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University College London Hospitals NHS Foundation Trust

Board of Directors Public Meeting

Education Centre, 1st Floor West, 250 Euston Road Wednesday 27 November 2019

Start tme: 14:00

BOARD OF DIRECTORS PUBLIC MEETING

Wednesday 27 November 2019 2:00pm

Venue: Education Centre, 1st

Floor West 250 Euston Road London NW1 2PG

AGENDA

Agenda item Lead Page

number

1. Welcome and apologies for absence Julia Neuberger Verbal

2. New Declarations of Interest Julia Neuberger Verbal

3. Minutes of the last meeting Julia Neuberger Page 5

4. Matters arising Julia Neuberger Verbal

5. Presentation: Be the Change Tony Mundy Presentation

6. Chair’s report Julia Neuberger Page 13

7. Chief Executive and Senior Directors’ Team report Marcel Levi Page 15

8. Performance report

Cancer performance discussion

Marcel Levi Page 47

9. Chief Financial Officer’s report Tim Jaggard Page 67

10. Workforce Committee report Althea Efunshile Page 71

11. Research and Innovation Committee report Junaid Bajwa Page 73

12. Quality and Safety Committee report David Lomas Page 77

13. Audit Committee report Rima Makarem Page 89

14. Electronic Health Records System report Gill Gaskin Page 91

15. Mortality surveillance quarterly report Tony Mundy Page 95

16. Audit Committee minutes – for information Page 107

17. Any other business - verbal

18. Questions from the public – limited to 10 minutes

19. Dates and times of next meetings in public: Wednesday 22 January 2020

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Board of Directors Minutes of the meeting held in Public on Wednesday 25 September 2019

Present Junaid Bajwa, Non-Executive Director Geoff Bellingan, Medical Director, Surgery & Cancer Board Jane Collins, Non-Executive Director Gill Gaskin, Medical Director, Specialist Hospitals Board Clare Gerada, Non-Executive Director Charles House, Medical Director, Medicine Board Tim Jaggard, Finance Director Marcel Levi, Chief Executive Rima Makarem, Non-Executive Director Tony Mundy, Corporate Medical Director Baroness Julia Neuberger, Chair Flo Panel-Coates, Chief Nurse Caspar Woolley, Non-Executive Director

In attendance Debra Glastonbury, Head of Discharge Services (agenda item 5 only) Simon Knight, Director of Planning and Performance Ben Morrin, Workforce Director Luke O’Shea, Director of Innovation Karin Roberts, Head of Corporate Governance Rachel Stoukas, Trust Administrator Melanie Watts Interim Head of Operations, Medicine Clinical Board (agenda item 5 only) Bryan Williams, Director of Research and Development Dr Robert Urquhart, Chief Pharmacist & Divisional Clinical Director (agenda item 7 only)

Item Matters covered BoD/74/19 Welcome and apologies for absence 74.1 The Chair welcomed members of the Board and members of the public to the

meeting. Apologies had been received from Althea Efunshile and David Lomas. BoD/75/19 New declarations of interest 75.1 There were no new declarations of interest. BoD/76/19 Minutes of the last meeting 76.1 The minutes of the meeting held on 24 July 2019 were approved subject to

inclusion of Rima Makarem’s attendance. BoD/77/19 Matters arising 77.1 There were no matters arising. BoD/78/19 Presentation – Achieving Safe Patient discharge

78.1 The Board welcomed Debra Glastonbury. She provided an overview of the actions taken by the Trust to; reduce unnecessary days as a hospital inpatient, reduce readmissions, improve patient and staff experience and improve patient flow. She explained the role of the Integrated Discharge Service (IDS) and how the Trust worked with North Central London partners and indeed other boroughs to optimise patient care and reduce delayed transfers.

78.2 Caspar Woolley asked what provisions were in place for patients with complex needs and whether patient pathways were changed after being set and agreed as an inpatient. Debra explained that every patient has an individual assessment of their needs, if patients are assessed as having complex discharge needs they will be referred to the complex discharge team for further input.

78.3 Junaid Bajwa asked if consideration had been given to how technology could be used to help with the discharge process for example video links to assist remote monitoring of patients. Debra confirmed video clinics were well used in the outpatient setting however it does take a vast amount of work to set up. However with the introduction of Epic there will be continuous improvements and new ward processes were also helping including rhythm of the day - early discharge risk assessments.

78.4 The Chair thanked Debra for her presentation. The Board noted the actions being taken by the Trust and the joint working across North Central London to improve the patient discharge process.

BoD/79/19 Chair’s report79.1 The Chair welcomed Adam Sharples to the Board who was attending his first

meeting.

79.2 The report was noted.

BoD/80/19 Chief Executive and Senior Directors’ Team report80.1 The Chief Executive introduced his report. Since he had written the report there

had been good progress in preparation for the opening of the new Royal National ENT and Eastman Dental Hospitals on Huntley Street. He thanked all staff involved for their hard work. Almost six months post go-live of Epic the system is working well in most areas and there are plans in place to address the administrative and financial processes that are not working so well. The referral to treatment (RTT) performance remained a concern; this was in part a data quality issue cause by an inadequate transition of some data from the old systems to Epic and also a demand and capacity issue. The performance report provided further detail on the issues and mitigations.

80.2 EU exitFlo Panel-Coates presented to the Board. She explained that all organisations had received regulatory guidance in late 2018 and the Trust had responded to this by setting up a task and finish group with a membership of subject matter experts. The group focused on readiness preparation, communications, reporting supply of medicines and vaccines, supply of medical devices and clinical consumables, supply of non clinical consumables, goods and services, workforce reciprocal healthcare, clinical trials and clinical investigations, data sharing, processing and access.

80.3 Robert Urquhart provided an update on medicines. He provided assurance that the Trust had contingencies in place and a good level of stock as per business as usual processes. He confirmed that the Trust would adhere to national guidance with regards to bulk orders or stockpiling of medicines. Flo Panel-Coates advised the Board that the same principles applied to medical devices.

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80.4 With regards to workforce, staff from mainland EU were being fully supported and offered help with applying for settled status.

80.5 Rima Makarem asked if the Trust had considered how it would deal with the possibilities of having to choose which patient received a particular medication should there be a shortage and what plans were being made for the flu season. Ben Morrin confirmed that the Trust would shortly be launching its flu vaccination campaign and a ‘flu pod’ would be set up in the atrium of UCH for staff. Local flu vaccination clinics would also be available to staff. There had also been a very good uptake of staff volunteering to be peer vaccinators. With regards to the medication shortages, Robert Urquhart confirmed that North Central London Chief Pharmacists work together and have memorandum of understandings in place to support each other and share medicines when necessary. In response to Clare Gerada’s question about availability of radioisotopes, Flo Panel-Cotes confirmed UCLH was a priority site and would receive stock.

80.6 Jane Collins asked if patients were starting to ask questions and if they were worried. The Chair added she had spoken to a patient in UCH who had shared concerns with regards to their eligibility to receive treatment after 31 October 2019. Flo Panel-Coates confirmed patients were worried and were expressing concerns to staff. Staff had been advised to remain calm and refer to advice available on the staff intranet MyUCLH.

80.7 The Chair thanked Flo and Robert for the updated. The Board were assured that the Trust had responded well to the advice from the regulators.

80.8 PerformanceThe Board discussed the month 5 performance report in detail. The Chair asked why there had been a deterioration in emergency department performance. The Chief Executive confirmed there had been high level of attendances during August; this was an unusual seasonal trend. The Tower was also full to capacity which was also the picture in neighbouring NHS hospitals. Rima Makarem challenged the narrative set against the ED performance. Her view was that the only element out of the Trust’s control was patient attendance. She felt that reduced capacity in majors due to the refurbishment and junior doctor change over (which happens every August) should not have affected the four-hour standard target. The Chief Executive acknowledged this challenge. He explained that unfortunately a flood in the ED had caused a delay to the refurbishment works. He stressed that more needed to be done by the system to address the amount of patients presenting to the ED that could be seen in primary care but he understood this was sometimes an access issue as well as a patient choice issue. Clare Gerada suggested it would be useful if the Board had a future evidential based discussion about acute care and primary care trends using the knowledge and expertise available on the Board.

(Action Karin Roberts)

80.9 Adam Sharples remarked that the number of patients presenting with mental health issues was striking and asked what if anything could be done to turn the trend around. The Chief Executive agreed. This was a national issue with a lack of mental health beds available across the country. The Trust currently has mental health as a red risk on the risk register.

80.10 The Board were pleased to see improving performance for cancer targets and complaints although acknowledged further work for both standards was needed.

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80.11 Designated Body Statement of Compliance (DBSC)UCLH is required to annually submit a DBSC (Framework of Quality Assurance for Responsible Officers and Revalidation) to NHS England to confirm that appropriate systems are in place to assure the Board that the doctors’ fitness to practise and arrangements for medical and dental appraisal and responding to concerns are in place. The Board approved the DBSC.

80.12 North London Partners in Health and Care North Central London STPThe Board reviewed the quarterly update report from the NCL STP. The Non-Executive Director Board members in particular remarked that they understood very little about the future direction of travel of integrated care organisations (ICOs) and UCLH’s involvement with the STP. The Chair reminded the Board that there had been a previous STP seminar discussion however agreed this was a good opportunity to start discussions again as she had recently attended a Chair’s Network meeting where similar feelings were also shared. Adam Sharples shared his knowledge about working with Haringey clinical commissioning group (CCG) explaining there had been some process with collaborative working with the five NCL CCGs. He encouraged the Board to begin to come forward with ideas on the future direction of travel for ICOs. The Chief Executive confirmed the Trust was active in the STP leading on two workstreams; provider productivity and planned care. Ben Morrin added that some workforce processes had begun to be streamlined with other organisations within NCL. Tim Jaggard explained that the Trust had been active in trying to influence discussions at a system wide level. The Chair confirmed a future Board seminar discussion would be arranged.


80.13 Workforce Race Equality Standard and Workforce Disability Equality Standard (WRES and WDES)The Board reviewed the Workforce Race Equality Standard noting the key areas of focus on two standards; to enhance steps to reduce the number of staff from a black minority and ethnic (BME) background that go through any form of investigation and to proactively consider steps that allow the Trust to enhance the diversity of the Trust's leadership. The WRES would be monitored via the Trust's Diversity and Equality Steering Group and the Workforce Committee. UCLH has a statutory responsibility to publish performance against the WDES which is a new data based standard that uses a series of measures to improve the experiences of disabled staff in the NHS, mandated for all NHS and Foundation Trusts from this year. The Trust's focus this year is to develop the right foundation to enable us to work together to identify the specific challenges that negatively impact on staff experience for staff with disabilities.

The Board endorsed the publication of the Trust's performance against the WRES and supporting action plan and endorsed the first performance report against the WDES and supporting action plan.

80.14 The following reports had been received and noted by the Board:The Caldicott Guardian report, The Senior Information Risk Owner report, the Quarterly report on safe working hours (doctors and dentists in training) for the period 1 April 2019 to 30 June 2019 and the nursing and midwifery bi-annual staffing report.

80.15 Data Protection and Confidentiality PolicyThe Board endorsed the following policies: Data Protection and Information Security.

BoD/81/19 Chief Financial Officer’s report

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81.1 Tim Jaggard introduced the month 5 finance report. The August financial position before exceptional items and Provider Sustainability Funding (PSF) / Financial Recovery Funding (FRF) is a deficit of £5.0m, £0.2m adverse to plan. This brings the year-to-date deficit on the same basis to £22.4m, £1.5m adverse to plan. After taking account of exceptional items including EHRS revenuecosts (£0.8m excluding EHRS contingency) the in-month control total performance is a deficit of £5.9m, £0.3m adverse to plan and control total. Excluding one-off and prior period adjustments, the recurrent operational position in-month was £1.8m adverse to control total, driven by the large value of non-recurrent CIP (£1.7m). Risks to the financial position remained, notably; reporting and billing of drugs.

81.2 The Board were informed that the national financial architecture for 2020/21 is yet to be finalised, but indications are that PSF will no longer exist and the FRF will be a higher value targeted at deficit organisations. Of significant concern is that the UCLH 2020/21 control total may adjust back out the 2019/20 adjustment for EHRS costs which are not all non-recurrent and this would result in an unacceptable level of challenge compared to current run-rate financial performance. Given this, Adam Sharples asked how the Board was going to plan for these changes. Tim Jaggard confirmed a 2020/2021 deep dive planning session was planned for the October Finance and Investment Committee. Junaid Bajwa asked what the estimate Cost Improvement Programme (CIP) target was. He also commented that the Trust had committed to a lot of change and would have to consider future strategic items with financial caution. Tim explained the CIP target was likely to be as high as £60m which the Trust would not be able to achieve.

81.3 The Board noted the reported financial performance, risks and assumptions for month 5.

BoD/82/16 Workforce Committee report82.1 Clare Gerada introduced the report. The Workforce Committee held its inaugural

meeting on 5 September. The Committee membership includes Non-Executive Directors, senior leaders and staff representatives. There was discussion on the role of the Committee which focussed on retaining staff, inclusion and diversity, flexible and innovative ways of working, empowering staff, leadership and management skills and ensuring staff are provided with the resources they need to do their job. There were presentations from the Paediatrics and Imaging divisions. Paediatrics has a staff experience score in the upper quartile of the NHS whereas Imaging’s score is in the lower quartile. The Committee discussed the culture of both services and actions and learnings the Imaging Department could make in order to improve staff experience.

82.2 Ben Morrin added that the Committee had spent time addressing the actions being taken to address the imbalance between BME and white staff who are subject to formal disciplinary action.

82.3 The Board noted the report and approved the revised Workforce Committee Terms of Reference.

BoD/83/16 Electronic Health Records System report 83.1 Gill Gaskin outlined the current position explaining that the Trust remains in the

stabilisation period. 8,400 patients are currently actively using MyCare UCLH, the patient portal. The Epic team undertook their second scheduled comprehensive “Post-Live Visit” in July and confirmed that emergency, inpatient and theatre-based Epic use is generally going well and the principal areas for focus are outpatient routines and administrative processes.

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83.2 Beacon chemotherapy protocols were taken out of scope for the main Epic Go-Live because they could not be built and validated in time. A new date was set for October, but at the September Programme Board it was agreed that the Go-Live date should be deferred to be incorporated into the 14 November upgrade, allowing four further weeks to complete build and validation and clinical signoff, with additional staff in place.

83.3 The Board noted the report and offered congratulations to Natasha Philips who had won the Chief Nurse Information Officer of the year in the annual DigitalHealth awards and to the EHRS implementation team who had been shortlisted for the Staff Engagement Category of the 2019 HSJ awards.

BoD/84/19 Quality and Safety Committee report84.1 Clare Gerada introduced the report which covered key issues discussed at the

QSC meetings held in July and September. She highlighted the positive audit findings following an audit of the documentation of nasogastric feeding tube insertion and management in adult, paediatric and neonatal patients at UCLH in 2019.

84.2 Rima Makarem referred to the administration and patient access programme (APA) update and asked if there was any update on telephone answering performance. Luke O’Shea explained that this was not currently part of the APA programme however he was keen to address the issues and had begun to formulate ideas to be discussed at a future SDT meeting.

84.3 The Board noted the QSC report and received and noted the following 2018/19 annual reports: Patient Experience, Complaints, Infection Prevention and Control, Safeguarding Adults and Child Safeguarding.

BoD/85/19 Mortality surveillance report85.1 The Board reviewed the report on deaths and learning for the period April 2019 to

June 2019. Tony Mundy noted there was a gap in the number of structured judgement reviews that had taken place and actions were be taken to train staff to become expert reviewers.

BoD/86/19 Audit Committee report86.1 The report covering key issues discussed at the July 2019 meeting was noted.

Rima Makarem noted that the requirements of the Committee to understand its role with regards to climate change and sustainability had been discussed and Deloitte had agreed to offer assistance. The Audit Committee had also recommended this be a topic for a future Board Seminar.


BoD/87/19 Any other business87.1 The Chair informed the Board that her recommendation that Jane Collins be

appointed the role of Vice Chair of UCLH had been approved by the Nominations, Appointments and Remuneration Committee. This would now be presented to the Council of Governors in October for ratification.

BoD/88/19 Questions from the public88.1 The UCLH Lead Governor asked a question in relation to the high locum usage in

the emergency department and whether this had an adverse effect on performance.The Chief Executive responded. ED staffing remained a challenge owing in part to national availability of trainees. Whilst locum usage was a contributory factor to ED performance there were also other key issues including capacity within the Tower and a high number of patient attendances to the department.

