.

Actions Outcome Resources

• Identify staff requiring WRAP using ESR data

• Identify number of staff current in WRAP training

• Identify number of staff to access training to meet 85% target

• Promotion of Training

Staff requiring WRAP = 3799

Rate at:

30.12.17 - 2536 (66.8%)

28.2.18 - 2643 (71.4%)

Number to access training to achieve 85% target =

517 (as at 28/2/2018)

• Prevent was included in Safeguarding training but is now a separate, standalone session so

assessing ESR data has been challenging.

• We had 16 face to face sessions planned in Q4. (9 done, 5 remain in March 2018)

• Since the first Unify2 report at the end of Q3 2017/18 we have introduced the eLearning and

advertised in our hospital weekly newsletter and our Safeguarding Newsletter.

• Emails have been sent to all Managers and Matrons with the eLearning link.

• Education leads have received all the Prevent training dates and the eLearning link.

• An advert has been repeated in Buzz (hospital weekly newsletter) to be published every week

throughout March.

Registered

midwives/

nurses

Care Staff Overall

4.5 3.2 7.7

4.2 3.1 7.3

2.3 2.4 4.7

4.1 3.1 7.2TRUST

The CHPPD care hours has fluctuated in January 2018, due to an increased bed occupancy, with escalation beds open. The rate has

improved from 6.8 overall to 7.2 in February 2018. This is indicative of an improvement. The registered nurse and midwife rate is the

lower than peers. This is reported to the Quality and Effectiveness Committee in detail.

Care Hours Per Patient Day (CHPPD) - February 2018 (Month 11)(Data accurate as at 15/03/2018

Utilising actual versus planned staffing data submitted to UNIFY and applying the CHPPD calculation the care hours for February 2018 are

shown below

Site Name

BASSETLAW HOSPITAL

DONCASTER ROYAL INFIRMARY

MONTAGU HOSPITAL

Month

`2

4

0

0

2

1

0

0

YTD

107

16

Number referred for

investigation

YTD

Outcomes

YTD

Complaints & Claims - February 2018 (Month 11)(Data accurate as at 08/03/2018)

Complaints

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Parliamentary Health Service Ombusdman (PHSO)

Number of cases

referred for

investigation

Number Currently Outstanding

Feb-18 0 4

2016/17 8

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

2017/18 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over

deadlines are excluded data.

Claims

Current Month Month Actual

Clinical Negligence Scheme for Trusts (CNST) Not including Disclosures Feb-18 5

Liabilities to Third Parties Scheme (LTPS) Feb-18 0

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

February 2018 Complaints Received

Risk Breakdown

Low Risk

Moderate Risk

High Risk

Year to Date Complaints Received

Risk Breakdown

0

10

20

30

40

50

60

70

80

Ap

r 2

014

Jun

20

14

Au

g 2

014

Oct

20

14

Dec

20

14

Feb

20

15

Ap

r 2

015

Jun

20

15

Au

g 2

015

Oct

20

15

Dec

20

15

Feb

20

16

Ap

r 2

016

Jun

20

16

425

83

428

26

428

87

429

48

430

09

430

70

431

32

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Ap

r 2

01

4

Jun

20

14

Au

g 2

01

4

Oct

20

14

Dec

20

14

Feb

20

15

Ap

r 2

01

5

Jun

20

15

Au

g 2

01

5

Oct

20

15

Dec

20

15

Feb

20

16

Ap

r 2

01

6

Jun

20

16

42

58

3

42

82

6

42

88

7

42

94

8

43

00

9

43

07

0

43

13

2

Concerns Received

Concerns Mean UCL LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Complaints Resolution Performance

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Number of Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days - Previous years performance

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family - February 2018 (Month 11)(Data accurate as at 12/03/2018)

Inpatients

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

0%5%

10%15%20%25%30%35%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Response Rates (%)

Trust Rate NHS England Yorkshire & the Humber

0.930.940.950.960.970.980.99

1

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

Dec

-17

Jan

-18

Feb

-18

Likely to recommend (%)


0%

2%

4%

6%

8%

10%

12%

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Response Rates (%)


0.780.8

0.820.840.860.88

0.90.920.94

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Likely to recommend (%)


Sickness absence

Appraisals

SET

Staff in post

Executive summary - Workforce - February 2018 (Month 11)

Following the recent increases in sickness rates in December and January there has been a reduction in February to 4.54% in month and 4.5%

cumulatively, the latter which is similar to the rates in 2016/17. There has been a reduction in episodes of absence associated with absences in

excess of 6 months and between 1 and 6 months. There have been a reduction in both the long term and short term absence rates.

The Trusts appraisal completion rate has continued to see a further rise to 66.48% which is the fourth month of improvement since April

2017. Plans are underway for the transition to a 3 month appraisal season.

We have seen a further rise in compliance with Statutory and Essential Training in January to 78.03% ; topic specific compliance rates have

been shared with both Board committees following recent discussions.

Please see attached tab covering staff in post by staff group. Vacancy rates are provided to both Finance & Performance and Quality &

Effectiveness Committees.

Workforce: Sickness Absence - February (Month 11)

Workforce: SET Training - February (Month 11)

Workforce: Appraisals - February (Month 11)

Workforce: Staff in post - February (Month 11)

Title Chair’s and NEDs’ Report

Report to Board of Directors Date 27 March 2018

Author Suzy Brain England, Chair


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work in February and March 2018 and includes updates on a number of activities:

• Smart ER • Great British Spring Clean • Governor activities • NED recruitment • Other meetings • Welcomes and Goodbyes


N/A


The report relates to all of the strategic objectives.


N/A


That the report be noted.

Chair’s Report – March 2018

Smart-ER As part of last year’s discussion around our new strategic plan we discussed in great detail our pledge towards innovation and improvement. We are now walking the talk. Last month, I had the pleasure of meeting with Amjid Mohammed, ED Consultant, to discuss Smart-ER, an online tool patients are asked to complete in the waiting room, describing their ailment or injury as well as providing general health details. By completing this process, the patient is able to explain the reason for their visit, while also disclosing previous medical problems, all of which becomes part of their medical record. Completing this step improves communication in the Emergency Department and also uses the patient’s waiting time more productively, reducing overall waiting time. The system has been piloted in DRI and Montagu and will soon be coming to Bassetlaw. Amjid is due to come to a Members’ Event on the morning of Friday 11 May at Bassetlaw to discuss this and the A&E developments at Bassetlaw in further detail. All members are invited but please note capacity is limited so please register with Matthew. Great British Spring Clean Thanks to all governors and others who supported the Great British Spring Clean where the simple aim was to bring people across the country together to clear up the litter that blights our towns, villages, countryside and hospitals!