BoD/89/19 Date and time of next meeting89.1 Wednesday 27 November 2019

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Signed___________________________________________

Baroness Julia Neuberger, Chair Date:

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Board of Directors Meeting

27 November 2019

Farewell and thanks

I would like to say farewell and a huge thank you to Dr Rima Makarem whose term of office as a non-executive director comes to an end in December 2019. This will therefore be Rima’s last Board meeting. Rima has been a non-executive director at UCLH since 2013 and has been a wonderful and diligent chair of the Audit Committee for 5 years. She has made an enormous contribution to UCLH in her time as a non-executive director and has always shown great insight. I’m sure you will join me in wishing her well for the future.

Vice Chair and Senior Independent Director

The appointments of Jane Collins as Vice Chair and of Althea Efunshile as Senior Independent Director were confirmed by the Council of Governors and I am pleased to confirm that Jane and Althea took up their new responsibilities on 1st November.

Appointment as Chair of Whittington Health

I am sure you are aware that NHS Improvement has appointed me as Chair of Whittington Health from April 2020. I will take on this role alongside that of Chair of UCLH. The roles are two separate appointments to two separate Boards – it does not mean that the two organisations are merging.

However, the appointment will strengthen the partnership between our organisations as we develop working as part of a broader and coordinated system for the communities we serve and will help to strengthen collaboration between Whittington Health and UCLH.

Winter Preparedness

We are still expecting a serious influenza season and extreme weather conditions over the next few months. The next few months will also bring lots of patients with acute problems needing a hospital bed. The Emergency Department is already busier than ever and we will need excellent teamwork to minimise delays in the ED and ensure that cancellations of elective patients are as few as possible.

Having a flu vaccination is also an important part of the preparations for our staff, and I am pleased that we have done so well this year with encouraging staff to be vaccinated.

End of Life Care Report

We had an extensive discussion of the excellent End of Life Care Report from the Council of Governors at the October Board Seminar. I am now working closely with Flo Panel-Coates and Charles House to take this work forward and we will provide an update to the Board in due course.

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UCH Atrium

I have also spent considerable time watching what goes on in the atrium at UCH and observing how our patients are welcomed at reception and more generally. I have been much impressed by our reception staff and I am still working on being the “mystery shopper” for other services.

Stakeholders

I am continuing to meet as many of our stakeholders as possible. I chaired the Council of Governors’ quarterly meeting in October where we had a presentation on the new Royal ENT and Eastman Dental Hospitals.

UCLH Charity

I have been working with the Charity to help bring in new funders for much of our work, especially for improving the environment for patients and staff.

Festive Celebration

I hope you will be able to join me at the UCLH Festive Celebration on 5th December from 4.30 p.m. until 6 p.m. I wish season’s greetings to all our staff.

Baroness Julia NeubergerChair

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27 November 2019

Chief Executive and Senior Directors’ Team Report

ForewordAs we are nearing winter we are preparing ourselves to be ready for the increased demand from acutely ill patients. Working closely together with system partners, we are trying to mobilise additional capacity inside and outside the hospital, smoothing pathways to prevent admission or facilitating early discharge, and improve appropriate provision for mental health patients. In addition, we are massively engaged to improve flu vaccination rates of staff at UCLH and preliminary results look very good (see further). Nevertheless, our A&E performance is already heavily under pressure, similar to almost every other organisation in the UK. Still, we are developing plans and are still very keen to improve our A&E 4 hour wait performance in the next few months. There is some positive news regarding our cancer performance. With a lot of hard work from a very large number of people and teams we have significantly improved our performance and we are hitting all relevant cancer performance targets, which is something we have not achieved for many years. Later on the agenda we will discuss the critical success factors in getting there, as a learning experience to improve our performance in other areas. We are seeing a slow but progressive improvement of our referral to treatment (RTT) targets after the decline in performance after EPIC go-live. We are still seeing a combination of reporting issues (due to the new system) and real waiting times that have been built up in the early weeks after go-live. A lot of focus is directed at 52 weeks waiters with plans in place to have eliminated this at the beginning of next year.

In October we celebrated black history month with a wonderful event on the 22 October ‘A celebration of black history’ we had celebrity guest speakers and Q&A sessions from our very own Board members, Althea Efunshile, Flo Panel-Coates and Charles House. We were also very privileged to have celebrity guest speakers, Akala, Ashley Walters and Richard Blackwood and ex NHS Chief Executive John Brouder. It was a wonderful and empowering event. I am very proud of all of the Staff Networks we have at UCLH which give staff a voice and create a sense of community and support. We currently have five Networks – Women in Leadership, Lesbian, Gay, Bisexual and Transgender (LGBT), Black, Asian and Minority Ethnic (BAME) Mental Health and Disability.

On behalf of the Senior Directors’ Team I would like to say a huge thank you and fond farewell to Rima Makarem who will be leaving us at the end of December as her term as a Non-executive Director has come to an end. She will be sorely missed and has made a huge contribution to the Board and indeed a personal thank you from me as Rima was very welcoming towards me and helped me settle in when I joined the Trust three years ago.

Finally as this is the last Board meeting of 2019 I would like to take this opportunity to say a big thank you to all of our staff for all your hard work during the year. Thank you very much also to our Board members and Council of Governors. I wish you all a very happy festive period.

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https://my.uclh.nhs.uk/Interact/Pages/Section/Default.aspx?Section=5319

Board Assurance FrameworkA full review has been undertaken of the BAF. Two changes to be noted: New riskDatix ID2532 UCLH is unable to adapt quickly to new payment mechanisms that may replace payment by results (PBR) affecting financial sustainability Increase in risk score:Datix ID2525 EHRS programme implementation has unanticipated adverse impacts on service delivery, finance, other strategic developments. Risk score increased from high amber (15) to very high red risk (16).

The Board is asked to review and discuss the BAF.

Annual flu vaccine The flu vaccine offers protection against this potentially dangerous and unpredictable virus. Front line health workers are among those most at risk of catching and spreading the virus. You can be a carrier – without showing any symptoms. The UCLH flu campaign launched in October and as of 15 November we have vaccinated 4879 staff which is 60% of staff. Also according to the data sent to us from immunisation commissioner (NHS England – London Region), UCLH has vaccinated the second highest number of staff in London only a little less than Guy’s and St Thomas’ NHS Foundation Trust. I continue to encourage all staff to receive their flu jab. I also would like to thank all of the peer vaccinators who are doing a fantastic job running flu clinics and manning the flu pod in the atrium at University College Hospital.

General Medical Council (GMC) junior doctor trainee surveys and the report from the guardian of safe working hours (doctors and dentists in training)In March 2019 the GMC launched the 2019 training survey which was open to all doctors in postgraduate training (not Trust grades). UCLH had a response rate of over 99%. The results contain a significant amount of data. However, the main focus of Health Education England (HEE) is on the positive and negative outliers. UCLH has maintained its third place ranking of the eight Trusts in North Central and East London for overall satisfaction. UCLH ranked fifth amongst the ten Shelford Group Trusts for overall satisfaction in 2019. At a recent meeting the SDT analysed the results and met with the Trust’s Director of Postgraduate Medical Education to discuss the areas with the highest number of positive and negative outliers and to discuss immediate actions to be taken in response to the HEE criteria. Full survey results are available to Board members on request.

The attached quarterly report on safe working hours for doctors and dentists in training covers the period from 1 July to 30 September 2019. 36 exception reports were submitted during the reference period, of which 34 were in relation to work and hours.

The Board are asked to discuss and note the quarterly report.

Telephone performanceThe SDT have acknowledged, via feedback from our Governors and patients that there are several issues with regards to performance of telephone answering across the Trust. Our Director of Innovation and Head of Programme Admin Transformation have been looking at how telephone answering can be

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improved, working with key divisions. Initial ideas include a dedicated cancellation line for patients, an alternative provision to act as an overflow service and new telephony software. Progress on improving appointment making and the cancelation processes using email, SMS and other mechanisms will continue. A task and finish group is being set up to address the concerns and develop a Trust wide approach. The new approach and options are being costed and will come to back to SDT for approval.

Meetings of interest to the Board On 30 September 2019 I presented a keynote lecture during the European Orphan Medicine symposium in Brussels, Belgium

On 4 October 2019 I spoke at a symposium on integration of acute and mental health service organised by the International Acute Medicine Federation in London.

Flo Panel Coates and I enjoyed being peer vaccinators in the UCLH staff flu vaccination campaign on the various sites of the Trust during October and November.

I chaired the International Workshop on Innovative Medical Devices for prevention and management of Cardiovascular Disease in Edinburgh on 14 October 2019.

On 30 October I gave a key note lecture at the launch of the Interdisciplinary Centre for Health Innovation Research of City University, London.

On 7 November I presented the closing speech of the International Medical procurement Organisation meeting in Paris, France.

On 8 November I attended the 10th anniversary of the MRC Centre for Neuromuscular Disease of UCLH/UCL and presented a lecture entitled: “Towards a research hospital”.

I presented the opening lecture at the European Physician Assistant Congress (15 November 2019) on “New models of care in curative medicine” in Frankfurt, Germany.

On 26 November I organised and chaired the International Symposium on Microbiome in Health and Disease together with the King and Queen of the Netherlands in the Royal Palace, Amsterdam, the Netherlands.

Entries in the seal register since the last report to the boardThis table below updates the Board on the use of the Trust Seal since the July meeting. The Trust Seal is used by the Board of Directors to execute legal documents (such as formal contracts and lease agreements) agreed on behalf of the Trust. All documents have been authorised by one executive and one non-executive member of the Board. The Board is asked to note the use of the Board Seal for the listed transactions.

Number Date of Entry Entry Details Supporting Information

1086 25 Sept 2019 Surrender of Eastman Dental Hospital Telecommunications Agreement.

Deed of Surrender relating to roof top lease between UCLH, EE Limited and Hutchison 3G UK Ltd.

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Professor Marcel LeviNovember 2019

1087 25 Sept 2019 Surrender of Eastman Dental Hospital Telecommunications Agreement.

Deed of Surrender relating to agreement to install equipment between UCLH and EE Ltd.

1088 25 Sept 2019 UCLH Phase 4 Grant of Lease to HCA. Lease for part of 4th Floor, whole of 5th Floor and 5th Floor Roof garden between UCLH and HCA.

1089 25 Sept 2019 Phase 5 Royal National ENT and Eastman Dental Hospitals Phase 5 Grant of Short Lease.

Lease of part ground floor for use as a café between UCLH and Medirest/Compass Contract Services (UK) Ltd.

1090 29 Oct 2019 Surrender of Eastman Dental Hospital Telecommunications Agreement.

Side letter permitting disconnected equipment to remain between UCLH, EE Limited and Hutchison 3G UK Ltd.

1091 29 Oct 2019 Pathology Joint Venture - Short Term occupation arrangements for UCLH.

Licence to occupy Shropshire House between UCLH and TDL.


Underlease to occupy 5th Floor West, 250 Euston Road between UCLH and TDL.


Side letter recording the rent agreement for entries 1091 and 1092 between UCLH and TDL.

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BOARD ASSURANCE FRAMEWORK, November 2019 version 1

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UCLH strategic theme: Provide the highest quality of care within our resources Responsible monitoring committee: Quality and Safety Committee (QSC)

PRINCIPAL RISKS Description of risks

LEAD Which director leads on manage-

ment of this risk

KEY CONTROLSWhat controls / systems are

already in place to manage the risk

ASSURANCES ON CONTROLS

What evidence can be used to show that our controls

are working

CONTROLS AND ASSURANCE GAPS AND ACTIONSWhat controls should be in place to manage the risks but

are not?

What evidence should be in place to show the controls are working / or effective but is not currently in place

Risk ratingLikelihood x impact =

risk

Gap Date Current Target

Weaknesses in tracking patients requiring review or treatment could lead to failures to provide best care

Datix ID 1794

Gill Gaskin [as medical director lead for patient admin-istration workstream]

Administrative processes in divisions for booking and tracking patients after A&E attendance, outpatient or inpatient stay

Patient booking lists, patient target lists (PTLs) and waiting times reports

EHRS workgroups have a number of workstreams covering booking processes, ongoing plans for patients who do not attend and management of inbaskets and work queues. A central team is validating RTT waiting lists.

Head of APA programme closely involved to ensure that admin staff and support and training is aligned. An EHRS workgroup is refining processes for results routing to facilitate a closed loop process for action on abnormal results.

Look back exercise on a subset of cancer patients with concern of loss to follow-up prior to Epic presented to QSC. No evidence

Internal Audit undertake annual reviews of a sample of Cancer and RTT data to validate against board level reporting/returns.

Control gaps

Epic implementation has led to a reduction in waiting list data quality. Ongoing work with Epic to facilitate accurate recording.

Assurance gaps

Suite of indicators demonstrating that booking and tracking systems are operating appropriately has not yet been completed

Internal audit programme to cover cancer and RTT/diagnostic waiting times within the new Epic setting, starting with cancer waiting times

Q3 and Q4 2019-20

December 2019

January 2020

5 x 3 = 15

3 x 3 = 9

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of issues impacting outcomes.

Suite of new reports in place for cancer tracking.

Development of a set of reports that identify Epic in-basket / work-queue actions that are not complete.

Delivering required levels of financial savings / efficiency in our long term financial model, or delivering tactical responses to deficits, reduce the quality of care at UCLH

Datix ID 1797

NO CHANGE IN STATUS

Medical directors

Quality impact assessment of savings schemes prior to acceptance into the programme, refreshed for 2018/19

Use of safer nursing care tool to determine ward staffing levels

Productivity programme emphasis on targeting waste and improving patient experience through greater efficiency.

Medical Director (and, where appropriate, other clinical) scrutiny of CIP plans before implementation.

Quarterly Quality and Safety Committee review of quality indicators

Quarterly Monitoring of complaints and patient experience surveys

Monthly improving care walk rounds

Monthly Reporting of actual staffing vs desired staffing

Oversight of DATIX incident reporting

None noted

Note that external pressures on the organisation in 2019/20 (eg reduction in market forces factor funding) risk significant impact on funding and thus on all aspects of the organisation

4 x 3 = 12

3 x 3 = 9

Overall of 112


Page 3 of 19

State of disrepair on older parts of the estate has a sustained and significant impact on provision of high quality services for patients in a period of constrained capital funding / potential reliance on emergency funding

Datix ID 1779

NO CHANGE IN STATUS

Director of Estates and Capital Investment

Planned preventative maintenance regime, enhanced checks and (re)validation of areas

Capital programme is in place and project works are being undertaken

The replace and refresh / backlog programme for 2017/18 is progressing with projects being carried out across the portfolio, with circa 80% of scheduled works now complete for period.

Schemes for 2017/18 have been agreed by CIB and are being developed and prioritised

Phase 4 and phase 5 will have a positive impact on risks associated with older estate

Backlog maintenance contribution from Ifm continues through the period 2017/18

Annual condition B survey

Technical Estates compliance audits continuing through 2017/18

CEF-D engineers proactively and reactively audit sites throughout the portfolio in accordance with agreed SLA and contract monitoring with Ifm.

Surveys and risk assessments of existing infrastructure

Review of building cladding for compliance with fire safety regulations, in line with NHS

The Capital Estates and Facilities Division are monitoring the relevant service provider to ensure checks and monitoring is taking place as required (ongoing)

This strategic backlog maintenance risk is reviewed every year alongside the condition B survey and planned preventative maintenance programme.

Audit on Backlog maintenance and management found no gaps / issues

None noted 3 x 4 = 12

1 x 4 = 4

Overall of 112


Page 4 of 19

guidance. All tests passed

Insufficient capacity to deal with the number of patients referred to the Trust means that UCLH incurs financial penalties / lost income (regulatory / contractual interventions and lost activity)

Datix ID 1780

Chief executive

Demand and capacity modelling

Ongoing relationships with commissioners: new focus on escalation of delayed discharges, with discharge to assess pathways now in place

Modelling and planning for strategic building projects, and subsequent delivery of new capacity

Review of current plans for disposal of existing buildings for impact on capacity requirements

Development of new models of care

Plans to improve pathways and reduce length of stay

Strategic capacity planning steering group to assess longer term requirements / potential gaps

Revised 7 day bed prediction modelling tool in place

“MADE” events to promote best practice in discharge and multiagency working.

Monthly monitoring of performance against waiting times standards and other access and flow metrics including mixed sex breaches; cancelled operations

Quarterly reports on referral numbers and market share

Control gaps

Further work required on diagnostics modalities: CT; ultrasound; sleep studies

Strengthen bed and theatre longer term modelling and use to test scenarios based on growth and efficiency assumptions; progress made, but further work to complete

Turnaround programme for theatre utilisation

Assurance gaps

Outpatient utilisation report suite incomplete.