It gave Mike and I an opportunity to check out the new ‘litter zones’ at DRI (above) while governors Peter Abell and Hazel Brand can be seen tackling litter at Bassetlaw Hospital, although they did say there wasn’t a great deal around which is what I like to hear!

Governor activities In spite of the inclement weather, governors made it into DRI for their latest Timeout on 8 March where we were treated to sessions on System Perfect, Freedom to Speak Up and Living the Values as well as a recap on the recent Core Skills training from January.

Thanks to everyone who facilitated and especially to Lynn Goy who stood in at the last moment. We do evaluate each session with this one getting an overall rating of 4.47 out of 5. I am also very grateful to David Purdue who, in addition to running a Timeout table, also gave the Governor Briefing on 6 March around the clinical site development strategy. Non-executive Recruitment Governors met after the Timeout to agree the timetable and process for the second round of non-executive director recruitment which is due to start imminently. It has necessitated some changes to the diary which have been notified to everyone. The main one is that the next Timeout will now take place on 18 June in the afternoon and be preceded by a special Council of Governors to appoint the successful non-executive candidates. Other meetings Following the NHS Providers’ Board on 7 March, I met with senior staff at NHS Providers to consider Facing the Facts, Shaping the Future – the draft workforce strategy drawn up by Health Education England and Department of Health. Workforce is a big issue in the NHS and the final report will likely have an important and long-term impact for provider trusts. I also held a walkabout with Gill Payne, Specialty Services Lead, met with Sue Cookman, regional UNISON rep, observed the Children and Families Board and held one to ones with the Chief Executive and Director of Estates. I am also supporting the Trust’s LEAN programme bid on 20 March and attending an NHS Improvement mock interview to prepare the next generation of executive directors for their next move. Welcomes & Goodbyes It was a pleasure to meet with new non-executive directors, Kath Smart and Pat Drake, as part of their induction meetings with executive and corporate directors on 15 March 2018. Both are due back at DRI on 21 March for further introductions before they start in post 1 April 2018. I would like to place on record my thanks to John Parker who steps down after serving as a non-executive of the Trust for eight years. In addition, Ruth Allarton completes her associate role on 31 March and I would like to place on record my thanks to her on behalf of the Board and Council of Governors.

1

Chief Executive’s Report 27 March 2018

Services continue despite bad weather Despite heavy snowfall services at Bassetlaw Hospital, Doncaster Royal Infirmary and Montagu Hospital continued as normal. The Estates and Facilities team were hard at work ensuring that our hospitals were well-gritted and, via social media, visitors, patients and staff were asked to take extra precaution when coming to and from the site.

Throughout this period everyone worked hard to get into work and to ensure that our patients continued to receive high quality care and treatment regardless of the weather. The Deputy Chief Executive, Chair, governors and I have all expressed our thanks to staff for their commitment and hard work.

Meeting with NHSI The regional team from NHS Improvement met with members of the Executive Team on 16 March to discuss current progress in relation to the Trust’s breach position, finances, performance and quality of care. The meeting was positive with the NHSI team recognising the Trusts efforts in all areas over the past 12 months. Catering Update Since the commencement of our new catering services in January 2018, we have been working closely with Sodexo to ensure we manage that any difficulties during the transitional period are effectively managed. While there have been some teething issues we were in regular contact with Sodexo communicating our expectations for inpatient meals, as well as our catering services for visitors and staff.

2

Due to the poor weather the work being undertaken to improve our kitchens at Doncaster Royal Infirmary are behind schedule by two weeks with the work on the Subway (located within East Dining Room) and Costa expected to be complete in early April. As with any major improvement works and large scale change there are always challenges, Sodexho and the Trust are working hard to address any issues and ensure that we have a fantastic, fit-for-purpose, catering service for our patients, visitors and team. Microsystem Festival On February 27, Cindy Storer, Head of Nursing for the MSK and Frailty Care Group, and Becky McCombe, Senior Sister on Gresley Ward, travelled to the Microsystems Festival in Sweden to present work that they have been undertaking in the Trust, in collaboration with the Improvement Academy. The Microsystems Festival is an international conference, providing an opportunity for people who are committed to healthcare improvement to meet and share their improvement work. The Improvement Academy, part of the Yorkshire and Humber Academic Health Science Network, have been supporting seven wards across Doncaster and Bassetlaw Teaching Hospitals, with a project called Achieving Reliable Care (ARC). Cindy and Becky will be attending this Board meeting to provide an update on ARC which is an evidenced based improvement tool focusing on reducing the variability of patient care, helping patients to get what they need, when they need it. Consultants Connect

Patients are being saved an unnecessary trip to hospital thanks to the great work of our consultants as they discuss patient cases directly with local GPs. NHS Doncaster Clinical Commissioning Group started using Elective and Acute Care phone lines in August 2017 and January 2018 respectively. During this time, our consultants have answered 328 calls from 44 Doncaster surgeries, with 39% of these calls resulting in a referral or admission being avoided.

Similarly, NHS Bassetlaw Clinical Commissioning Group surgeries use the Elective Care phone line only and, since August 2017, the nine surgeries have had 85 calls answered by the Trust, with 53% resulting in an avoided referral.