Plan by Q4 19-20

Ongoing

Ongoing

Q2 19-20

4 x 3 = 12

2 x 3 = 6

Overall of 112


Page 5 of 19

UCLH fails to deliver benefits from technology change (lack of investment or implementation failures) leading to quality issues or financial loss

Datix ID 1896

Gill Gaskin, Medical Director, Digital Healthcare

Digital Services Delivery Board

Appointment of Medical Director of Digital Healthcare to provide leadership and focus

Monthly Digital Services reports to SDT

EHRS Programme Board

EHRS benefits realisation workstream led by dedicated benefits manager and Director of Innovation.

EHRS clinical leadership and engagement programme

5 EHRS multi-professional groups

Baseline assessment of digital maturity to identify areas of weakness, working towards HIMSS accreditation for digital maturity level 6 then 7 with oversight by benefits manager.

NCL digital engagement and financial leadership by UCLH to align technology delivery with sector plans

Contract management of Atos Digital Transformation Partner (DTP) contract

Fast Follower in the national Global Digital Exemplar programme, with oversight by NHS Digital. Learning from Epic UK collaboration.

CIP team represented in planning of EHRS work programme for Q3/4. Benefits reports to EHRS Programme Board

External Audit of DSP Toolkit submission

EHRS programme board trackers

External assurance of EHRS programme during implementation

Pre-live assurance by NHS Digital/NHSE

Epic benchmarking of adoption of functionality (in top half globally 2019-20)

Attendance of NHS Digital at EHRS Programme Board

Control gaps

Dependent on adoption at individual level

Pressures of “business as usual” limit time for attention to benefits delivery.

Risk that optimal availability of end-user technology is constrained financially.

Risk that budgeted Epic build and training teams have insufficient capacity to maximise benefits

On-going

4X3=12 2X3 =6

Overall of 112


Page 6 of 19

EHRS programme implementation has unanticipated adverse impacts on service delivery, finance metrics and/or other strategic developments, particularly when combined with other service pressures, leading to worse patient outcomes, poor patient experience, regulatory intervention and reputational impact.

Datix ID 2525

Gill Gaskin, as SRO for EHRS programme

Substantive Epic build/fix team in place; Epic software updates and upgrade taken on time and successfully.

EHRS programme board meeting with executive director attendance

Weekly programme team meetings and risk registers,

Three clinically-focussed governance groups, prioritise actions according to safety and operational impact

Technical governance group involving Atos and Epic, alongside EHRS leads and Digital Services.

Admin billing and reporting EHRS governance group leading on patient pathway management, referrals waiting times and billing processes. Income assurance group in place.

Strong support from Epic implementation and technical teams, with.additional Epic support in place for key areasSafety surveillance mechanisms / lead in place

Clinical leadership roles (CMIO, CNIO, CRIO), Admin support through APA Programme lead and patient engagement

Contingency budget

Post Go-live stabilisation and optimisation programmes

Downtime procedures and business continuity arrangements

Targeted training where indicated.

Oversight of performance and clinical quality by Operational Excellence, Elective Access Boards, SDT and Quality and Safety Committee.

EHRS programme reports

Reporting directly to Board of Directors meetings and sub-committees

Inclusion in Internal Audit programme

Oversight of business continuity by Trust EPPR committee

Phase 5 ICT delivered for opening, Lessons learned for Phase 4 implementation, with dedicated EHRS/technical input.

Control gaps

Block contract and challenging control total impact on resourcing for additional clinical activity to reduce waiting backlog.

Remedial action further exacerbated by national consultant pensions issues preventing take-up of additional sessions to reduce waiting lists

Delays in funding, providing or repairing new end user technology and infrastructure have greater impact than pre-Epic leading to inefficiency. (action: new processes being brought to EHRS programme board)

Full suite of BI reports not yet available to operational teams..(action: prioritised release list)

Complexities of UK waiting list and pharmacy processes not fully reflected in Epic impacting on booking efficiency and high cost drug billing (build modifications underway).

Combination of strategic developments and intensified operational management post Epic exceed management capacity leading to increased waiting times and poorer financial performance,.

Assurance gapsFull and accurate set of operational and quality reports post Epic not yet available for assurance (action: progressing through a prioritised release list)

Ongoing4 x 4 = 16

2 x 4 = 8

Overall of 112


Page 7 of 19

A cyber-attack could lead to critical IT systems not being available, with an impact on quality of care and income streams for a prolonged period

Datix ID 1947

Director of digital services

Senior Information Risk Owner (SIRO) reported to SDT & Board of Directors showing compliance risks and data security posture risks. Improved monitoring has resulted in new risks identified. This has countered improvements in other areas.

Incident management. No reportable incidents to DHSC under NIS directive 2018 about critical loss due to cyber attack. Internal incidents, Datix and Atos incidents shows no near miss incidents or losses of critical systems which indicates controls are valid

Digital Services Business Continuity Plan agreed with EPRR committee and integrated with EHRS

NHS Data Security and Protection toolkit status is now “standards met” for 2018/19.

Interim submission to NHS Data Security and Protection Toolkit is on track for “standards met” for 2019/20

No critical services running on unpatched or unprotected equipment.

SIRO and information security officer control security patch exception decisions.

Approx. 5% of mobile devices are obsolete, which is tolerable.

Adoption of NHS Digital Active threat Protection Service in progress.

SIRO reports to Board of Directors and governance boards

Incident management procedures

Annual penetration tests (including approved improvement plan)

NHS Data Security and Protection toolkit

UCLH Information security policy and framework reviewed by NHS Digital and approved by SDT

UCLH has joined the NHS Cyber Security Support model which provides central resources and cyber security protection

Business continuity plans.

Disaster recovery plans

Consider an agreement with commissioners to secure monthly payments in the event of a cyber-attack – still pending.

Annual IT Health Check found vulnerabilities that need a risk treatment plan

There is a need to treat Windows 2008 servers which become obsolete in Jan 2020 and for which funding is being considered.

There is a need to improve procedures that control security especially joiners, movers and leavers. A manual workaround is in place.

Deliver publicity campaign for the new Information Security Policy. To include advice on upgrading mobile phones in critical areas

Achieve Mandatory Cyber Essentials Plus by Q4 19/20 (to avoid compliance risk in March 2020)

Board of directors and information asset owners to receive dedicated cyber security training within next 12 months.

Atos Disaster recovery plan requires review and testing

March 2020

June 2020

Dec 2019

March 2020

Jan 2020

March 2020

October2020

March 2020

3 x 5 = 15

2 X 4 = 8

Overall of 112


Page 8 of 19

UCLH strategic theme: Support the development of our staff to deliver their potential Responsible monitoring committee: Picked up in relevant Board committees as needed

e



ment of this risk





are working


are not?



risk


Lack of long term Organisational Development (OD) and succession / leadership plans lead to negative impact on the effectiveness of the organisation.

Datix ID 1782

Workforce director

The first stage of senior leader development is now complete. A third programme for the 150 most senior leaders being led by Yogi Amin has now commenced.

Learning strategy for the trust in support of our right capabilities goal within our strategy refresh. Leader development programme covering leadership, change and improvement.Coaching and mentoring opportunities, including executive coaching and a reverse mentoring programme for senior leaders.

Portfolio of apprenticeship qualifications from level 2 business and administration up to a level 7 MBA. Recruited to the NHS graduate management training scheme as well as our internal scheme.

Senior director succession plan, used to inform selection planning and decisions on two senior director successions

Regular workforce reports to the Board on progress

From the last meeting of the Workforce Committee in June, we are also moving to quarterly deep dives and dedicated reviews on staffing at our BoD.

Business as usual programmes have now resumed following Epic go live. These include our current leadership and management programmes. We are currently engaging with stakeholders to determine what should be included in our leadership and management development pathways with a view to launching a revised version in January 2020.

Two specific actions to allow for fresh impetus on leadership diversity should progress this autumn: A mid year evaluation was presented to the

the SDT in October 2019.

Proposals for reverse mentoring approved in October and will launch Nov 2019

The MBA apprenticeship scheme’s first cohort were selected in October 2019 and invited to start the programme from January 2020. The selection process was informed by a diversity by design workshop in September and the cohort intake reflects a diverse intake.

The CEO is bringing forward proposals informed by the SDT for our future structure from 2020/21. That plan will go to pre-consultation this Winter with a supporting OD plan from formal consultation in the new year.

Q4 19-20 3 x 4 = 12

2 x 4 = 8

Overall of 112


Page 9 of 19

Junior doctor post vacancies at UCLH (currently estimated at 10-15% of total junior doctor posts) could place undue additional clinical service requirements on those junior doctors in post with an impact on the quality of training and education that they receive

No change in status

Workforce director

The CEO has secured charity for part research and part clinical roles. 27 posts were approved in 2017/18. A further scheme was run in 2018/19 which secured another 30 such posts.

As part of the ESR/GL reconciliation process, all medical workforce budgets are being reviewed and aligned across Finance, Workforce, Education and HEE. This will provide clarity on where our junior doctor gaps are and enable us to develop focussed strategies to fill any confirmed gaps in rotas. Funding for two education fellow posts has been approved.

A trust doctor strategy is being developed to ensure that we become the employer of choice for this staff group.

A medical workforce plan for which includes international recruitment and new types of rotation is being put in place.

The SDT and BoD receive and act on quarterly reports from our Guardian for Safe Working Hours including detailed assessment on any rota gap by sub speciality.

Fill rate of junior doctor posts

Agency spend covering junior doctors

GMC trainee survey overall satisfaction and workload information

Number of vacant posts

Agency spend

Exception reports filed for breach of hours and inadequate training

Oversight and Scrutiny Board: Medical Workforce plan

Further Physician Assistant and Associate posts are being allocated. We have submitted a request for funding from the Charity to develop a masters’ programme for Anaesthesia Associates in partnership with UCL, which if approved should create a pipeline for this workforce at UCLH. The charity’s decision is due by 20 November 2019.

Work with the Local Negotiating Committee (LNC) to identify hot spots where vacancies are having a significant impact on the service and put in place short term solutions to relieve immediate concerns.

Regular review of learning from Guardian for Safe Working Hours’ trust wide and local reports has led to in-depth analysis of position in challenged areas. Following recent actions in obstetrics and gynaecology have led to new flexibilities for locum supply: enhanced pay and in year change to rota including additional ST3+ roles. Ongoing review necessary through close working review with Guardian.

April 19 onwards

October- December 2019

October and Novem-ber 2019

3 x 3 = 9

2 x 3 = 6

Overall of 112


Page 10 of 19

The impact of multiple factors on the availability of sufficient nurses and midwives to cover hard to fill shifts and roles will make it difficult to deliver the highest quality of care within our resources.

Note: Multiple factors include the loss of the bursary, reduction in post registration development funding from HEE, reduction in EU registrations to the NMC, new roles for nurses and midwives to move into at higher pay bands.

Datix ID TBC

No change in status

Chief Nurse

Monthly monitoring of fill rates and movement of staff internally through the transfer process

Monthly monitoring of recruitment rates into posts and national/international markets

Learning from NCL chief nurse and Local Workforce Action Board and Capital Nurse and Midwifery programmes

Exemplar ward accreditation and monitoring of indicators at ward level

Exit interview and local workforce intelligence within clinical boards

Establish a new nursing and midwifery careers framework with steering group

Review of temporary staff usage via bank partners

Listening via breakfast with the Chief Nurse Essex Wynter charity funded initiative

Oversight via the monthly professional Nursing and Midwifery Board, reporting to Senior Directors Team meeting.

Vacancy rates

Turnover rates for Nurses and midwives

Agency usage

Bank staff usage

Exemplar ward monitoring

Transfer request trends

Return to practice numbers

Student learners in placement

Apprenticeship

Additional support with a charity funded retention and recruitment nurse to focus on areas (such as the NHNN) -where there a higher than average turnover and vacancy rate at band 5

Additional overseas recruitment in place to ease impact of turnover

Improvement plan for the on-boarding and preceptorship for new nurses and midwives to address the leave rates within the first 12 months

Additional leadership development, action learning sets and coaching for ward sisters and charge nurses, clinical nurse specialists and Matrons.

Establishment reviews with additional look at establishing posts adding temporary staffing demands (ED, CCU, HCA’s) and review of bank rates to reduce agency usage ahead of winter

New nursing associate apprenticeship started in December 2018. Second cohort planned for December 2019. Reviewing other opportunities for HCA’s, ACP’s and Graduate training.

Review of information and opportunities for flexibility in working patterns and over 50’s

Review and increased return to practice placements.

New nursing degree apprenticeship programme starts in December 2019.

Review of the professional education team aligning to three key focus areas of undergraduate, apprenticeship and post graduate offerings.

Review ongoing between workforce and finance teams to ensure the locally held data re vacancies is accurate, aligned to ESR and available to be part of local dashboards.

June 2019

August 2019

October 2019

November 2019 review

Dec 2019

October 2019

October 2019

Dec 2019

Sept 2019

tbc

3 x 4 = 12

3 x 3 = 9

Overall of 112


Page 11 of 19

National and international shortages in professional clinical leading to gaps put at risk patient safety and our ability to deliver planned activity

Workforce director Workforce framework, including

headline supply targets for non-medical and medical recruitment. Focus on hard to recruit areas, with innovative supply ideas.

The Workforce Board reviewed international workforce supply trends in March 2019. We met our end M12 vacancy target – with overall trust wide vacancies falling to 7%.

Medical workforce recruitment team developing new recruitment routes for national shortage areas.

Streamlining management of joint appointments between UCL and the trust. Facilitating deployment of staff between NHS organisations to fill staffing gaps.

Detailed initiatives to improve all leave planning and training requirements for staff will help the trust to manage staffing levels across the trust.

We told staff that we will cover the application costs for any EU national who decides to apply for pre-settled or settled status during the pilot of the government’s new settlement scheme (taking place during December 2018). Over 220 staff accepted. A CEO led communication on how we value our international staff launched in March 2019 and he intends to write to all affected staff again by end September 2019

Monitored in the CEO performance pack:

1. Vacancy rates

2. Stability rates

3. Time to Hire for all staff and for junior doctors

Staff Survey 2018/19

Turnover rates for mainland EU/Irish and other non-UK staff

Mainland EU / Irish starters and leavers data

The shortages in certain staff groups identified are a long-term challenge. Whilst the trust can work to identify new supply routes and developing its reputation as an employer of choice, the labour market for these identified areas is limited. Nevertheless, the trust’s vacancy target met its M12 target for end-year (18/19) and is broadly in line with our 19/20 trajectory at M8.

Service areas are reviewing the way they deliver our services to look for opportunities for new ways of working that enables the trust to deliver the quality of service we aspire to, but with different staff, new ways of working and automation where possible. This shall involve developing new education pathways, experimenting with different roles to deliver the service and re-scoping AI options.

Further specialist advice for staff, i.e financial advice

Review of retention incentives that could be offered to mainland EU and Irish staff and quarterly reporting on supply trends in place for new Workforce Committee (new sub BoD committee)

Fresh exploration of Indian and Sri Lankan supply for medical intakes with UCL

Ongoing 2019

Ongoing

On hold

3x4 = 12

3 x 3 = 9

Overall of 112


Page 12 of 19

Staff perception that bullying, harassment and abuse from colleagues is increasing and incidents are poorly acted upon, leading to poor staff experience.

WorkforceDirecr

Trust wide ‘Where Do You Draw the Line?’ campaign to improve staff experience and highlight importance of positive behaviour

Resolution pathway provides staff with guidance regarding the support available when concerns around relationships arise

Freedom to Speak up Guardian provides external, independent contact point for staff to raise concerns and quarterly oral and written reports go direct 1:1 to CEO and Chair

Review of freedom to speak up concerns taking place to examine causes of concern with FTSU guardians, staff side representatives, OH and staff psychological & welfare services.

Local action plans to address specific staff survey concerns in place and dedicated reviews taking place with DCD/DMs

Staff networks for BAME, LGBTQA. Women in Leadership and staff with mental health conditions are active and reporting line to Workforce Committee is established. New pledges to staff have been launched that include a clear commitment to improve staff experience with supporting actions through 2019/20

Staff Survey Results

Formal ER case numbers

Workforce Race Equality Standards (WRES) metrics

Turnover rates

The second phase of work that builds on the earlier ‘Where Do You Draw the Line?’ campaign is being developed.

The second phase involves change building on the strong organisational foundation of our values and puts a spotlight onto ‘civility’ and kindness to ensure that we create an inclusive and compassionate working environment for all staff through a reduction in bullying and harassment behaviour.

Resources are being created in partnership with a wide range of stakeholders, to support this work including;

i) A UCLH values Charter proposal, based on the current UCLH values, that is more accessible to staff and gives clear examples of what staff have the right to expect, responsibility to do

ii) An editable values charter template to support teams to define and agree how they will live the values. What do these values mean to us?

iii) A manager conversation toolkit has been created to support managers to have meaningful conversations with their teams, develop trust based relationships and create an environment where feedback is requested and received in support of our values. All are now in testing.

We have made changes to our staff FFT survey local questions to assess how we are living our values. We will use this data as a pulse test to measure the impact of the range of initiatives being introduced as well as get a baseline measure of where we are starting.

The new pledges provide the overarching framework for the initiatives that we will be delivering to improve staff experience. Following quarterly review on impact will follow to early December SDT

Q4 19/20

Q4 19/20

Completed

December 2019

3 x 3 = 9

2 x 3 = 6

Overall of 112


Page 13 of 19

UCLH strategic theme: Achieve financial sustainability Responsible monitoring committee: Finance Committee



ment of this risk

KEY CONTROLSWhat controls / systems are already in

place to manage the risk


What evidence can be used to show that our controls are working

CONTROLS AND ASSURANCE GAPS AND ACTIONSWhat controls should be in place to manage the risks but are not?



risk


UCLH is set efficiency targets, control totals or growth / expenditure constraints that it is unable to achieve, with a consequent risk to financial sustainability and an impact on staff and patient experience / waiting times

Datix ID 1778

Chief Financial Officer

Continued focus on rigorous cost improvement planning, delivery and oversight process including monthly SDT review of local and trustwide scheme progress. PMO continues to work with 'special measures' areas with significant financial challenges

UCLH, Shelford Group and NHS Providers engaging with NHSI/E to ensure the 2020/21 financial settlement for the provider sector, and NHS financial architecture, helps secure financial sustainability for UCLH and other providers.

NHS Improvement’s review of financial planning and in-year positionIn-year monthly financial reporting and forecasting

Recovery plan and progress against identifying cost improvement plans monitored through Senior Directors Team meeting

Increased emphasis on productivity and the underlying financial position including Carter metrics published monthly on the UCLH intranet

Assurance gapsImplications of the STP’s system control total and financially constrained CCG contract values in future years are not yet understood.

Control gapsData issues relating to Epic mean that a clear view of activity throughput at divisional and activity type level is not yet available, and block contract has reduced focus on maintaining activity levels and throughput.

Need for increased focus on productivity agenda and providing good, useful information to all areas of the business to deliver productivity improvements through existing structures

Lack of clarity on how to respond to setting of 1% growth constraints / assumptions in 2020/21 planning round, particularly in areas that are likely to outgrow this significantly eg ED, oncology, radiology, 2 week referrals. The options to deal with this will include trying to ensure extra growth can be dealt with at marginal cost and working with commissioners to acknowledge that growth will not be uniform and may not be in the control of the Trust.

Ongoing

Ongoing

Ongoing.

4 x 5 = 20

4 x 4 = 16

Overall of 112


Page 14 of 19

Due to the lack of national funding allocated to the NHS, there is a risk that STP partners and NHS England specialist commissioners shift financial risk to UCLH through reduced prices (including reduction in Market Forces Factor) or non-payment

Datix ID 1784

No change in status


Active engagement with North Central London Sustainability and Transformation Plan (STP), and joint leadership with the CCGs of financial improvement through the Medium Term Financial Strategy

Closer working relationships with CCG commissioners and other local providers including the Whittington and Royal Free.

Block contract to minimise financial risk in 2019/20

Continued work with NHS Improvement and NHS England to ensure that local prices are not reduced and that control totals are set fairly.

Monthly reporting to Finance and Contracting Committee on key service developments

Reporting to Investment Committee on tender / new business opportunities and financial risks as needed

Chief Financial Officer part of STP leadership team, and linked into national discussions about payment models and tariffs

NHS Improvement’s review of financial planning and in-year position

Contract process monitoring through Senior Directors Team and Board of Directors

In-year monthly financial and contractual reporting and forecasting

Control gaps

Ensure clinical leadership and project resources support those STP workstreams critical to UCLH’s financial sustainability.

Ongoing

4x 4 = 16

3 x 4 = 12

Overall of 112


Page 15 of 19

UCLH is unable to adapt as quickly as required to new payment mechanisms that may replace Payment by Results, leading to a lack of alignment with the wider health economy and a threat to UCLH’s own financial sustainability

No change in status


Engagement with STP and with national colleagues in design of new payment mechanisms and financial architecture, to ensure there are no unintended adverse consequences.

Leadership of new care models that use different tariff arrangements, leading to exposure to different ways of funding and running clinical services

Focus upon cost reduction rather than income growth in CIP plans.

Acknowledged engagement of commissioners in strategic intent document and annual planning process

Control gaps

Specific awareness raising for clinical and management staff on the move to new payment mechanisms

Training mechanisms for technical staff on new tariff arrangements and how they can be used to support running of services and improved patient outcomes

On-going

4 x 4 = 16

3 x 3 = 9

No deal Brexit generates risks across a range of disparate issues, either because of impact of withdrawal from European Union (EU) regulation (for example medicines or procurement), lack of EU funding sources (for example research) or the impact of wider economic

Chief Nurse (as SRO for EPRR)

EU Exit Operational Readiness Task Force commenced in early 2019 at UCLH consisting of the chief executive and chief nurse co-chair and including lead SME’s.

Preparedness based on the guidance from the Department of Health and Social Care entitled ‘EU Exit Operational Readiness Guidance’ published 21 December 2018, following eight areas of activity as listed below:

Readiness Preparations Supply of medicines and

vaccines; Supply of medical devices

Regular task and finish group meetings restarted in July 2019

Update to trust board seminar in February 2019

Update to SDT and trust board and presentation in September 2019

Each SME has reviewed their own area and reported back to

Awaiting additional information from national and regional EU Exit teams in relation to requirements for situation reporting frequency and route, escalation and actions required for ‘out of hospital’ risks such as public access to medicines and social care workforce/service.

One of the areas identified as an area of priority is to increase the level of communication to staff either as an EU national or more generally regarding EU exit and what this means for UCLH staff and patients.

Ensuring standard business continuity plan have been updated in the last 12 months and reviewed by our EPRR manager in line with our business continuity policy. EPRR agreed to prioritise areas linked to national EU exit areas

Meetings in September 2019

September 2019

October 2019

3x3= 9

3x3 = 9

Overall of 112


Page 16 of 19

and clinical consumables; Supply of non-clinical

consumables, goods and services;

Workforce; Reciprocal healthcare; Research and clinical

trials; andData sharing, processing and access

SRO and EPRR manager attending national and regional events to ensure engaged and able to share any expectations and/or organisational concerns

EPRR committee reviewing submitted business continuity plans and escalating non submitted

Agreement to use the control and command approach should there be a requirement to do so

Oversight of the SRO and EPRR manager of any FOI requests regardless of SME area

Assurance review by NHSE confirming good level of assurance

of activity.

At this stage the key area of focus is to ensure the group is agile, to be able to respond to any change in risk, either internally, regionally or nationally.

Additional specific risks will be drawn out from this general risk and added to the BAF as/if they emerge over time

Specific risks will be drawn out from this general risk and added to the BAF as/if they emerge over time.

NHSE confirming good level of assurance

Ongoing monitoring via monthly task force

October 2019

Overall of 112


Page 17 of 19

UCLH strategic theme: Improve patient pathways through collaboration with partners Responsible monitoring committee: Strategic Programme Board



ment of this risk





are working


are not?



risk


STP proposals for redesigning care pathways could fail to deliver the activity shifts at sufficient pace, with impact on delivery of access standards and financial plans

Datix ID 1791

No change in status

Director of strategic develop-ment

Active participation in

STP governance meetings

STP clinical working groups

Weekly meetings with Camden CCG to monitor local delivery

Exploration of partnership working, including collaboration with the Whittington, the Haringey & Islington Wellbeing Partnership and Camden Local Care Strategy

UCLH STP coordination calls to identify concerns and agree escalations

Improved information sharing within UCLH

A&E delivery board co-chaired by UCLH and Camden CCG

Feedback on STP from external agencies

Improving relations with local partners

Joint working on system leadership projects as both system leader, partner or contributor

Control gaps

Develop closer relationships with GPs, in particular in their CHIN groupings. Understand their priorities and how UCLH can contribute to delivering them.

Secure clinical leadership roles for STP work streams that will have most impact on UCLH

Advocate for a better alignment of CCG resources to STP work streams to stop duplication of design effort across CCGs

On-going

On-going

On-going

4 x 4 = 16

2x4=8

Overall of 112


Page 18 of 19

Risk that through lack of engagement in the governance and plans of the specialised Sustainability and Transformation Plan (STP) that we lose opportunities / autonomy to develop critical mass and world class services in our strategic service areas, leading to less clinical resilience, loss of status and loss of income

Datix ID 1792incre

No change in status

Director of strategic develop-ment

Founding membership and participation at all major UCLP events

Leading engagement in underpinning financial analysis, solutions development and implementation of the specialised services STP

Influencing specialised STP focus to areas of opportunity for UCLH e.g., drugs, imaging, referrals, chronic-disease management

Acknowledged engagement of commissioners in strategic intent document and annual planning process

Exploring whether UCLH can have a more formal role in representing NCL STP on the London Specialised Planning Group.

Use sector wide clinical leadership roles to ensure decision-making regarding changes to patient flows are based on an evidence based assessment of the full financial and care quality impact of affected providers, in particular via:

Cancer vanguard/ alliance

London neurosciences network

On-going 3 x 4 = 12

2 x 4 = 8

Overall of 112


Page 19 of 19

UCLH strategic theme: Generate world-class research Responsible monitoring committee: Board of directors


LEAD Which director

leads on manage-ment of

this risk





are working


are not?



risk


Risk that some annual research funding streams will be constrained over time leading to budgetary pressure on workstreams that underpin delivery of our research objectives

No change in status

Director of Research

Delivery mechanisms within the biomedical research centre (BRC), clinical research facility and wider research community ensure that we meet standards that are used to allocate this income

BRC governance structures

Clinical research facility governance structures

Quarterly performance reports

Control gap

Lack of control over future funding constraints that may lead to reduction in income streams from NIHR and comprehensive research network

For information: DHSC has informed Trusts that the Research Capability Funding allocation will be reduced over the coming 5 years. The reduction in funding will be greatest in the larger centres like UCLH that have BRCs and other NIHR infrastructure

3 x 3 = 9 2 x 3 = 6

Overall of 112

Overall of 112


27 November 2019

Quarterly report on safe working hours:Doctors and Dentists in Training

This quarterly report on safe working hours within UCLH covers the period from 1 July 2019 to 30 September 2019. This is a requirement of the 2016 junior doctor contract and the aims of the report are to provide:

a current view of working practice in relation to working hours; assurance that safety criteria are being met; highlight areas of concern; and seek to give confidence to junior doctors that the trust is upholding the standards set in the national

terms and conditions.

Overall of 112

2

1. EXECUTIVE SUMMARY

By the end of the reference period 518 junior doctors were on the 2016 contract 36 exception reports were submitted during the reference period, of which 34 were in

relation to work and hours No work schedule reviews have been requested during the reference period No fines were levied during this period

2. PURPOSE OF REPORT

This Quarterly Report on Safe Working Hours within UCLH covers a period from 1st July 2019 to 30th September 2019. This is a requirement of the 2016 junior doctor contract and the aims of the report are to provide:

a current view of working practice in relation to working hours; assurance that safety criteria are being met; highlight areas of concern; and seek to give confidence to junior doctors that the trust is upholding the standards set in

the national terms and conditions.

3. HIGH LEVEL DATA

Number of doctors / dentists in training (total): 525Number of educational supervisors with UCLH 287 Recommended amount of job-planned time 0.25 PAs per traineefor educational supervisors:

4. ABBREVIATIONS

GSWH – Guardian of Safe Working Hours MWT – medical workforce team MDES – Medical and Dental Education ServiceES – Educational Supervisor TOIL – time off in lieu

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5. EXCEPTION REPORTS (WITH REGARD TO WORKING HOURS)

The following exception reports were submitted:Specialty Rota Grade No of

doctors submitting exception

reports

No. exceptions

raised

Outcomes/ Comments

A&E FY2 1 1 TOIL provided (1hr)AMU FY1 1 1 Declined (see comments below)

Elderly Care FY2 1 1 TOIL provided (1.5 hrs)Elderly Care GP 1 1 Response awaited since Sept 2019Elderly Care CT1 2 2 TOIL provided (1hr)

Infection FY1 1 1 Payment approved (4hrs)Neurology ST1-2 1 2 TOIL provided for both (3.5hrs)

CT1-2 2 3 2 closed and payment made (5 hrs) – 1 outstanding since July

FY2 2 5 4 closed and TOIL provided (7.5 hrs) – 1 outstanding since August (2hrs)

O&G

GP 1 3 Payment made (6hrs)CT 1 5 All outstanding since August (10.5 hrs)

Oncology D-Flexi SpR 4 12 2 closed with TOIL (6.5hrs) – all other

outstanding since August (26.5 hrs)

ANALYSIS OF EXCEPTION REPORTS BY SPECIALITY:

ACCIDENT AND EMERGENCY: trainee stayed late due to difficulty in handing over/referring patient to the medical team. An isolated incident and the issue was fed back to the medical teamAMU: One exception report was submitted due to missed FY1 teaching due to zero day and nights – there is no expectation for trainees to attend teaching when not rostered to work. ELDERLY MEDICINE: two exception reports due to exceptionally heavy clinical workload. One exception report submitted due to an EDU shift that over-ran.INFECTION: exceptional circumstances, due to heavy workload, late consultant ward round and evening discharges.NEUROLOGY: due to unusually heavy workload but trainee confirmed that these were isolated occurrences.OBSTETRICS AND GYNAECOLOGY: At ST1-2 level two exception reports were submitted due to late finish to theatre session and one due to missed educational opportunity. At FY2 level, one exception report was also submitted due to late theatre finish. Four exception reports were submitted because trainee was expected to cover shifts with earlier starts than stipulated on the work schedule, with less than one week notice and this has been highlighted to the clinical department. Three exception reports were submitted by GP trainees, on one occasion due to a late theatre finish, and the others due to heavy clinical workload.ONCOLOGY: 16 exception reports were submitted during this quarter, of which 14 are still open without a full response from the clinical department. Of the 11 reports submitted by ST3+ trainees, four of the exception reports were due to the increased supervision needed

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for the new CMT/SHO level doctors in August, three were due to increased workload resulting from CMT level rota gaps and four were due to heavy clinical workload. Five exception reports were submitted by CMT, all due to an intense and excessive workload, and CMT/SHO rota gaps were cited as a factor in two of these exception reports.

6. WORK SCHEDULE REVIEWSNo work schedule reviews were requested by trainees between 1/7/2019 and 30/9/2019

7. FINES

Fines (cumulative)Balance at end of last quarter

Fines this quarter Disbursements this quarter

Balance at end of this quarter

£848.91 0 £848.91 0

The funds were used in this quarter to part fund a Junior Doctors summer social event.

8. TRAINEE VACANCIES AND LOCUM USAGE (1/4/2019-30/6/2019)

Appendix A lists the vacancies in the training and Trust grade posts, unfilled shifts and total locum usage, listed by grade and speciality, across UCLH. The vacancy data was provided by individual clinical departments and lists unfilled posts, for example a trainee vacancy backfilled by a Trust grade appointment would no longer be considered a vacancy. Bank Partners supplied the locum usage data.

Although high levels of vacancies were reported in a number of specialities including Neurosurgery, GI Medicine (CMT level), Neuroradiology, Emergency Medicine, Neonates and Oncology (CMT), this was not associated with significant numbers of exception reports. High levels of locum usage were reported in ENT, Urology, Emergency Medicine, General Surgery, Neurosurgery, Neurology and Neuroradiology, but exception reports were not submitted from these specialities and thus the exception reporting process did not provide any evidence to suggest that the high proportion of locum usage in these specialties had a detrimental impact on the safe working hours of trainees in these departments. Rota gaps were observed in Oncology, but locum usage was comparatively low, and this was associated with a marked increase in the numbers of exception reports during this quarter.

COMMENTS:

Negotiations between NHS Employers, and the Department of Health and Social Care and the BMA have resulted in an agreed revision to the junior doctors’ contract. This will incorporate increased safety rules with a phased implementation over the next 12 months. We are in the process of updating the exception reporting guidance for the Trust accordingly.

Eleven exception reports were submitted by trainees in Obstetrics and Gynaecology. Areas of concern have been highlighted in previous board reports, and there have been some improvements including measures to reduce the intensity of the night shifts at SHO/CT level. The exception reports submitted during the quarter indicated that there

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remains a problem of excess hours associated with late theatre finishes, and this is something that has been highlighted to the department, and I will continue to seek a response to this issue. Initial feedback from a recent HEE Risk Based Review to the GP Obstetrics and Gynaecology programme, recognised some of the improvements that have been made, and some of the proposals for future improvement, but their full recommendations are awaited.