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Health Select Committee visit the Trust In February, the Trust was visited, as a key partner in the South Yorkshire and Bassetlaw Accountable Care System (ACS), by the Commons Health Select Committee to aid in their inquiry into integrated care. The Committee visited Doncaster Royal Infirmary to gain an understanding of our integrated secondary/primary care system, including Consultant Connect, and our Integrated Discharge service, which also included a tour of Stirling Ward. A number of medical and clinical staff were on hand to discuss innovations at the Trust and how our work can be shared both regionally and nationally. Some of the good practice witnessed during the visit has been cited in Parliamentary debates about the ACS. Ovarian Cancer Project The Gynaecology Outpatients Department (GOPD) at Doncaster Royal Infirmary is urging women to talk openly about ovarian cancer, and understand the potential symptoms in an effort to save more lives. The team, who look after women who are undergoing treatment for the illness, have all pledged to talk to 50 women about ovarian cancer and what to look out for in the hope that more cases can be caught early on. Sharing ‘We Care’ The Trust is hosting a conference on Thursday 26 April in the Education Centre at DRI to showcase examples and experiences of patient care around three themes: patient safety, patient experience and patient centredness. Anyone interested in attending can register at: https://www.dbth.nhs.uk/wp-content/uploads/2018/02/WeCare_Conference-1.pdf Inpatient Survey The Trust has been notified that the 2018 National Adult Inpatient Survey will start shortly with survey fieldwork completed by January 2019. This year specific guidance has been drawn up to protect patient confidentiality.

https://www.dbth.nhs.uk/wp-content/uploads/2018/02/WeCare_Conference-1.pdf

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DBTH scoops nursing award The Trust, along with our Doncaster and Bassetlaw partners, recently won the Royal College of Midwives award for partnership working. This was awarded because of the excellent work that is done in early pregnancy to highlight the families that need additional support either from social care or early help services. Debbie Rees-Pollard, Named Midwife for Safeguarding, collected the award (see picture). Appraisal Season Our new Appraisal Season will take place from April to June 2018, when we will be aiming for 90% completion of good, quality appraisals. In order to help with this goal, the Trust’s HR Business Partners are currently organising a number of training sessions and materials in order to support managers to deliver quality appraisals.

Farewell Andrea Andrea Smith, Director of Procurement, left the Trust at the end of February to take up the same, full-time, post at Sheffield Teaching Hospitals. We would like to wish her well for the future and look forward to working with her as part of the Integrated Care System Procurement Group. Richard Somerset, Deputy Director of Procurement, is stepping up to take over from Andrea in an acting capacity for the immediate future. New Chair of Children’s Services Trust Doncaster Children’s Services Trust has announced that Tony Hunter has been appointed as the Chair of the Trust Board. The appointment comes as current Chair, Colin Hilton, retires at the end of this month. Tony had been a non-executive director since 2014. He has a wealth of experience and knowledge in children’s services having started his career as a social worker in Doncaster. He is the Chief Executive of the Social Care Institute for Excellence (SCIE) and will continue in that job alongside the role announced today. Tony was awarded the OBE in the Queen’s Birthday Honours List in 2010, for services to social care.

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Minutes of the Meeting of the Management Board of

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust on

Monday 12 February 2018 at 2pm in the Boardroom, DRI

Present: Karen Barnard Director of People & Organisational Development Kirsty Edmondson-Jones Director of Estates & Facilities Eki Emovon Care Group Director - Children and Families Moira Hardy Director of Nursing, Midwifery and Allied Health Professionals Ken Agwuh Director of Infection, Prevention and Control (for Andrew Barker) Simon Marsh Chief Information Officer Richard Parker Chief Executive (Chair) Marie Purdue Director of Strategy & Transformation Gillian Payne Care Group Director - Speciality Services Jon Sargeant Director of Finance Sewa Singh Medical Director Jochen Seidel Care Group Director – Surgical Nick Mallaband Care Group Director – Emergency Care Group In attendance: Matthew Kane Trust Board Secretary Kate Sullivan Corporate Governance Officer Jen Simpson ED Consultant Apologies: Thrinath Kumar Care Group Director - MSK & Frailty Tim Noble Associate Medical Director Willy Pillay Assistant Medical Director Andrew Barker Care Group Director - Diagnostics & Pharmacy David Purdue Chief Operating Officer Action

Minutes of the previous meeting

MB/2/18/1 The minutes of Management Board on 15 January 2018 were approved as an accurate record. It was noted that acronyms would be written out in full in the first instance.

Matters arising and action notes

MB/2/18/2 The action notes were reviewed and updated.

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CORPORATE ISSUES

ACS/ACP Update

MB/2/18/3 Richard Parker provided an update on the Hospital Services Review and a meeting of Accountable Care System (ACS) Chief Executives (CEs), hosted by Sir Andrew Cash, and this was followed with detailed discussions on the following key areas:

The South Yorkshire & Bassetlaw (SYB) ACS was considering becoming an Integrated Care System (ICS).

Chief Executives of the ICS had discussed a developing ICS governance structure.

Eight key work streams had been proposed and the ICS was now considering looking for nominations for directors and deputy directors to be seconded to take forward the work.

MB/2/18/4 The ICS CEs had discussed planning assumptions and had received a detailed presentation from the ICS finance director. The Chief Executive gave an update on key messages from the presentation including:

The proposed process for the allocation of STF funding; this was unclear at this stage and further discussions were required.

Changes to Emergency Department (ED) targets; Trusts now had to match, or better the previous year performance.

There had been a presentation on progress with the Hospital Services Review (HSR). Trusts were due to receive the draft for five of the work streams in March for consideration by Trust Boards. Detailed modelling was due after this and would be taken through in house capacity or reference groups.

Some programmes of work had been postponed including payroll services and some HR sub-groups.

Currently next steps were unclear. Sir Andrew was due to attend a number of high level meetings over the coming weeks to clarify the position.

MB/2/18/5 Partners had reached an agreement on the draft Memorandum of Understanding (MoU) for the Pathology work stream and if accepted by Trust Boards this would enable the move to the options appraisal stage. A commitment had previously been made to the programme in terms of a programme manager, a Job Description (JD) had been developed, however agreement had not yet been reached on a dedicated resource. A discussion with NHS Improvement (NHSI) was scheduled to discuss the matter later in the week. In response to a query from Ken Anderson the Chief Executive provided some clarity on the agreement in terms of sites identified for consideration of an augmented hub.

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MB/2/18/6 Management Board discussed the proposed ICS governance structure and

proposed secondments of executives and deputies. The Board considered the time commitments required for this, how it would be paid for and how Trusts would cover the core work of these very senior staff. It was expected that support to cover/backfill roles would be funded; there were already examples of this for staff with roles within the ICS. Sir Andrew felt that partners needed to demonstrate a commitment to the success of the ICS and that seconding in very senior managers and executives was the key to this. It was noted that the offer to submit nominations had been extended to colleagues of both acute Trusts and CCGs and would be on an individual basis. From the Trust’s perspective it needed to consider the advantages of being at the centre of the work of the ICS, in terms of having a greater influence on outcomes, and would look to support staff that wished to be involved.

MB/2/18/7 Trusts had previously been advised that there would be an ICS control total and that organisations would have to sign up to that; Jochen Seidel asked if there was an option to withdraw from this and if so at what stage. This was discussed and it was clarified that the Trust did not have to sign up to the ICS control total at this stage however, in terms of receiving funding, organisations had to be part of an ACS/ICS to be eligible to receive it. The CE gave an overview of challenges moving forward. It was key that the rules for the ICS were established and understood and there needed to be clarity on this.

MB/2/18/8 The ACS/ICS update was DISCUSSED and NOTED.

Finance Report

MB/2/18/9 Management Board received the Finance Report for December 2017.

MB/2/18/10 The month 9 position for 2017/18 was a deficit of £15,094k. After removal of the 16/17 STF adjustment and the variance relating to donated assets, this was restated to a deficit of £15,473k, £31k favourable to plan.

MB/2/18/11 In December the Trust had submitted the quarter 3 return to NHSI. Quarter 3 STF funding was dependent upon delivering the financial plan and the Trust had released some winter pressures monies to achieve this. The Director of Finance gave an update on discussions with NHSI relating to Tranche 1 funding received by the Trust in December. NHSI had advised that in order to receive the funding it required the Trust to adjust the 2017/18 forecast by an amount equal to that of the funding; the Trust had agreed at this stage however there would be further discussions with NHSI on the matter.

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MB/2/18/12 The Director of Finance (DoF) gave an overview of the M10 (January)

position; the results had been encouraging with the Trust breaking even in the month without applying an adjustment and an overview of key areas of improvement were provided. There were still two months to go to the year end and although the Trust continued to forecast that it would hit the year end control total there were still some risks around this forecast and these were outlined in the paper. The Chief Executive and the Director of Finance thanked Management Board for their work in January; the Trust needed to continue with this progress and remain focused on discretionary spend.

MB/2/18/13 The Finance Report was NOTED.

Planning Guidance

MB/2/18/14 Management Board received a presentation from the Director of Finance and the Director of Strategy and Transformation (DST) on Business Planning Requirements for 2018/19. The presentation provided a detailed update and highlighted key points:

• There was a 2 year contract and planning cycle in 2017. • The 2018/19 refresh was published on 2 Feb 2018. • Joint planning focus – Place and Integrated Care System (ICS) – ICS

single system operating plan narrative. • A Trust wide update of 2018/19 plans would be required to inform

this. • Care groups and corporate teams needed to develop annual plans

to deliver (in the context of three year plan). • Contract variation to be agreed and signed no later than 23 March

2018.

MB/2/18/15 Detailed updates were provided on:

• The 2018/19 refresh headlines for Emergency and Elective care • The 2018/19 refresh headlines for Finance. • Work to Inform Plans. • Budget Setting Principles. • Timeline. • Next Steps and support available.

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MB/2/18/16 The Director of Finance gave a detailed update on the refresh headlines for finance and drew attention to the following: Control totals - For the ICS a system control total would be generated and payment of Sustainability and Transformation Funding would be on the basis of system performance, not individual organisations, allowing by agreement some organisations to miss their control total if performance in the system nets off. Where performance was such that it required an intervention the System Leadership would agree the approach and actions with NHSE and NHSI. The SY&B control total was an overall surplus of £1.295m. Details of ICS provider control totals and adjustments were provided. The control totals were very challenging, particularly in the context of the ICS control total and the Management Board considered the matter, including what the incentives were for providers to be part of the ICS. The Trust was working with NHSI to understand the change to its control total particularly in regard to the CNST changes and the Chief Executive and Director of Finance provided an update on the discussions with NHSI and the questions raised.

MB/2/18/17 Capital – An overview of capital work allowed for in Trust plans was provided. It was noted that any additional capital would require support from the STP/ICS and needed to be supported by a full STP Estates Strategy.

MB/2/18/18 Work to Inform Plans – The Trust was working through the guidance in terms of activity increases and would then engage with Care Groups in terms of non-elective and planned activity to develop a capacity plan and there would be further work required on job planning and workforce planning.

MB/2/18/19 Timeline – A time line was provided; this would be updated and recirculated.

MP

MB/2/18/20 Next Steps – A round of budget setting meetings had already taken place and there would be more to follow. RTT work was ongoing with final capacity and demand to be agreed and final Care Group/Corporate Department plans due by the end March 2018.

MB/2/18/21 The Planning Guidance presentation was DISCUSSED and NOTED.

Draft Health and Care Workforce Strategy for consultation

MB/2/18/22 Management Board considered a presentation from the Director of People & Organisational Development on the Draft Health and Care Workforce Strategy which was out for consultation.

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MB/2/18/23 The Strategy would lead to the first system wide workforce strategy for

twenty five years and covered health and social care, and carers, self-carers and volunteers. It Included what had been done since 2012, what the sector was doing now and what it should do next. The strategy had been produced by Health Education England (HEE), with NHS England (NHSE); NHSI; Public Health England (PHE); and Department of Health (DH) as main partners but also Chief Professional Officers; Regulators; Unions and others in key sectors.

MB/2/18/24 HR Business Partners would go out with the questions asked by the consultation document and would be organising several events. Management Board were invited to provide feedback to the Director of P&OD outside of the meeting.

ALL

MB/2/18/25 The Draft Health and Care Workforce Strategy for consultation was NOTED.

Vacancy Control Process

MB/2/18/26 Management Board received an item on the Vacancy Control Process from the Director of People and Organisational Development. The paper included a process flow chart, standard operating procedures, template forms and working instructions.

MB/2/18/27 The Trust was looking for attendance of senior managers (Care Group / Directorate Directors / Deputy Directors / General Managers / Heads of Nursing/Therapies) to present cases for vacancies to the Vacancy Control Panel (VCP). The time currently set aside for VCPs needed to be extended and this would commence from March 2018. Concern was raised about the ability of very senior staff to attend and the impact this may have on services and this was discussed; it was clarified that Care Group Directors themselves did not have to attend but there must be a representative with sufficient expertise and managerial responsibility to provide the Panel with relevant information. The new process had been introduced to save time; in the past cases were being rejected due to the need for further information and it was expected that having a suitably knowledgeable person at VCPs would help to stop this in the future and speed up the process.