There was a marked increase in the numbers of exception reports submitted by trainees in Oncology during this quarter, which have arisen because of CMT/SHO rota gaps. There are plans to recruit to these vacancies, but two appointments have been complicated by visa problems. I have held discussions with the Oncology trainees and it is clear that rota gaps have resulted in very low morale and dissatisfaction among both core trainees and higher trainees. The following issues have been flagged up, and have been highlighted to the clinical department, and I will continue to liaise with the trainees and the clinical department about how they can be addressed:- Trainees report that CMT/SHO rota gaps have resulted in intense working conditions

for the remaining CMT level doctors- Trainees feel the department have not been sufficiently pro-active in anticipating

future unfilled shifts, which has resulted in shifts not being filled. - This has had a consequence in daytime CMT level doctors being diverted to cover

night shifts with short notice, causing a further depletion in day-time ward cover - Unfilled shifts have resulted in increased workload for higher trainees, including

several instances of SpRs having to cover both SpR and CMT/SHO duties, both during normal working hours and at weekends.

- Exception reports have not been handled in a timely fashion.

9. RECOMMENDATION

The Board is asked to note the report.

Prasad Korlipara Guardian of Safe Working Hours UCLH

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APPENDIX A: TRAINEE VACANCIES AND LOCUM USAGE (1/04/2019- 30/6//2019)

*Bank partners were not able to subdivide the unfilled shift/locum usage in the medical specialities and the total figures are listed under ‘Medical Spec’

TRAINEE/TG VACANCIESSURGERY AND CANCER

BOARDGRADE

Number trainees/

TGwhenfully

establishedJuly Aug Sept

UNFILLED SHIFTS: NO

(hrs)

LOCUM USAGE: No shifts (HRS)

CT1-2 9 0 0 0 1 (3)Anaesthetics

ST3+ 25 2 2 2 7 (81) 29 (284.58)FY1 2 0 0 0 3 (29)FY2 3 0 0 0 0

ST1-2 1 0 0 0 1 (12) 131 (1436.25)General Surgery

ST3+ 13 0 0 0 56 (403)FY1/2 9 0 0 0 0

CMT1-2 7 1 2 3 1 (9.5)GI medicine

ST3+ 11 1 1 1 64 (23)Radiology ST4+ 22 0 0 0 105 (532.59)Nuclear

medicine ST3+ 3 0 0 0 0

FY1 1 0 0 0 0CMT 9 2 1 1 12 (134.5)HaematologyST3+ 22.35 0 0 0 3 (53)F1/2 5 0 0 0 2 (18)

ST1-2 5 0 0 0 4 (36)Trauma and Orthopaedics

ST3+ 13 0 0 0 69 (512.5)ST1-2 8 0 0 0 118 (1283.92)UrologyST3+ 22 0 0 0 34 (208.5)FY2 2 1 0 0 0

CMT1-2 11 1 3 2 4 (49)OncologyST3+ 19 0 0 0 25 (254)

TRAINEE/TG VACANCIESSPECIALISTHOSPITALS

BOARDGRADE

Number trainees/TG

whenfully

establishedJuly Aug Sept

UNFILLED SHIFTS: NO

(hrs)


ST1-2 0 0 0 0 0Anaes NHNN

ST3+ 17 2 2 3 24 (269)CT 5.5 0 0 0Neurocritical

care ST3+Anaes RNTNE ST3+ 5 0 1.5 1.5 35 (427.5)

ST3+ 12 0 1 1 10 (100) 214 (2071.03)ENT ST1-2 7 0 2 2 20 (222.5)

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SPECIALISTHOSPITALS

BOARDGRADE

Number trainees/TG

whenfully

established

TRAINEE/TG VACANCIES UNFILLED SHIFTS: NO

(hrs)

LOCUM USAGE: No shifts (HRS)July Aug Sept

ST1-2 18 3 5 4 61 (632.25)Neurosurgery

ST3+ 23 2 8 6 78 (713.75)ST1-2 14 0 0 0 6 (70.17)FY1/2 2 0 0 0 0ST3+ 18 0.5 0.5 0.5 74 (735)Obs and

Gynae GP (Special

ty doctor)

2 0 0 0 58 (579.02)

Oral medicine DSpR 5 2 2 2 0DCT 8 0 0 0 0

OMFS DSPR 2 0 0 0 18 (144.25)Orthodontics DSPR 21 4 4 4 0

ST4+ 15 1 2 2 29 (300)ST1-3 8.5 0 0 0 4 (43)Paediatrics

GP 4 0 0 0 0ST3+ 12 1 1 1 27 (475.25)NeonatesST1-2 11 2 2 2 6 (67.75)DSPR 6 0 0 0 0Restorative

DCT 1/2 3 0 0 0 0CMT1-2 6 1 1 1 0ST1-2 8 1 1 3 174 (1666.93)NeurologyST3+ 19 0 0 0 38 (210)CT 9 0 0 0 2 (7.5)

Stroke ST3+ 9 0 1 0 2 (12) 25 (246)

Neuroradiology ST3+ 12 (3 paid by GOSH 4 4 4 138 (1206.5)

TRAINEE/TG VACANCIES

MEDICINEBOARD GRADE

Number trainees/TG

whenfully

established

July Aug Sept

UNFILLED SHIFTS NO

(HRS)


F1/2 8 0 0 0 7 (65) 24 (209)GP 5 1 (8) 31 (229.75)

ST1-3 16 2 2 2 200 (1970) 522 (4888.91)

Emergency medicine

ST4 12 4 4 4 1 (10.5) 36 (332.5)Clinical

Neurophysiolo-gy

ST3+ 3.4 1 1 1 66 (463)

FY2 7 1 1 1 0ST1-2 12 0 0 0 1 (13) 18 (179)Critical CareST3+ 7 1 2 1 44 (311.5)

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MEDICINEBOARD GRADE

Number trainees/TG

whenfully

established

TRAINEE/TG VACANCIESUNFILLED SHIFTS NO

(HRS)

LOCUM USAGE: No shifts (HRS)July Aug Sept

FY1/2 9 0 0 0 2 (17)ST1-2 15 0 0 0 3 (30) 68 (552.42)

GP 6 1 1 1 0AMU

ST3+ 1 0 0 0 93 (860.58)F1/2 1 0 1 1 0

CMT1-2 6 0 0 0 0ST1-2 1 0 0 0 0

Care of Elderly

ST3+ 2 0 0 0 21 (180)F1/2 1 0 0 0 0

CMT1-2 0.5 0 0 0 0RheumatologyST3+ 3 0 0 0 37 (279)F1/2 2 0 0 0 0

CMT1-2 1 0 0 0 0RespiratoryST3+ 3 1 1 1 0ST1/2 1 1 1 1 0EndocrinologyST3+ 5 1 1 1 23 (164)F1/2 4 1 1 1 0Clin PharmST3+ 3.8 0 0 0 0CMT 0.5 1 1 1 0

Dermatology ST3+ 4 0 0 0 1 (4)ST3+ 11 0 0 0 0HistopathologyST1-2 3 0 0 0 0F1/2 2 0 0 0 0

CMT1-2 4 0 0 0 14 (118.5)Infectious diseases

ST3+ 14 0 0 0 6 (42)CMT1-2 0Medical

Virology ST3+ 0Medical

microbiologyST3+ 5 0 1 1 0

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27 November 2019

Performance Report

Please find enclosed the monthly performance report. We are still developing an appendix to list our performance against other national and key indicators in data format to indicate trend. We aim to include the first tranche of these indicators from next month, with the full set to be made available in the next three months.

Simon Knight, Alex Gregg & Jonathan RickettsPlanning and performance20h November 2019

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Summary of UCLH Performance: October 2019Arrow direction indicates the direction of performance. Colour is a subjective assessment of performance against standards and expectations.

Emergency Department

October was extremely challenging in ED with performance dropping to 80.8% against the 4-hour standard while attendances continued to increase. This performance remains well above national (74.5%) and London (73.5%) type 1 performance.

There were ten 12-hour trolley breaches for patients requiring mental health beds.

Referral to Treatment (RTT)

Pre-validated performance for October is currently 75.9%, an improvement of 1.7% compared to September.

We are provisionally reporting 24 52-week waiters for October compared to 16 in September. These are largely driven by ongoing capacity issues in gynaecology as well as theatre availability for paediatric dentistry.

October’s performance for diagnostics six-week waits is currently 90.5%, up 4.9% compared to September.

Cancer We surpassed the 62-day performance target in September for the first time since 2013 and ahead of our trajectory target to be compliant by October. This reflects the significant effort across our multi-disciplinary teams to improve patient pathways and coordination of patient care.

We remained compliant with the two-week wait to first outpatient and 31-day standards for all treatment types.

Quality Overall performance worsened for some of the key metrics in October.

We had one MRSA case in October. This brings the trust total to three year to date against a target of zero.

Response times to patient complaints within target have significantly worsened after a sustained period of improvement.

VTE is worse than threshold. There have been changes in workflow-pathways and difficulties locating completed VTE risk assessments within the system.

Finance The trust’s month 7 year to date control performance is £6.6m ahead of plan.

The trust’s month 7 use of resources finance rating is 3.

Workforce Overall, there are 9,286.1 wte in post at the trust. This represents a growth of 118.2 wte between September and October.

The vacancy rate is 9.9%, which is slightly higher than trajectory, but continues to display a downward trend.

Although we did not hit the target of 90% appraisals reported at Tier 2 by the end of September 2019, we continue to make significant process with 65.9% of appraisals in this tier reported as complete. This represents a 12.1 percentage increase in reporting between September and October.

We are still developing an appendix to list our performance against other national and key indicators in data format to indicate trend. We aim to include the first tranche of these indicators from next month, with the full set to be made available in the next three months.

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Emergency Access performance updateOctober final

Performance in October was 80.8% against a trajectory of 91%. We continue to remain better than the London average of 73.5% performance for type 1 attendances in challenging conditions.

Sep-19 Oct-19 Nov-19 Dec-1984.6% 87.1% 87.1% 83.9% 83.7% 80.8%

Apr-1977.4%

May-19 Jun-19 Jul-19 Aug-19

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%UCLH 4-hour performance 2019/20

4-hour performance Trajectory Monthly performance London Monthly Type 1

The following were the key drivers of our performance in October:

Attendances at the emergency department (ED) continue to be very high. The daily average was 431 attendances for October, up 8% compared to last year. One day saw a record 520 attendances. We have also seen a similar increase in the number of ambulance conveyances.

The ED periodically saw majors over-run with more than double the number of patients compared to available cubicles, with patients waiting in the department for an available bed throughout the day. In these circumstances some urgent treatment centre (UTC) spaces were allocated to majors patients and patient safety was prioritised over performance. This was reflected in reduced UTC performance of 92% compared to our internal target of 95%.

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Dec-1988.9% 94.1% 96.3% 92.5% 92.8% 95.3% 92.0%Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

65%

70%

75%

80%

85%

90%

95%

100%UTC Performance

Monthly performance Trajectory

A key driver for majors over-crowding included exit block due to insufficient beds being available. On some days there were fewer than the expected number of discharges and the discharges were too late in the day. Key parts of our response on beds are:

– Eight beds that had been closed over the summer have now been re-opened and allocated to medical patients where we see a winter surge in demand.

– The Operational Excellence board is looking at proposals to create an overnight surge area.

There were a high number of attendances of patients with mental health issues, and for a number of these cases we often need to dedicate significant staff resource in support of the person when they are under our care. There are regular delays waiting for an Approved Mental Health Professional (AMHP) from the responsible local authority to assess and if necessary admit.

On one weekend the police repeatedly brought section 136 patients (those over whom they have the power to move from a public place to a place of safety) to UCH bypassing other options and without phoning ahead to check for capacity. For much of that weekend the ED contained 11 mental health patients and therefore majors lost eight cubicles to these patients because the UCLH Transitional Assessment Facility (TAF) has only three spaces. 12-hour trolley breaches are increasing.

Camden and Islington Foundation Trust (the local MH provider) plan to open alternative options for mental health patients, including a three bed place of safety (in December) and a Crisis Café.

Refurbishment work in ED continues. The first phase is complete with the return of the area that was lost to the sewage flood in July including the Clinical Decision Unit. The upgrade of the area used for Rapid Assess and Treatment of patients arriving by ambulance is due for completion for Xmas.

November has started with very challenging conditions and continued high demand on ED with daily average attendances over 420 in the first two weeks. Performance for the month to date is below 80%.

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18 week referral to treatment and diagnostic six-week waits summaryOctober provisional

1. Referral to treatment waiting times

October’s final performance is 76.7% against the standard that patients wait less than 18 weeks for treatment following referral. This remains significantly worse than both the 92% target and the national average (85% in September).

The overall waiting list size is 52,617 patients, an increase of 2,060 pathways compared to September. This remains significantly higher than the March 2020 target of 42,237 patients. The increase this month is a result of the inclusion of three patient cohorts that are now appropriately part of our PTL:

Pathways where patients had been added to an elective waiting list following a previous RTT clock stop. These waiting list entries had not been generating clock starts in Epic, but this has now been addressed and resulted in around 1,400 pathways being added to the PTL.

Pathways where patients had been recorded as DNA but had no outcome indicating discharge or follow up. These pathways had previously been excluded from the PTL in error as a result of changes in implementation of Epic. Around 519 pathways were added to the PTL.

Bookings from our backlog of appointment slot issues (ASIs) following effective recovery actions across RNTNEH and other areas made up the remaining PTL volume increase.

Despite the increase in the overall waiting list, our backlog of patients waiting above 18 weeks for treatment has reduced in October. The backlog is currently showing 12,244 pathways, which is 826 below September’s final position. This reflects that booking and validation efforts are having a greater impact on long waiters.

As reported last month, the NHS Improvement Intensive Support Team (IST) visited in early October to review our recovery plan and validation processes. We have since received and accepted their feedback, the key components of which were:

We could get a higher rate of validation through use of a supervisor (now recruited) and focussing validators on lists of the same problem rather than working down the PTL directly.

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We review patients not on active RTT pathways, including those on planned treatment pathways, to ensure we have better grip on all our patient cohorts. This is in line with the increases in the PTL numbers described above

2. 52-week waiters

There were 24 patients who waited longer than 52 weeks at the end of October, an increase of 8 since September but better than our original forecast of 30 for the month. We have advised commissioners and regulators that our 52-week wait position will get worse before it improves. We are currently forecasting around 20 patients waiting longer than 52 weeks at the end of November, with another 20 patients at some risk of having waited more than the 52 week threshold.

Our key areas of further 52-week risks are as follows:

Uro-gynaecology: There are currently 16 breaches of this standard in October. Long waits in the general uro-gynaecology service are driven by long-term sickness for key staff whilst the mesh service continues to be challenged by the limited surgical capacity of its lead specialist consultant. In order to manage the situation, the division is recruiting a locum who will be able to cover a proportion of clinics beginning in November and December in the non-mesh service. To ensure the service remains safe, we are working with commissioners to consider controls around new GP referrals. For specialist mesh procedures, the lead consultant has secured a number of additional operating lists in November and December and will work in parallel with other clinicians in theatre to maximise operating capacity. We are also working with other clinical teams, in particular Urology, to prioritise appropriate patients for transfer to services with much shorter waits.

Eastman Dental Hospital: There were eight breaches in October: five in paediatric dentistry due to limited specialist theatre capacity, two in orthodontics being clinical reviewed and one in restorative dentistry due to clinic allocation. However, we are currently forecasting further breaches in dental services, and these are mainly due to data quality issues in booking lists and PTLs hampering visibility of longest waiting patients.

Commissioners wrote to us in late October seeking further assurance in our management of waits above 40 weeks, citing the increase in our total waiting list size and number of 52- week breaches over the past few months. They have indicated in the letter that without such assurance they may issue a contract penalty notice which may at a future point have financial ramifications. We continue to hold weekly discussions with local commissioners and regulators, keeping them up-to-date with progress against long waits in the trust. We have also invited the IST to observe a few of our corporate PTL meetings in mid-November as part of our work to improve our approach to PTL management.

3. Backlog of appointment slot issues (ASIs) and referral assessment service (RAS) cases awaiting triage

During October our backlog of ASIs waiting to be booked reduced by 155 to 3,089, although those still waiting for triage increased by 208 to 996 at month end.

The majority of the ASI backlog remains in RNTNE. The ENT team has been providing capacity for additional cases in October following the relocation of the hospital, which is helping to reduce the ASIs backlog and tackle long waits in the service.