MB/2/18/28 There was further debate and it was agreed to trial the process and to schedule a review to come back to Management Board in April.

KB

MB/2/18/29 The Vacancy Control Process Report was NOTED.

Corporate Risk Register

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MB/2/18/30 Management Board considered a report of the Trust Board Secretary which

set out for consideration the Board Assurance Framework and Corporate Risk Register.

MB/2/18/31 Three ‘extreme’ risks were escalated via Datix in the month and these were discussed.

MB/2/18/32 Following brief discussions it was agreed to refer the risks to be considered by the Clinical Governance Committee to test the soundness of the ratings. If the risk ratings were considered to be accurate they would be brought back to Management Board.

MK/SS

MB/2/18/33 An update was provided on a risk previously escalated to Management Board relating to a Shortage of CPAP Machines; an overview of mitigations was provided. The risk was now less than it had been previously but longer term solutions were needed and a business case for five new CPAP machines was being developed.

MB/2/18/34 The report on the Corporate Risk Register and BAF was NOTED.

Forthcoming Assessments, Inspections and Reviews

MB/2/18/35 Management Board considered a report of the Trust Board Secretary which set out forthcoming assessments, inspections and reviews.

MB/2/18/36 The report was NOTED.

Business Resilience Steering Group ToRs

MB/2/18/37 The Business Resilience Steering Group ToRs were APPROVED.

MB/2/18/38 KEY ISSUES FOR CARE GROUPS

MB/2/18/39 Standard Operating Procedure - Emergency Care Standards of the Emergency Department (ED) - Partnership working to achieve the Four hour Target

MB/2/18/40 Jen Simpson, ED Consultant, presented the Standard Operating Procedures (SOPs) for the Emergency Care Group Emergency Care Standards of the ED - Partnership working to achieve the Four hour Target Standard Operating Procedure. She gave some background information, including some examples of the challenges faced by ED which had led to the SOPs being developed.

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MB/2/18/41 The purpose of the SOPs were to improve communication and to ensure a consistent approach was adopted that supported and encouraged partnership working of the Emergency Department and the rest of the organisation to achieve four hour targets at Doncaster Royal Infirmary (DRI) and Bassetlaw District General Hospital (BDGH).

MB/2/18/42 The paper was discussed in detail and Management Board reflected on the following:

• It was felt that there was a lack of reflection on escalations within ED and the internal ED process.

• There needed to be more clarity around communication with critical care in terms of the transfer for critical care patients to DRI and whether or not it was appropriate to bring them to ED.

• The SOPs needed to state that prior to transfers ED escalation processes needed to be followed.

• There needed to be a communication strategy and time allowed for the SOPs to be communicated across the organisation.

• Concern was raised about the wording relating to suitably trained staff required to escort patients being transferred as it would be assumed that this meant anaesthetists.

MB/2/18/43 The Standard Operating Procedure - Emergency Care Standards of the Emergency Department (ED) - Partnership working to achieve the Four hour Target were DISCUSSED and NOTED and the following actions were agreed:

• Comments from the meeting (above) would be incorporated in to the document and further comments should be sent back to Jen Simpson within two weeks.

• Start communication plan. • Agree potential date for implementation. • Revised draft to be circulated. • Bring back to MB in March.

ALL/JS

MB/2/18/44 Clinical Admin Redesign (Standing Item) – There was no update at this time.

MB/2/18/45 Carers Leave

MB/2/18/46 Gill Payne raised the matter of lack of consistency in terms of how the carers leave policy was applied. There was a feeling that the rules were sometimes applied differently to medical staff and non-medical staff and she gave examples of instances when she had challenged the use of carers leave to visit sick relatives abroad and had been overruled.

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MB/2/18/47 It was clarified that carers leave was only available to staff who needed to care for dependants, visiting a sick relative abroad would be emergency or special leave which could only be authorised for 1 (maximum 2) days and was thereafter to be supplemented by annual or unpaid leave.

MB/2/18/48 The update was NOTED.

MB/2/18/49 Number of permanent staff allowed on annual leave per department

MB/2/18/50 At the previous meeting a number of issues had been raised in terms of inconsistency across specialties with regard to the percentage of staff allowed on annual leave at any one time. The matter had been discussed and it had been resolved to consider the matter further at the care group directors meeting with the Medical Director. Since that time some work undertaken by BDO had shown a high level of consistency with every speciality following the leave policy as described and there was consistency in how it was being applied. However, concern was raised about the methods used by BDO and this was discussed. The Medical Director commented that there needed to be further reflection in terms of the number of consultants in each department, not percentages, for example if there were only two consultants in a department then the annual leave limit would have to be 50%. Management Board considered the matter further in the context of the ICS; this would make the matter more complex if organisations had different rules. It was NOTED that at the moment the rules of the host organisation applied.

MB/2/18/51 The following information items were NOTED:

Business Intelligence Report as at 31 December 2017

Chief Executives Report

Minutes of the Corporate Investment Group meeting held on 18 December 2017

Minutes of the Planned Care Programme Board meeting held on 21 December 2017

Minutes of the Children’s & Family Board meetings held on 13th October and 10th November 2017

Minutes of the Elective Care Steering Group meetings held on 4th December 2017

Minutes of the Urgent & Emergency Care Steering Group meetings held on 4th December 2017

MB/2/18/52 Any other business None.

Items for escalation from sub-committees

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MB/2/18/53 None.

Date and time of next meeting

MB/2/18/54 The next meeting of Management Board would take place 12 March 2018 at 2pm in the Boardroom.