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4. Diagnostics six week wait

Following our return to reporting in September, October’s position has improved by 5.0% to 90.6% of patients waiting less than six weeks for diagnostic tests. We are really pleased to see this improvement in turnaround times for patients waiting for diagnostic tests, driven by hard work of administrative and clinical staff in a number of the departments. We have shared plans with commissioners to improve performance in areas with the largest volumes of long waiters, which are Queen Square imaging, UCH radiology, and endoscopy.

The endoscopy service anticipates a return to compliance by March 2020 using a mixture of sources for additional capacity (e.g. overtime, additional weekend lists, outsourcing).

UCH Imaging predicted that their business-as-usual capacity measures will achieve compliance by January

Queen Square Imaging also anticipate achieving compliance in January, but plan to increase the uptake of outsourced capacity to reach this target.

Our plan had been to return to compliance by March 2020. However, we have recently identified a large cohort of patients where Epic had not been generating pathways following requests for tests. Divisions have been sampling the cohort to help us more accurately assess the scale of the issue and identify if any risk to patient safety is likely. Early feedback has indicated that this list size will reduce significantly, but it does still represent a risk to our forecasted return to compliance. Clinical harm reviews are underway for time-sensitive conditions whereby delays could represent clinical risk. No harm has been identified to date.

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Cancer waiting times summary September final and October provisional

Two week wait to first outpatient- We remained compliant with the two week wait standard in both September and October, including breast symptomatic.Work continues to reduce waits to first outpatient appointment to a consistent level to achieve this standard. Our median wait for first outpatient appointment was nine days at the end of September two better compared to August. In addition to breast, key areas where we have shortened waits are in gynaecology and upper GI. We have seen significant increases in referrals to gynaecology over the past year due to changes in NICE guidelines, and the team have consistently been putting on additional capacity in response, but without fully mitigating the risk of breaching the two week wait standard; we may now be seeing the benefits of their hard work with the median waits figure reducing further through October.31-days first treatment - Remains compliant at 96.1%. This is due to continued success in treating patients referred for robotic prostatectomy. Current waiting time from decision-to-treat to the day-of procedure has remained stable at 17 days in recent weeks. We continue to look for opportunities to build additional flexible capacity for prostatectomies to help us absorb surges in demand. We expect to have maintained this standard in October.

62-days from GP referral - achieved: September’s overall performance of 87.7% surpassed the 85% target a month ahead of our trajectory submitted to NHS Improvement as part of our 2019/20 annual planning. This is the first time in six years that UCLH has met the standard and reflects the cumulative effort across many multi-disciplinary teams to improve pathways and enhance coordination of patient care.

Within this figure, we reported 90.4% for pathways that both start and end with treatment at UCLH. Some incoming referrals from other trusts still arrive late in the pathway, with 38% received after day 38. This is comparable with 36% in August, though better than over 50% in previous months. Where a formal referral is not possible, providers have been asked to provide an alert that a referral is likely in the near future so that our teams can make arrangements to treat incoming patients before their 62-day breach date. October’s position is still provisional and subject to change, pending upload of all shared pathways across the sector. Our latest cut of the data indicates performance is holding up above 80%.Encouragingly our backlog reduced to its lowest level of 51 patients during October. These improvements have been driven by the sharper focus on the 62-day PTL management process.

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There are a number of complex pathways in the backlog for upper and lower GI, which the service is working to progress as quickly as possible. The breast number of pathways in the backlog is reflective of temporary shortage in staffing. However, we expect the volume to decrease in the coming weeks.

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Quality summary

This summary provides information about quality indicators for October where we were significantly worse than target or where there were key updates in performance.

MRSA

There was one case of MRSA in October. The patient was admitted with falls and bi-lateral leg ulcers. They had an inferior vena cava filter in situ from a previous deep vein thrombosis in 2013. The patient was identified as having urinary sepsis with ESBL E-Coli in urine/blood. The patient's poor skin integrity increased due to the patient’s non-compliance with care for the dressing; however, this was not documented. They were referred to a tissue viability nurse for assessment who noted there were superficial wounds and continued the dressings. Gaps in the line care documentation make it difficult to assess if the cannula and invasive devices had been managed accurately. The patient was not unwell and had a history of MRSA colonisation. The patient was in isolation and had suppression therapy for four days

MSSA – four cases in OctoberThese were on:

T13N ward under the cancer division T09S for GI division Neonatal unit for women’s health Medical ITU for Queens Square.

Further information on these will be provided within the report to the Quality and Safety Committee later in the month.

ComplaintsSignificant progress has been made to reduce amount of long waiting cases. The trust currently has only one complaint overdue by over 100 days and only one complaint outstanding by over 90 days. Overall performance for response times to complaints worsened in October to 51% of cases answered in the month within the deadline agreed with the complainant.

We are working on changes to the indicators to have more focus on the longest waiters and an assessment of the length of wait for complaints not responded to yet (rather than measuring the length of time for those completed in the month).

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FallsThere were 89 falls in total in October 2019, three more than October 2018. There were 64 no harm, 25 low harm, two moderate and zero severe harm (excluding Gowers).

There were two moderate harm patients. One patient on Evergreen was admitted who had been having difficulty managing at home, fell in the evening at the trust and sustained compression fracture of the spine. A review of the fall found good care prior to the fall, but learning was identified. The other patient with a fall resulting in moderate harm happened in the emergency department, resulting in a hip socket fracture. This was managed conservatively with pain killers and a review of the care is pending.

VTEWe were worse than threshold for VTE assessment at 73.4%.

A small task and finish group with clinical input has been established. The group reviewed and rationalised the admission Epic VTE risk assessment ‘alerts’ and VTE risk assessment workflows. Changes to the ‘alerts’ were approved by the Epic Governance group and implemented from November. Changes to the VTE risk assessment workflows were approved and will be incorporated into the next Epic system upgrade (approximately mid-November). Changes will be demonstrated during the ‘Get to Know Epic week’ that the trust is running at the beginning of December.

Reduced VTE risk assessment reporting will be flagged with all divisions in the context of this new workflow, emphasising the importance of VTE risk assessment amongst clinical staff.

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Workforce: Trust Overall Performance

8217

8327

8352

8402

8419

8525

8606

8643

8626

8637

8659

8687

8,77

4

377

417

427

458

474

481

512

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

0

2000

4000

6000

8000

10000

Substantive Staff in Post Honorary Staff in Post

Staff in Post 12 Month Trend (WTE)

The proportion of temporary staff as part of the total workforce has increased to 12% in month 7 from 11.7% in month 6, even though staff-in-post has increased. Bank fill rates by Bank Partners are high, with the shift fill rate for medical and dental at 96% and 89% for Nursing and Midwifery. The time to hire for month 7 has slightly increased to 9.5. A paper is being prepared to be presented to the SDT at the end of November 2019 with proposals to improve the time to hire and recruitment experience for new starters.

The trust has utilised more staff to deliver activity in month 7 than planned for and has been derived from date on the general ledger in Finance.

There were 10 junior doctor recruitment episodes with an average time to hire of 9.8 weeks.

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Appraisal: We are reporting a 65.9% compliance rate for completed appraisals at Tier 2. We have engaged again with the Divisional Managers Forum to agree clarifications to facilitate managers to report appraisal and further ways we can support reporting and increase engagement in this process. These actions will support the trust to meet the compliance target of 90% for all Tiers to be met at the end of December 2019.

Statutory and Mandatory Training: The compliance rate for the trust has slightly increased in month 7 at 89.0% from 88.2% in month 6. Medical & Dental is the only professional staff group below the target, but is improving month on month (76.7% in month 6 and 78.8% in month 7). The team continue to work with the service to meet compliance for this staff group.

Equality & Diversity: These ratios are updated once a quarter, and will be updated for the January 2020 performance report.

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Financial Performance

Please see the finance report for commentary analysis.

Use of Resources Rating Summary

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Appendices

Nursing and Midwifery Dashboard

Nursing and Midwifery Detailed Dashboard - Month 7, 2019/20Key Workforce Metrics & Indicators

NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ All NA 2-4 RN 5-7 RN 8a+ AllEstablishment FTE* 181.4 667.3 48.0 896.7 238.3 1011.1 46.2 1295.6 312.9 1246.8 59.9 1619.6 0.0 42.1 14.0 56.1 732.6 2967.3 168.2 3868.0Staff in Post FTE* 170.8 536.6 39.2 746.5 193.4 893.7 51.5 1138.7 248.6 1094.5 61.7 1404.8 0.0 35.9 16.6 52.5 612.8 2560.6 169.1 3342.5Vacant Posts FTE* 5.6 131.5 10.3 147.4 44.9 98.3 2.6 145.7 64.3 140.8 3.5 208.6 -1.0 4.2 4.2 7.3 113.8 374.7 20.6 509.1Starters FTE 1.0 6.5 0.0 7.5 7.0 21.0 1.0 29.0 12.0 42.6 0.0 54.6 0.0 0.0 0.0 0.0 20.0 70.1 1.0 91.1Leavers FTE 0.0 9.0 0.0 9.0 2.0 13.0 1.5 16.5 2.3 5.8 0.0 8.2 0.0 0.0 0.0 0.0 4.3 27.9 1.5 33.7Vacancy Rate 3.1% 19.7% 21.5% 16.4% 18.8% 9.7% 5.6% 11.2% 20.5% 11.3% 5.9% 12.9% 0.0% 9.9% 29.8% 13.1% 15.5% 12.6% 12.3% 13.2%Turnover Rate 12.9% 17.9% 8.6% 16.3% 10.7% 16.6% 7.4% 15.0% 9.3% 13.4% 3.2% 12.2% 0.0% 19.5% 0.0% 13.2% 10.7% 15.5% 5.3% 14.1%Temp Staffing Usage 26.4% 16.9% 1.2% 18.6% 28.3% 13.8% 1.0% 16.6% 33.9% 13.5% 0.7% 17.8% 0.0% 5.9% 6.0% 6.4% 30.2% 14.2% 1.5% 17.4%Sickness Absence 7.5% 3.6% 3.9% 4.6% 5.8% 3.8% 1.5% 4.1% 4.8% 4.4% 1.6% 4.3% 2.8% 2.2% 0.2% 1.9% 5.8% 4.0% 1.8% 4.2%

Right Staffing Level by Shift 98.1% 97.1% 114.3% 105.5% 121.0% 99.0% N/A N/A 111.4% 100.0%

Medicine Board Surgery & Cancer Board Specialist Hospitals Board Corporate Board UCLH Trust

Notes: The nursing vacancy rate is high in relation to healthcare assistants, but local resourcing in plans are in place, which will allow for significant reduction in this rate by the end of December 2019. There are currently 81 external candidates in the recruitment pipeline for this staff group, of which, 16 have start dates agreed and 26 are at the pre-employment check stage. Recruitment is working to prioritise the on-boarding of these identified candidates to start as soon as possible and working with manager to process EC1 forms where necessary. A similar approach is being taken to focus on nursing candidates in the pipeline. This trend has continued in month 7, as we have had a high number of newly qualified nurses due to start. We also have a strong international pipeline in place for the January to March period, which we are considering pulling forward to manage the increasing vacancy rate. The SDT will be asked to consider this in November 2019. Turnover has decreased at 14.1% in month 7 from 14.7% in month 6. Temporary staffing as a proportion of the nursing and midwifery workforce has increased in month 7 at 17.4% compared to 17.2% in month 6. This mirrors the overal trend in temporary staffing usage and should be monitored to reverse the trend. Sickness absence rates have remained steady between month 6 and month 7, but remains higher than the rest of the trust. Right staffing rates have reached exactly 100.0%.

96.7% 101.3% 91.9% N/A 95.6%

020406080100120

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Cash flow and Better Payment Practice Summary

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Trust Wide and Board Financial Performance

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Trust Wide Workforce trends

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Board of Directors

27 November 2019

Chief Financial Officer’s Report

Brief Summary of Reporta. The October financial position before exceptional items and Provider Sustainability

Funding (PSF) / Financial Recovery Funding (FRF) is a deficit of £1.8m, £2.3m adverse to plan. The year-to-date deficit on the same basis is £26.2m, £3.6m adverse to plan.

b. After taking account of exceptional items including EHRS revenue costs (excluding EHRS contingency) the in-month control total performance is a surplus of £6.1m, £6.5m favourable to plan and control total. This brings the year-to-date position to a £23.9m deficit, £6.6m favourable to control total. This favourable position has been impacted by earlier than planned receipt of £8.5m EDH sale contingent payment (of which £7.5m had been planned for in month 12). The adjusted in-month position after removing this is £2.1m adverse to plan.

c. Excluding one-off and prior period adjustments, the underlying operational position in-month was £3.4m adverse to control total. The year-to-date underlying position is £12.6m adverse on the same basis. This remains a significant concern and needs to be a key focus of all areas, ensuring that performance is in line with budget on an underlying basis, not just through non-recurrent measures or benefits.

d. The reported CIP position for month 6 is £0.2m behind plan (excluding EDH contingent payments which have been counted as CIP). The underperformance versus plan continues into the remaining months of the year. The forecast value for non-recurrent CIP is £21.4m or 48% of the total, this represents a material risk to the Trust’s run-rate going into 2020/21.

e. The in-month underlying performance has been impacted by an increase in the reported drugs costs through Epic Willow pharmacy, resulting in a net adverse variance for income and costs of £1.2m against budget. The reason for this increase is being investigated.

f. The actual pay position in October was £0.4m higher than the run-rate for months 1-6 and continues to trend significantly higher than last year.

g. Some risks in this position still exist, the largest of which is the reporting and billing of drugs. Additionally, a number of specific areas have been identified as being high risk (e.g. Provider to Provider Radiology; HCA and private patient Radiology) following delays in billing.

h. The NCL STP submitted a draft Long Term Plan (LTP) at the end of September 2019, with a subsequent submission in November which is still considered to be draft due to the large NCL gap against the Financial Improvement Trajectory (FIT). Separately, the Chief Financial Officer has written to Directors and Divisional Managers to outline the challenging nature of the current sector discussions and to ask them, with some urgency to review and improve on their bottom-up plans for the second iteration, due on 27th November.

Actions Required/RecommendationThe Board is asked to note the financial performance, risks and assumptions for month 7

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1. Month 7 Position1.1. The summary financial position for month 7 is shown in figure 1 below.

Figure 1 – Month 7 Trust summary financial position

1.2. The reported in-month position is £6.5m favourable to plan on a control total basis, bringing our year-to-date position to £6.6m favourable to control total. Key drivers of the month 7 in-month position are:

Earlier than planned receipt of £7.5m Eastman Dental Hospital (EDH) contingent payment (timing difference only without having an overall impact on our annual financial plan); plus an additional £1.0m received relating to our vacant possession before 31st October.

The remaining position is £2.1m adverse to plan in-month due to:o Net drugs variance (income and cost) of £1.2m adverse in-month;o CIP residual under-performance after restating for the EDH contingent payments

of £0.2m adverse in-month;o Pay overspends in Emergency Services, Medical Specialties and Women’s

Health of £0.3m adverse;o Pay increase in Theatres as a result of additional theatre sessions, £0.2m

adverse;

Offsetting the above factors are non-recurrent benefits from:o EHRS project underspent of £0.3m in-month;o ITDA favourable position of £0.6m in-month mainly associated with depreciation

savings around the change in timing of when Phase 5 & EHRS assets come into use.

1.3. The month 7 reported position on drugs is adverse by £1.2m, which brings our year-to-date net variance on drugs to £1.6m adverse. This large adverse movement is currently being investigated as part of the pharmacy module action plan.

1.4. The Trust’s cash balance at 31st October 2019 was £240m, £30m higher than the planned cash position of £210m.This favourable cash position against plan is due to a combination of (a) improved receipts resulting from the block contract arrangements and VAT recovery, (b) delays to processing Epic Pharmacy and other invoices, and (c) lower than planned

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payments for capital invoices. The current forecast for November month-end is a cash balance of £233m, which would be £34m higher than plan.

2. Underlying position

2.1. The month 7 one-off and prior period adjustments accounted for £9.9m favourable variance in-month, resulting in a recurrent position which is £3.4m adverse in-month and £12.6m adverse year-to-date (YTD) against control total. The recurrent YTD variance by board is shown in figure 2 below:

M7 YTD variance -

as reported

Non-recurrent

CIP

Balance sheet,

other one-off & prior year adjs.

M7 YTD recurrent variance

M7 YTD recurrent

actual

Medicine (1.8) (1.7) 0.0 (3.5) 3.1Specialist Hospitals (3.1) (3.1) (0.1) (6.3) 29.7Surgery & Cancer 0.1 (0.8) (0.7) (1.5) 14.9R&D / T&E 0.1 (0.1) (0.0) 0.0 (2.6)Corporate Directorates (0.8) (1.4) (0.0) (2.2) (110.0)Central Budgets (1.3) 1.7 (0.8) (0.4) 86.7ITDA (before donation adjs.) 3.3 (0.9) (1.1) 1.2 (45.7)I&E surplus/(deficit) - before exceptional items (3.6) (6.1) (2.9) (12.6) (24.0)

Other control total items 10.2 (8.5) (1.7) - -I&E surplus/(deficit) - control total basis 6.6 (14.6) (4.5) (12.6) (24.0)

Figure 2 – Month 7 YTD recurrent position by board

2.2. The value of non-recurrent benefits in month 7 is considerably larger when compared to prior months due to the non-recurrent receipt of EDH contingent payments of £8.5m.

2.3. The recurrent in-month adverse variance of £3.4m is more than double the average underlying performance for months 1-6 of £1.6m adverse per month. This is in the main due to the net drugs variance of £1.2m adverse in-month. However, it should be noted that pay expenditure is £0.4m higher this month than the run rate for the prior 6 months.

2.4. Other material non-recurrent benefits in month include: £0.4m pathology Q1 reconciliation benefit, £0.2m depreciation due to Phase 5, £0.3m EHRS project costs and £0.3m non-recurrent CIP in-month.

3. Progress against the Cost Improvement Programme (CIP)3.1. The month 7 full year CIP forecast identifies £44.5m of CIP against a target of £45.0m. Of

the £44.5m identified, £21.3m relates to local schemes and £23.2m is driven through trust-wide programmes. This represents a £0.3m decrease in identified schemes compared to the month 6 forecast. The main forecast movements are:

£1.0m increase to the EDH contingent payment, now £8.5m in total (Trustwide); £0.1m increase in the Private Patient full year forecast (Trustwide); Removal of the £0.5m non-pay scheme due to delivery being delayed until 2020/21

(Trustwide); and, Removal of the £1.0m PFI contract dispute benefit due to delivery being delayed until

2020/21 (Local).3.2. The month 7 year-to-date CIP delivery is £29.9m against a plan of £20.3m and represents

an over-performance of £9.6m. The over-performance relates mainly to the timing of the receipt of a contingent payment in relation to EDH, received in month but planned to be

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received in month 12. In aggregate, £17.9m or 60% of the £29.9m year-to-date delivery is non-recurrent.

3.3. The month 7 in-month CIP delivery, after removing the £8.5m contingent payment, is £0.2m below plan. The underperformance against plan is forecast to continue into the remaining months of the year, underlining the fact that material, non-recurrent savings are bolstering the trust’s CIP performance this financial year.

3.4. Figure 3 shows the non-recurrent balance reducing from 60% in the year-to-date position to 48% at year-end as there are no remaining material non-recurrent schemes to be delivered.

Figure 3 – Full Year forecast, Recurrent/Non-Recurrent split

4. Financial risks relating to the EHRS implementation 4.1. Whilst the majority of financial risks for this year have largely been mitigated by block

contracts with commissioners, a number of financial risks remain as reported previously, and these are monitored by a monthly Income Assurance group (reporting into the EHRS programme board through the Activity and Billing Reimbursement group) and via the Joint Epic/Trust Management meeting, held weekly for specific assurance on Pharmacy issues. The key areas of concern relate to drugs reporting and billing, the billing of provider to provider income and the visibility of activity and productivity information in order to be able to monitor throughput and efficiency. Activity outputs remain challenging to interpret given the number of data quality issues impacting these outputs currently, both at a Trust level and between specialties and divisions.

5. 2020/21 Planning 5.1. The NCL STP submitted a draft Long Term Plan (LTP) at the end of September 2019, with

a subsequent submission in November which is still considered to be draft due to the large NCL gap against the Financial Improvement Trajectory (FIT).

5.2. For UCLH, the FIT would be extremely challenging even in a year without the additional costs relating to Phase 4, Epic and the full year effect of Phase 5. With these additional costs it would appear to represent an impossible level of financial improvement.

5.3. The Chief Financial Officer has written to Directors and Divisional Managers to outline the challenging nature of the current sector discussions and separately to ask them, with some urgency to review and improve on their current planning positions, in particular, focusing on the level of non-recurrent savings assumed to unwind in the 2020/21 position.

Tim JaggardChief Financial Officer

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27 November 2019

Workforce Committee Report

The Workforce Committee met on the 8 October and 12 November. This report provides a summary of key issues discussed at both meetings and includes a recommendation for a future Board Seminar discussion.

Performance against the Workforce Strategic ObjectivesAt both meetings the Committee reviewed performance against the workforce strategic objectives. Underperformance on Appraisal and Statutory & Mandatory training compliance remained areas of concern. It was noted that the process for reporting completed appraisals remained arduous, therefore likely a contributing factor. Once the appraisal has been completed there are numerous steps that the appraiser needs to take in order to record the appraisal on the Electronic Staff Records (ESR) system. In November the Committee discussed what practical steps could be taken to improve performance and the Workforce Director was going to give some further thought to short term and long term solutions to ensure appraisals were being completed and recorded in a timely manner. This would include engaging with the ESR central team and engagement and learning from other Trusts. In addition the Clinical Medical Directors, Chief Nurse and Corporate Directors had all committed to work with their teams to encourage and support staff to ensure there was dedicated time available to complete appraisals.

In October the Committee had a long discussion about statutory and mandatory training compliance rates particularly amongst the medical and dental workforce. The main cause was thought to be a lack of time to complete the training / backfill / cover arrangements. This led to a wider discussion about; whether the Trust had the right set of mandatory training courses on offer, if the delivery of the training was sufficient and accessible to all staff and if enough was being done to ensure staff were given time to complete training. The Director of Education agreed to review the current course syllabus with input from divisions. As with appraisal compliance, the Clinical Medical Directors, Chief Nurse and Corporate Directors had all committed to work with their teams and support staff to ensure there was dedicated time available to complete training.

Leadership and Management CultureIn October, Yogi Amin (senior organisational development lead for leadership) presented to the Committee. He gave an overview of the UCLH leadership development programme describing the aims and objectives; awareness of self and others, disclosure and the role of providing feedback and personal leadership style. The Committee had a constructive discussion about the importance of the leadership programme and how to apply learning from the recent big projects (Epic implementation and the opening of the new Royal National ENT and Eastman Dental Hospitals). It was agreed that the Trust needed a stronger internal narrative on what a UCLH good leader looked like and what UCLH wanted from its leaders. This would help support and inspire staff to feel valued and would help develop a mix of senior leaders across the organisation.

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Diversity and InclusionIn November the Committee received an informative presentation from the Head of Staff Development, the Co-Chair of the Women in Leadership Network, the Staff Networks Development Manager and the Head of the Staff Psychological and Welfare Service. There are now five UCLH staff networks in place which share common aims; for the organisation to engage staff from underrepresented groups, to create a sense of community and support and give staff a voice. The Committee was impressed with the work of the networks, and noted that feedback from network members had revealed collective asks of the organisation including; career progression and support, the opportunity for networking, for the Trust to address bullying and harassment and to improve wellbeing and for there to be an opportunity for flexible working and mentoring opportunities. The Committee reviewed and supported the proposed actions to enhance diversity and inclusion and were pleased to hear of the initial plans the Director of Innovation was taking to modernise flexible working. The Committee noted the disproportionate differences in the percentage of staff not declaring a disability via the ESR system (in comparison to reporting in the anonymous staff survey) and the need to address the instances of bullying and harassment. The Committee agreed that at both Trust Board level and local levels, more clarity was needed on what “diversity & inclusion looked like” and their importance for the achievement of the organisation’s strategic objectives. Managers would benefit from greater support on how to drive a more diverse and inclusive culture. These were themes that required further work and would be bought back for discussion to the January meeting.

Other Key Workforce Issues - New Starter Process and PensionsIn November the Committee received an update on the complex and demanding on-boarding process for all new starters since the introduction of Epic. Background work was ongoing to try and simplify the process and a further update would be provided in January 2020.

In October and November the Workforce Director provided updates on the NHS Pension changes and what actions were being taken to support staff. A proposal for further action would be taken to the next Remuneration Committee.

Recommendation to the BoardAfter the first three meetings of the Workforce Committee it has become evident how crucial it has been to reinstate the Committee to allow for important Workforce issues to be discussed at length as this is not always possible at every Board meeting. The Committee would like to ask the Board to consider a dedicated session as part of the February 2020 seminar to establish a board narrative for leadership, management, and diversity and inclusion, and their interconnections; and to authorise the Workforce Committee to develop these matters further. Whilst these themes were being addressed by the Committee on a monthly basis it was felt that a Board level strategic discussion was needed so a clear UCLH strategy could be shared with the organisation for the start of the next financial year.

Althea EfunshileChair of the Workforce Committee November 2019

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BOARD OF DIRECTORS

27th November 2019

Research and Innovation Committee Report

Membership

Junaid Bajwa Non-Executive Director (Chair of the Committee)Caspar Woolley Non-Executive DirectorDavid Lomas Non-Executive DirectorMarcel Levi Chief ExecutiveTim Jaggard Chief Financial OfficerBryan Williams Director of ResearchFlo Panel-Coates Chief NurseGill Gaskin Medical Director, Digital HealthcareGeoff Bellingan Medical Director, Surgery and Cancer BoardPhilip Brading Chief Executive, UCLH CharityGeraint Rees Dean of UCL Faculty of Life SciencesNick McNally Managing Director, ResearchSally Bennett Governor representativeGraham Cooper Governor representativeKarin Roberts Head of Corporate GovernanceJeannette Field PA to the Chair/CEO (minutes)

The Research and Innovation Committee (RIC) met on 11th November 2019 to consider and review the following important issues. The Chair of the AC welcomed all members to the second meeting of the RIC and alerted members to the Declaration of Interest forms that had been distributed by KR.

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Summary of the Meeting of 11th November 2019

Update on Research Hospital Strategic Pillar 1: Early translation and experimental medicine – the UCLH Biomedical Research Centre

BW reported that a mid-term independent, expert review of the Biomedical Research Centre (BRC) is taking place on 12th and 13th November 2019. The aim of the review, which is a contractual obligation for all BRCs, is to get an independent view of the progress that the BRC has made since the last bid in 2016 and to get the panel’s insights into current thinking about future strategic priorities and themes’ structure for the next BRC bid.

BW reported on the national BRC Directors’ meeting that he attended. The DHSC will be issuing a tender for a review of the BRCs’ programme.

Update on Research Hospital Strategic Pillar 2: Later phase clinical trials and real world research, research management and governance

Clinical Research NetworkBW reported that he and NM have been lobbying North Thames Clinical Research Network to conduct a fundamental review of their funding allocation mechanisms. As a result, three significant changes have recently been unanimously agreed by all North Thames Member Trusts: (a) Funding to be devolved to Partner Organisations; (b) the Harmonisation system for costing and contracting should be disbanded; (c) there should be a review of how central Service Support (i.e. Pharmacy, Radiology and Pathology) block allocation funding is managed in North Thames. The recommendations need support at the UCL Partners Partnership Board to enable implementation to proceed.

UCLH bid for a Patient Recruitment CentreBW reported that UCLH had, following a successful Stage One Questionnaire, been invited to submit a tender for the provision of a National Institute of Health Research Patient Recruitment Centre (PRC). Included in the Government’s Life Sciences Industrial Strategy Sector Deal 2, the PRCs are being established with the aim of increasing the volume of late phase industry clinical trials in the UK. The aim is that the PRCs will deliver this growth through establishing ring-fenced space for clinical trials in the NHS coupled with strong partnerships between NHS organisations and effective deployment of technology to boost recruitment of patients into trials, particularly in chronic diseases. Each of the 5 successful PRCs will receive £1.3M for 3 years to support a core team. The deadline for response to the full tender is Friday 6th December and commencement of the successful PRCs will be 18th February 2020.

Update on Research Hospital Strategic Pillar 3: Leveraging our data for research, innovation and operations

BW reported that UCLH and UCL have been approached to join the London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare based at King’s College London. The RIC discussed the opportunities and risks of partnering with several other London Trusts and Universities within the Centre. Sector Deal funding will only be allocated via its existing funding Centres such as this one at King’s. The RIC agreed that further evaluation of the proposal was required to fully understand the risks, e.g. intellectual property, the revenue effects of capital funding and contractual risks.

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NM reported that all 4 Data Workstreams had met on at least one occasion and that all had produced advanced drafts of their Terms of Reference. The RIC had two presentations that were designed to enable deeper consideration of two of the Data Workstreams: Workstream 2 - Data Platforms and infrastructure and Workstream 4 - Data Value/Intellectual Property and Commercialisation.

MW updated the RIC on the Data Platforms strategy which emphasises the movement of data out of the Trust’s clinical systems (including Epic) into a safe, protected research environment, which enables researchers to access the platform to carry out research, experimentation, and the development of advanced analytics. MW explained that the Experimental Medicine Application Platform (EMAP) was central to the strategy. There was discussion as to how security would be maintained in Cloud solutions and how access to EMAP would be managed in practice. The RIC also discussed the potential of EMAP to link with partner hospitals. There was also discussion about the need to ensure that UCLH staff training and development is geared towards enhancing digital literacy.

DF updated the RIC on the activities of the Data Value/Intellectual Property and Commercialisation Workstream, notably its aims to ultimately recommend a framework for the Trust to use when considering data partnerships with third party organisations, including industry. The RIC discussed the lack of answers at a national scale to questions such as the value of data and therefore how it would be important for UCLH to (a) continue to build competencies and capabilities through partnership working; (b) work with speed and with common sense; (c) avoid ‘reinventing the wheel’ when solutions are already available; (d) focus on 1-year deliverables; (e) continue to connect with Government initiatives via NHSX and Office for Life Sciences and (f) take an open approach to partnership and explore opportunities with a range of organisations.

Launch of “Your Data: Our Challenge”

NM reported on the launch of the Biomedical Research Centre’s new initiative for involving patients and the public in helping to shape the workflows of the 4 Data Workstreams. There was discussion about the importance of the public involvement agenda in helping to build and maintain trust in how the Trust utilises healthcare data. It was noted that initially it will be helpful to consider the programme as a fifth data workstream to give it sufficient profile but that the longer term goal was to fully embed the views of patients and the public into the 4 Workstreams to deliver on the objective of a co-produced strategy.

Junaid Bajwa Chair of the Research and Innovation Committee15 November 2019

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27 November 2019

October 2019 Quality and Safety Committee Report

1. Rapid Colorectal Cancer Diagnostic and AssessmentQSC received an update on the implementation of the nationally agreed rapid assessment and diagnostic pathways for colorectal cancers at UCLH. QSC heard that a new standard has been introduced to ensure patients receive diagnosis or ruling out of cancer within 28 days, with formal reporting from April 2020. Our compliance is around 70% projected to improve to 80%. Work is in progress to improve compliance. QSC will receive an update in 6 months.

2. Nasogastric Tube training update QSC received an update on trust-wide compliance with the online nasogastric (NG) tube training. QSC heard that training compliance figures for doctors across all divisions are very low with little improvement in the last nine months. There are still issues with defining the audience but this has improved. Training compliance will be reported in the performance pack and steps can now be taken to improve training compliance. Consideration is being given to improving the collection of training data for nursing staff. QSC asked for an update in 6 months.

3. Statutory and Mandatory training reportQSC was informed that mandatory training compliance is currently 87% against our target of 85% completion overall. However, medical and dental completion rates currently sit at 74%. Capacity for classroom training is a challenge at the moment. The last few months have been particularly busy due to staff catching up after a period of intense training for Epic go live, and we are now undertaking staff appraisals, for which they need to be up to date with training. QSC heard that we are currently exploring the feasibility of a move from our current learning portal to OLM, which is a module on ESR, our electronic staff record. The advantage of this is that we will easily be able to transfer mandatory training records between trusts in NCEL, reducing the burden of training for new starters. A disadvantage of this is the fact that we require our staff to complete fewer mandatory training courses than other organisations and often less frequently, so we may need to increase our mandatory training requirements to fall in line with other organisations. A full analysis including resource and time requirements is being worked up and will be presented to the senior directors’ team in the near future.

4. Competency assessments for junior doctors4.1 The Director for Education reported that she has contacted the medical school to determine what competency assessments are part of the current curriculum and found that dementia, end of life care, post mortem consent and VTE prophylaxis are requirements for satisfactory completion of the Foundation training programme. These are also role specific training requirements here and we will consider if this is unnecessary duplication.

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4.2 QSC discussed the thorough training and competency assessments that nursing staff undergo before procedures such as catheterisation and venepuncture in comparison to the limited training and competency assessments that junior doctors receive.