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Working Together Partnership Vanguard Committees in Common Briefing for Trust Boards

Monday 12th March 2018

This is a new monthly briefing for Trust Board members to hear in their public board meetings about the Working Together Partnership Vanguard (WTPV) Committees in Common meeting. On a quarterly basis the South Yorkshire and Bassetlaw Trusts who form the Mental Health Alliance are also in attendance at the meeting. The Working Together Partnership is comprised of seven Acute Trusts who, by collaborating on a number of common issues, aim to strengthen each organisation’s ability to delivery safe, sustainable, local services. http://workingtogethernhs.co.uk/

General Programme Update Key highlights from the Working Together Programme Team this month (which can be found in more detail in the stakeholder newsletter here) include:

A pathology update including details about the MOU

Information about the publication of the second report into the Hospital Services Review

Information about an upcoming visit from International Health Commentator Don Berwick, and about a roadshow event that has taken place for South Yorkshire and Bassetlaw nurses

Pathology Memorandum of Understanding (MOU) An MOU around the development of a pathology network for South Yorkshire and Bassetlaw is now doing the rounds of each of the Trust Boards, and communications have been shared with each Trust for their staff and Governors. As you are aware the MoU confirms a commitment to work together as a network and in doing so to make sure we find the best opportunities to ensure high quality, sustainable and efficient pathology services over the coming years. It sets out key principles, governance arrangements and an outline programme plan, which builds in the appropriate consideration of options, feedback from key stakeholders / clinical reference groups, and learnings from other partnerships across the NHS.

Hospital Services Review update Work continues on the Hospital Services Review, with the team having completed and published reports on phases 1a and 1b of the work. These are available on the Health and Care Working Together website here. Initial options are now being shared with clinicians and patients/ public for feedback at events taking place in early March before the first draft of the section 2 report is completed by the end of March to commence circulation to the relevant meetings and Boards.

Working Together

http://workingtogethernhs.co.uk/#_blank

http://workingtogethernhs.co.uk/wp-content/uploads/2014/10/March-Newsletter.pdf

http://www.healthandcaretogethersyb.co.uk/index.php/what-we-do/working-together-future-proof-services/looking-at-hospital-services

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As at 22 March 2018

Board of Directors Agenda Calendar

STANDING ITEMS OTHER / AD HOC ITEMS

MONTHLY QUARTERLY BIANNUAL / ANNUAL

APRIL 2018

CE Report ANCR minutes Draft Annual Report

Business Intelligence Report Chief Executive’s Objectives Draft Quality Account

MB Minutes Estates Update Budget Setting / Business Planning / Final Annual Plan

HWB Decision Summary Staff Survey

Finance & Performance Minutes

Finance Report

Chairs’ Assurance Logs

MAY 2018

CE Report Board Assurance Framework & corporate risk register Q4 (inc. annual assurance summary)

Annual Report

Business Intelligence Report QEC Minutes Quality Account

MB Minutes Annual accounts

HWB Decision Summary ISA260 and quality account assurance


Charitable Funds minutes

Finance Report Mixed Sex Accommodation


JUNE 2018

CE Report Board Assurance Framework MB Annual Report

Business Intelligence Report Report from the Chair of the ANCR committee (Verbal)

SOs, SFI, Scheme of Delegation

Bed Plan Estates Update ANCR Annual Report

MB Minutes


Finance Report


2

As at 22 March 2018

JULY 2018

CE Report Chief Executive’s Objectives Reference Costs

Business Intelligence Report ANCR Minutes Diversity and Inclusion

MB Minutes


Finance Report


AUGUST 2018

CE Report QEC minutes Proposed AMM arrangements Health and Wellbeing

Business Intelligence Report ANCR Minutes Annual Security Report

Nursing Workforce Infection Control Annual Report

MB Minutes Risk Policy


Finance Report


SEPTEMBER 2018

CE Report Estates Update Catering Report

Business Intelligence Report Teaching Hospital

Nursing Workforce

MB Minutes


Finance Report


OCTOBER 2018

CE Report ANCR minutes Charitable Funds minutes

Business Intelligence Report Chief Executive’s Objectives Fred & Ann Green Legacy minutes

MB Minutes Complaints, Compliments, Concerns and Comments Report


3

As at 22 March 2018

Finance Report


NOVEMBER 2018

CE Report QEC minutes Annual Compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR)

Business Intelligence Report Board Assurance Framework & corporate risk register Q2

Nursing Workforce

MB Minutes


Finance Report


DECEMBER 2018

CE Report Report from the Chair of the ANCR committee (Verbal)

Business Intelligence Report

MB Minutes


Finance Report


JANUARY 2019

CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual Plan

Constitution

Business Intelligence Report Chief Executive’s Objectives SOs, SFI, Scheme of Delegation CT/HASU (part 2)

MB Minutes Complaints, Compliments, Concerns and Comments Report

Joint working


Estates Update External reviews policy

Finance Report


4

As at 22 March 2018

FEBRUARY 2019

CE Report QEC Minutes Budget Setting / Business Planning / Annual Plan

Finance Strategy

Business Intelligence Report Board Assurance Framework & corporate risk register Q3

MB Minutes

HWB Decision Summary


Finance Report


MARCH 2018

CE Report

Business Intelligence Report

MB Minutes

HWB Decision Summary


Finance Report


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Minutes of the meeting of the Board of Directors

Held on Tuesday 27 February 2018

In the Boardroom, Bassetlaw Hospital

Present: Suzy Brain England OBE Chair of the Board Alan Armstrong Non-executive Director Karen Barnard Director of People and Organisational Development Moira Hardy Director of Nursing, Midwifery and Allied Health

Professionals John Parker Non-executive Director Richard Parker Chief Executive Linn Phipps Non-executive Director David Purdue Chief Operating Officer Neil Rhodes Non-executive Director Jon Sargeant Director of Finance Sewa Singh Medical Director In attendance: Kirsty Edmondson-Jones Director of Estates and Facilities Matthew Kane Trust Board Secretary Marie Purdue Director of Strategy and Transformation Emma Shaheen

Clive Tattley Emma Challans Dr Jayant Duggar Deborah Hilditch

Head of Communications and Engagement Governor Deputy Chief Operating Officer (part) Guardian for Safe Working (part) Healthwatch Doncaster (part)

ACTION Welcome and apologies for absence

18/2/1 Apologies for absence were submitted on behalf of Philippe Serna, Simon Marsh and Ruth Allarton.

Declarations of Interest

18/2/2 Board was reminded of the need to keep their interests up-to-date.

Actions from the previous minutes

18/2/3 The list of actions from previous meetings was noted and updated.

18/2/4 In relation to 17/12/21, the Board requested a definitive date by which IT risks would be included on the Datix system.

SM/MK

Getting It Right First Time

18/2/5 The Board considered a presentation from the Trust’s Medical Director into the Getting It Right First Time (GIRFT) project.

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18/2/6 GIRFT was set up as a pilot in 2012 to remove unwarranted variation around a number of clinical services including prosthetic use (hips and knees). In 2014/15, £30m of savings were delivered by 70 trusts.

18/2/7 In November 2016, the Secretary of State for Health announced £60m investment into GIRFT. The project was extended to 35 specialties with the objectives of improving patient care as well as obtaining significant savings. Details of the methodology underpinning the project was provided.

18/2/8 The Trust’s Trauma and Orthopaedics Team was the subject of a GIRFT visit in 2014 where a number of areas were assessed. The work found the surgeons were often doing too few procedures, there was a need to streamline trauma and elective as well as rationalise use of the site. The Trust was also benchmarked in respect of a number of areas in relation to its claims within a number of specialties.

18/2/9 Action plans were in place following visits and further work by way of efficiency programmes were in place for a suite of services including procurement, length of stay and readmissions, theatre productivity, quality and legal and elective care.

18/2/10 In response to a question from the Chair, the Board was advised that efficiency work was ongoing into urology, vascular and gynaecology. Commenting on spinal injury work, where the Trust was less efficient than its comparators, Alan Armstrong asked what was required to improve productivity. The Board was advised that there was a need to plan the service more coherently across the South Yorkshire and Bassetlaw patch.

18/2/11 In response to a question from Neil Rhodes, noting that the Trust was in the fourth quartile for obstetrics and gynaecology work, the Board was advised that the statistics given in the presentation were at a point in time and over the past five years the Trust’s performance was much better.

18/2/12 In relation to claims and litigation, Linn Phipps advised the Board that she had met with the Medical Director and Acting Deputy Director for Nursing, Midwifery and Quality the previous week and it had been agreed to bring an annual report on the matter to Quality and Effectiveness Committee and also include relevant data within the quality dashboard.

18/2/13 It was agreed that a presentation from the Trust’s solicitors, covering issues such as claims and other services, may be beneficial at a future Board meeting.

KB/MK

18/2/14 The presentation on GIRFT was NOTED. The Chair, with the agreement of the meeting, agreed to take items 7 and 8 as the next items.

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Missed Hospital Appointments

18/2/15 The Board considered a report and presentation of the Deputy Chief Operating Officer and Healthwatch into missed appointments. Emma Challans, Deputy Chief Operating Officer, was joined by Deborah Hilditch, of Healthwatch Doncaster, who gave the presentation.

18/2/16 The aim of the study was to work with people across primary and

secondary care to understand why hospital appointments were missed. It was estimated that 130 appointments were missed every day at the Trust which amounted to roughly 50,000 a year.

18/2/17 The background to the project and the methodology was provided. As part of the study’s evidence gathering, approximately 800 people were interviewed in addition to gathering views via a social media survey. Work was also done with hard to reach groups (e.g. the Polish community in Doncaster), as well as with Doncaster College and the Partially Sighted Society. The work found:

One quarter of people interviewed had missed an appointment.

36% of people did not rearrange their appointment.

The main reasons for missing an appointment were that the date was not convenient and there were no repercussions for non-attendance.

Some felt that the Trust could do more to ensure they attended their appointment such as send an email or text reminder.

Some people interviewed were frustrated at the cost of missed appointments and their inability to get an appointment themselves.

18/2/18 A half of those interviewed provided ideas for how to improve the current rate of missed appointments. These included:

Communicate with patients more clearly about consequences of not attending.

Improvements to the administrative process and quality of correspondence.

Provide maps of the sites, especially for car parking, transport and Outpatients and improve signs.

Provide information in different formats, Easy Read, different language, Plain English.

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18/2/19 The recommendations and next steps from the report were set out.

18/2/20 There was a discussion about the methods used by the Trust to communicate appointments and the importance of keeping up with modern ways of working. There was also a discussion about Trust signage within its buildings which needed to kept up-to-date as services changed.

18/2/21 The Board SUPPORTED the report’s recommendations and SUPPORTED that the Task and Finish group continue for a further 12 months to develop an action plan based on the agreed recommendations and monitor implementation, supported by the joint planned care programme board. Guardian for Safe Working Annual Report

18/2/22 The Board considered the annual report of the Guardian of Safe Working (supported by the Director of People and Organisational Development) as part of the 2016 Terms and Conditions for Junior Doctors to assure the Board of safe working for junior doctors.

18/2/23 Board was advised that the Guardian was assured that all trainee rotas were legal under the 2016 contract. This was also borne out by exception reporting. There were two areas in medicine that had workload issues and were being addressed. The Guardian urged investment in an e-rostering system to allow safe rostering and identify gaps on a real-time basis. The Guardian assured the Board that the junior doctors generally had a safe working and learning environment.

18/2/24 The report from the Guardian of Safe Working was NOTED. South Yorkshire and Bassetlaw Pathology Network MoU

18/2/25 The Board considered a report of the Chief Executive that sought approval for the Memorandum of Understanding for a new Pathology network covering South Yorkshire and Bassetlaw. The Network in South Yorkshire and Bassetlaw was one of 29 proposed for the NHS.

18/2/26 They would provide high quality, rapid and comprehensive diagnostic services for patients delivered in the most efficient manner; and which would facilitate the introduction of, and widest access to, new investigations and diagnostic systems, and improve future training and career development for scientific and technical staff.

18/2/27 The networks would run as a hub and spoke model and the proposal for South Yorkshire and Bassetlaw (SY&B) was centred on Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) as the hub for the surrounding Trusts in Barnsley, Doncaster and Bassetlaw. Progress and key milestones were set out in the report.

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18/2/28 Further to a question from the Chair, the Board was advised of

engagement undertaken with relevant staff. It was noted that the Working Together Partnership brand would cease from 1 April 2018.

18/2/29 The Board APPROVED the Memorandum of Understanding for the South Yorkshire and Bassetlaw Pathology Network.

Use of Trust Seal

18/2/30 The use of the seal in relation to fire safety improvement work in the Women’s and Children’s Block, at Doncaster Royal Infirmary was APPROVED.

Chair’s Assurance Log for Board Committees

18/2/31 Board RECEIVED the Chairs’ Logs for assurance.

Finance Report – January 2018

18/2/32 The Board considered a report of the Director of Finance that set out the Trust’s financial position at month 9, 2017/18. The month 10 position was a deficit of £15.534 million, £397k behind our forecasted plan-to-date.

18/2/33 Whilst elective income was over £1 million less than plan, income from

Emergency HAD improved this position, with total income in January being the highest recorded all year at around £30 million. Underlying expenditure rate continued to be lower than expected, however, due to opening additional capacity. Spend on nursing increased slightly by around £180k and that was covered by increased Emergency income.

18/2/34 Approximately £600k of Tranche 1 funding had been utilised to ensure Sustainability and Transformation Funding. NHS Improvement had been advised that the Trust was not able to meet the revised control total. In order to hit the original control total of £16.1m the Trust could only overspend by a further £1m so it would require a concerted effort by all concerned since the Trust had been overspending at a rate higher than this in previous months. Cost improvement plans (CIP) of £1.7m had been generated in the month although £450k of this was non-recurrent. The cash position was positive.

18/2/35 Commenting on the CIP position, Alan Armstrong asked what impact being £2m short would have in this year. He also asked about the scale of the challenge in the following year. The Board was advised that further work with the CCG on income would help with the CIP challenge. Approximately £17.5m of schemes had been drawn up for next year and there was also likely to be some positive reduction in the Trust’s premiums as well as full realisation of the savings from the clinical admin review.

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18/2/36 In response to a further question from Alan Armstrong, the Board was advised that the Efficiency Director role was fixed-term pending further work with the Integrated Care System. In response to a question from Linn Phipps, the Board was advised that the consequences of missing the original control total were significant as it could result in loss of Sustainability and Transformation Funding which would increase the gap between the Trust’s control total and its final position. For next year, there was a wider consideration relating to the regional system’s finances.

18/2/37 The Board was advised that discussions with the clinical commissioning groups regarding the purchase of growth were ongoing. The Board was also advised that phasing of next year’s CIP might be undertaken differently.

18/2/38 The Board NOTED:

(1) The month 10 2017/18 financial position of £15.53 million deficit, £104k unfavourable against plan after removal of the 16/17 STF funding and any variance related to donated asset income.

(2) The risks to the Trust’s financial position particularly those relating to:

A proportion of the stock take and winter pressures monies were in

the position.

The continuing under booking of elective activity.

The back loaded CIP and significant savings that still need to come in

the next few months.

The Trust’s cash balance which had reverted to being ahead of plan

due to the receipt of the quarter two Sustainability Transformation

Funding (STF) and over-performance income received from the CCG

and NHS England last month.

In month the Trust was £105k adverse against plan despite the need

to break even over the last quarter to hit its forecast. While there

was still a significant improvement on run rate (excluding winter

pressure costs) it was likely that the Trust would need to earn the

winter pressures funding and be allowed to count it towards its

original control total in order to deliver the target. It was therefore

imperative that the Trust’s cost base was minimised in the final

weeks of the financial year to support this outcome.

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The Board adjourned at 11.00am and reconvened at 11.10am. Kirsty Edmondson-Jones joined the meeting.

Performance Report as at 31 January 2018

18/2/39 The Board considered a report of the Chief Operating Officer, Medical Director, Director of Nursing, Midwifery and Allied Health Professionals and Director of People and Organisational Development that set out clinical and workforce performance in month 10, 2017/18.

18/2/40 Performance against key metrics included:

4 hour access - In January the Trust achieved 89.2% against the 95%

standard (including GP access). In total, over 13,500 patients were

seen. System Perfect (launched 27 February) would focus on ED

performance amongst other things.

RTT – In January, the Trust performed below the standard of 92%

achieving 90%, an improvement over the previous month.

Cancer targets – In December the 62-day performance achieved the

85% standard, coming in at 87.8%.

HSMR – The Trust's rolling 12 month HSMR remained better than

expected at 87.24, a very minor increase from last month but

mirroring last year’s performance.

C.Diff – Remained below trajectory for the month, however still

above last year’s performance.

Nursing Workforce - The Trust’s overall planned versus actual hours

worked in January was 99% (this does not include supernumerary

newly qualified midwives). There were no wards that were red in

the month.

Appraisal rate – The Trust’s appraisal completion rate saw a further

rise to 63.97%. The Trust goal was to get to 90% with the

introduction of Appraisal Season in April 2018.

SET training - There had been an increase in compliance with

Statutory and Essential Training (SET) and at the end of January the

rate was 78.03%.

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Sickness absence – January had seen a further increase in monthly

sickness levels to 5.01%. Coughs, colds and flu had seen an increase

in the proportion of absence to 11.42% of all sickness absence

during the month.

18/2/41 There was a brief discussion about performance trends and the upcoming System Perfect work. In response to a question from John Parker, Board were advised that there was no sign of the 95% being ‘scaled down’. In response to a question from Linn Phipps, the Board was advised that a lot of work was being carried out on complaints resolution and monitoring.

18/2/42 The Board NOTED the Performance Report. NHS Improvement Undertakings Tracker

18/2/43 The Board NOTED the assurance from the NHSI Undertakings Tracker.

Reports for Information

18/2/44 The following items were NOTED:

Chair and NEDS’ report

Chief Executive’s report including corporate objectives

Minutes of Finance and Performance Committee, 28 January 2018

Minutes of Quality and Effectiveness Committee, 14 December and 4 January 2018

Minutes of Management Board, 15 January 2018

Working Together Partnership briefing

Board of Directors’ Calendar

Items escalated from Sub-Committees

18/2/45 None.

Minutes

18/2/46 The minutes of the meeting of the Board of Directors on 31 January 2018 were APPROVED as a correct record. Any other business

18/2/47 The Board wished Emma Shaheen, Head of Communications and Engagement, best wishes prior to her maternity leave.

Governors questions regarding business of the meeting

18/2/48 Clive Tattley made a request that the Missed Appointments work comes under Quality and Effectiveness Committee.

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Date and time of next meeting

18/2/49 9.00am on Tuesday 27 March 2018 in the Boardroom, Montagu Hospital. Exclusion of Press and Public

18/2/50 It was AGREED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Suzy Brain England Date Chair of the Board

the meeting of the board of directors to be held on …...2018/03/27 · the meeting of the board...

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