5. Risk Coordination Board ReportThe report from the September 19 meeting was received by the committee for information.

6. Patient Safety CommitteeThe report from the September 19 meeting was received by the committee for information.

7. World Patient Safety DayIt was reported to the committee that the trust celebrated World Patient Safety Day on the 17th September 2019 with a number of events running throughout the week. A new message was broadcast each day with the strap line of ‘Speak Up. Be the one who makes a difference’. The trust had a visit from the National Director for Patient Safety, Aidan Fowler, and the Deputy Director for Patient Safety, Matthew Fogarty. We also had a stand in the atrium covering a number of topics such as NEWS2, sepsis, medication safety, handwashing and launched a safety concerns form and a NEWS2 video. There was a patient safety related staff walk-about attended by staff representing a variety of roles such as directors and administrative staff. We also launched a new weekly safety message to staff across the trust focusing on a single issue, the first being ‘Civility Saves Lives’.

8. National Lung Cancer Audit updateQSC received the report into the performance indicators for patients diagnosed with lung cancer in 2017, and an explanation of the national data collection process. UCLH performed well on all unadjusted results except for patients seen by a lung CNS which was 68.2% (standard 90%) against the national average of 72.1% but this has since improved. Survival was 48% at UCLH compared to the national average of 36.5% and is similar to across Europe. Actions that will be taken in response to the results were outlined.

9. Quality Performance Pack9.1 QSC heard that the switch to Epic has impacted on how VTE risk assessments are performed and how such data is captured and reported. There have been changes in workflow-pathways and difficulties locating completed VTE risk assessments within the system. Prior to the introduction of Epic, a number of patient groups were ‘cohorted’ or excluded from the need to have a VTE assessment. These cohorting rules were replicated in the new Epic environment although in some cases, this has proven to be problematic, for example where clinical areas have changed names or codes. This is being addressed.

10. Operational Excellence Improvement work updateAt the request of the committee QSC received an update on managing patient placements from the Head of Operations for Patient Flow. QSC heard about the new patient flow policy and ‘Ward Rhythm of the Day’, both of which support the improvement work needed to reduce movement of patients late at night. Daily flow huddles are conducted twice daily and are well attended. A weekly flow dashboard from Epic is planned to be sent out to divisions to include timeliness of patient admissions, discharges, transfers and outlier repatriation to monitor practice and track improvements. An outlier report is also in development, replicating what we previously had before Epic went live, which would show at any given day how many

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patients were outside of their expected bed base. Areas that need further work include earlier discharges and turnaround times for porters and bed cleaning requests. QSC asked for an update to be provided in six months.

11. Clinical Audit and Quality Improvement Committee (CAQIC) report11.1. The committee is ensuring readiness for CQC queries and inspection by familiarisation with the monthly CQC Insight report and feeding back to divisions when there may be concerns.

11.2 The committee also looked at the findings of the National Audit of Care at End of Life Care. This audit monitors compliance against the priorities for care of the dying person set out in the ‘One Chance to get it Right’ report; following the withdrawal of the Liverpool Care Pathway. Documentation of the needs of families and others requires review as the result at UCLH (35% compliant with standard) was below the national figure of 56%. QSC was of the view that documentation may need to improve but was assured that care is of a high standard. Results were below national average under the Workforce/ Specialist Palliative Care section due to no weekend access for patients for face to face reviews with Clinical Nurse Specialists (CNS); services only available Monday to Friday. In addition UCLH has less than one third of the national average of number of CNSs for palliative care. This is being addressed.

12. Clinical Effectiveness Steering Group (CESG)The report summarised the safe, effective and innovative new interventional procedures introduced to UCLH, those not approved and those where outcomes were reported. Compliance assessments for National Confidential Enquiry into Patient Outcome and Death that apply to UCLH were reported along with reports from the six sub-committees to the CESG.

One of the reporting committees is the Organ Donation Committee (ODC). The ODC chair informed QSC about a letter from the NHS Blood and Transplant (NHSBT) addressed to the CEO and Corporate Medical Director which includes two actions for UCLH to support organ donation.

The ODC chair asked QSC to support the trusts alliance with NHSBT to minimise missed donation opportunities. QSC fulling endorsed this alliance.

13. Quality risks and issues arising from the Clinical Quality Review Group (CQRG)13.1 The Director of Planning and Performance reported on risks and issues discussed at the CQRG between June to September 2019 where QSC may want to consider further monitoring or action. However of the risks identified all had been resolved.

14. Mortality Surveillance Group report (MSG)14.1 QSC received the report from the September meeting of the MSG for information.

15. Quality prioritiesQSC received the quarter two update on the priorities for safety and effectiveness with patient experience to be considered next month. Good progress has been made against the safety priorities although there is no baseline data for several measures due to the challenges of extracting data from Epic.

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16. CQC Executive Steering Group report (CQCESG)16.1 QSC received the report from CQCESG September 19 meeting from information..

17. Patient Experience17.1 QSC received the report covering the headlines from discussions at the August Patient Experience and Engagement Committee (PEEC). QSC heard that monthly FFT Performance for August has remained largely stable in comparison to last month. Updated FFT guidance has been received from NHSE. PEEC requested an update from the phlebotomy team due to concerns regarding the increased pressure placed on the UCH atrium. PEEC were reassured that the team were aware of the impracticality and inconvenience caused and were seeking non-hospital based premises.

18. Complaints update18.1 QSC received an update on the current position with complaints and on the action being taken to support the divisions in improving the timeliness of complaint responses. There has been a reduction in the number of complaints overdue by over 100 days from approximately 30 per month to zero. Complaints in Datix Web has been introduced within Women’s Health division with a plan to roll it out across the trust. Work is ongoing to improve the lack of clinical sign off of complaints responses, monitoring of the five day telephone call, performance against the 85% target, sustainable training and reducing the number of outstanding complaints over 50 days.

November 2019 Quality and Safety Committee Report - this meeting was not quorate

1. Breast cancer- lost to follow-up updateQSC requested assurance that patients with breast cancer are not being lost to follow up. A task and finish group had been established to address the risk that was identified relating to patients from the Breast service that were potentially lost to follow up. QSC was informed that the patients were stratified into groups for focus in order of level of risk – primarily driven by the magnitude of the impact on the patient’s health in the event that they were found to be lost to follow up. Validation has been completed for 1074 out of a total of 3154 patients, including all of the highest risk patients. Where patients had been lost to follow up from this population (2.7%) they were followed up. QSC agreed that as the work had covered the groups of patients most likely to have come to harm the risk is significantly reduced.

QSC heard about the actions taken to avoid this happening again which included Epic taking over a manual process of checking follow ups, a permanent MDT coordinator and float coordinator in place, and a clinician responsible in place (with protected time) for the MDT and a ‘safety net’ process being introduced. The risk has now been reduced.

2. Risk Coordination Board ReportQSC received the report of the May and August meetings and the risks up to October for information.

3. Patient Safety Committee (PSC) OctoberQSC received the report of the October meeting for information and approved it for further distribution.

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4. Annual PROMs reportThe committee received the trusts’ annual report of our performance against the NHS Mandatory Patient Reported Outcome Measures Programme. QSC heard that the trust continues to meet and exceed the recommended 80% pre-operative PROMs participation rate. The trust’s case-mix adjusted average health gain for knee replacements has improved since the previous report which summarised the PROMs finalised data for 2016-2017. QSC commended the work to improve performance which centred on consultants operating and improvements in the implant we use at UCLH so that UCLH is no longer an outlier for knee replacements.

5. Quality Performance Pack October 195.1 QSC was informed that we achieved 61.2% of complaints responded to within the target time which is our best position since September 2018. Apart from a dip in May (43%), the overall trend has been one of improvement. We currently have no complaints over 100 days and only one complaint outstanding by over 90 days. A reduction in the overdue complaints has given divisions more capacity to process the shorter waiting complaints. QSC commended this excellent progress. 5.2 QSC noted the marked improvement in allergy status since the implementation of Epic.

6. Getting it Right First Time (GIRFT) Litigation data packQSC received the report on litigation in selected specialties data pack which was published in June 2019 so that clinicians, managers and staff are aware of the medical negligence claims across each of the specialties reviewed and to allow Trusts to benchmark performance against other acute and specialist trusts providing the same service. The limitations of the data were outlined. QSC noted particular areas with potentially higher litigation costs and asked for a further analysis in these areas and a report on learning.

7. Trauma, Audit and Research Network (TARN) reportQSC received the August 2019 report. QSC heard that the peer review highlighted many positives such as nurse training. QSC heard of areas for improvement and the plans to mitigate them which included the ascertainment rate, the trauma coordination service and the rehabilitation coordination service.

8. Quality Improvement (QI) updateQSC was presented with an update on progress with the trust quality improvement programme. There has been a strong uptake of improvement courses post Epic go-live, and an increasing demand or requirement for improvement coaching and support. The improvement team continue to ‘triage’ project requests to ensure support is well targeted and benefits are properly communicated.

9. Mortality Surveillance Group ReportQSC received the report of the October meeting of the MSG for information.

10. CQC Executive Steering Group (CQCESG) Report10.1 QSC received the report of the October meeting of CQCESG for information.

10.2 CQC inspection 2018 action plan update: QSC received assurance that the ‘Must do’ actions plan should be complete by the end of November.

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10.3 In relation to the ‘Should do’ actions some trust wide actions need to be continually reinforced including the safe disposal of unwanted medication, monitoring fridge temperatures, statutory and mandatory training for medical staff, infection control practices, and protecting patients confidential information on computer screens. Of the 66 actions 22 have been completed, seven are complete but awaiting assurance (audit, ICR, matron round), 33 have been acted upon but require ongoing monitoring and six require Epic data for assurance to be available.

11. Infection Prevention and Control (IPC) report11.1 The director for infection prevention and control provided an overall update on performance against infection targets, and a summary of IPC incidents that have occurred from September ‘19- October ’19.

11.2 Infection Control Improvement planQSC received the plan which should have been attached to the annual report which the Board received in September (plan attached). A regular update on the improvement plan will be added to the IPCC reports to QSC.

12. QSC work plan updateQSC received the updated work plan for information.

13. Patient Experience and Engagement committee (PEEC)QSC received the PEEC report for October. QSC heard that the friends and family test (FFT) recommendation scores for inpatients, day cases and the Emergency department continue to be on or above target. However, FFT recommendation scores for Transport have declined significantly.

14.2 Patient Experience Quality Priorities Q2 updateAn update on progress was provided.

14.3 National Cancer Patient Experience Survey 2018

QSC noted that UCLH has continued to improve with 38/52 questions improved or the same as 2017. We are still below the national average in a number of key areas. It was noted that question 11 ‘Given easy to understand written information about their cancer type’ is a trust quality priority this year and we achieved 69% against the national average of 74% in the survey. QSC discussed how this might be improved.

Please note: the November report is based on unapproved minutes

Cathy MooneyDirector for Quality and SafetyNovember 2019

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UCLH NHS Foundation Trust Infection Prevention and Control Improvement Plan 2019-2020 (24.07.2019)

Issue / plan Key Actions Primary lead

Lead/s

Target Dates Progress

1 Undertake strategic review of Infection Prevention and Control Programme at UCLH identifying areas for improvement and highlighting specific areas identified by CQC inspection

1. Undertake self-assessment against the Healthand Social Care Act, Code of Practice on theprevention and control of infections and relatedguidance. Document in assurance frameworkand any gaps to be added to the improvementplan

2. Assurance framework and gaps to be raised atthe IPCC

3. Review all meetings and structure of the IPCProgramme collaboratively and set outrecommendations for IPCC

4. Discuss training programme with Director ofeducation (and deputies) and review trainingprogramme and implementation

5. Review and update audit programme6. Review and update the presentation of

surveillance reports and how these are given towards (with matrons)

7. Review decontamination service delivery,reports and assurance

8. Review and update IPC Policies and protocols9. Review and update IPC link practitioner

programme10. Develop IPC strategic plan outlining

recommendations following review11. Agree IPC strategic plan at the IPCC

Ensure core components of prevention of infection are addressed throughout the IPC Programme including Hand Hygiene, Cleaning and Decontamination, Aseptic Technique, IPC Precautions,

IPC Team 1. Dec 2019

2. Dec 20193. Dec 20194. Mar 20205. Dec 20196. Dec 20197. Dec 20198. Mar 20209. Mar 202010. Dec 201911. Dec 2019

2 Improvement plan for influenza and outbreak preparedness -

1. Develop and implementation of fit testingprogramme Trust wide

2. Review of PPE (respiratory protectionguidelines, use of FFP3 vs surgical masks)

3. Develop training programme andimplementation for all UCLH staff that includesIPC precautions and PPE, donning and doffing,respiratory protection, flu vaccination etc

4. Audit compliance with new respiratory protection

1. Jul 2019

2. Dec 2019

3. Dec 2019

4. March 2020

5. July 2019

6. November

2019

Overall Page 85 of 112

guidance 5. Establish Winter preparedness group and review

the expansion of inpatient flu vaccination of at-risk patients (NHNN NRU and Evergreen

6. UCLH virology, with HSL support to provide raidflu/RSV testing in A&E hot lab during winter toassist with IPC decisions, bed planning,admission and discharge decision making

3 Identify, prevent and control CRO/CPO

1. Audit UCLH compliance with screening andmanagement protocol for CRO/CPO in high riskareas

2. Assess compliance with surveillance in high riskareas

3. Develop standardised training slides and providetraining for clinical practice development nursesand IPC Link practitioners

IPC team

1. Dec 2019

2. Jan 2020

3. Feb 2020

4 Reduce C difficile HCAI infection in compliance with national targets and quality improvement

1. Continue to use learning for RCA’s in education,monitoring and feedback.

2. Continue to undertake Root Cause Analysis(RCA) on all post 48 hour cases and sharelearning outcomes.

3. Collate information on Community onsethealthcare associated cases and include inEpidemiology report

4. Continue weekly review of C. difficile toxin andantigen positive patients to monitor progress andintervene at an earlier stage to avoid furtherrelapses or failed treatments

5. Review lapses in care with CCG

KS, SD,APRW, GMG,LH

1. Mar2020

2. Mar 2020

3. Mar 2020

4. Mar 2020

5. ongoing

5 Gram negative (including E.coli) bacteraemia reduction

1. Data collection and analysis identifying possiblesource to direct reduction strategies plans.

2. Continue to strengthen messages to improvehydration and minimising urinary catheterisation.

3. Continue key areas of work as outlined in thisplan to reduce device related infection, identifypatients at risk of developing gram negativeinfection and develop speciality specificreduction strategies

IPC team

1. Mar 2020

2. March 2020

3. ongoing

6 Improve IV line and invasive devices care management (this is also included in on-going work)

1. IV cannulation workshops planned & deliveredmonthly

2. Review of the IPC Quality Improvement Tool

KS, PW, Leila Hail (LH), Gema Martinez-Garcia

1. Jul 2019

2. Mar 2020


(ICQIT) to incorporate invasive devices management monitoring

3. Support and participate in the development of acorporate training programme for IV devicesmanagement through the Capital nurse project.

4. Audit of invasive devices to be conducted atleast annually and on a risk assessment basis (ifthere are increases in infections) using the HighImpact Intervention tools

a. Lines

b. VAP

c. Urinary catheters

(GMG) , JB (J Bitmead)

3. Dec 2018

4. Mar 2019

5 Improve isolation prioritisation and utilization

1. Data on appropriate usage of isolation facilities andbed days lost will be monitored and reported usingthe EHRS system.

2. IPC team continue to work with EHRS team toachieve optimal isolation an utilization of facilities

3. The Trust is building and planning additional isolationfacilities to increase isolation room capacity.

KS, LH, GMG, 1. Dec 2019

2. ongoing

3. When Phase 4& 5 open

6 Improve education and training (also links to item 1) and support of Infection Prevention and Control Link staff

1. Review mandatory training to incorporate recentchanges in IPC

2. Deliver Trust wide IPC study day and incorporatethemed workshops

3. Refresh IPC link staff programme to include training

and audits

4. Review and improve Intranet page to include online

resources

IPC team 1. Mar 2020

2. Mar 2020

3. Mar 2020

4. Mar 2020

7 Improve risk assessment documentation for infection prevention and control

1. Review current DATIX records relating to IPC to identifythemes

2. Document risk assessment for frequent but low riskinfection prevention and control issues

3. Risk register update to be added to IPCC agenda.

KS, LH, GMG 1.Oct 2019

2. Oct 2019

3. Jul 2019

9 Improvement in the prevention of surgical site infections

1. Roll out the One Together programme with 3MTrust wide

IPC team 1. Mar 2020


2. Development of theatre practice protocol inconjunction with theatre staff

2. Dec 2019

10 Review of procurement initiatives as part of the IPC STP network

1. Participate in the IPC STP network to provideclinical expert advice on procurement initiatives

2. Monitor and evaluate product reviews and trialsas part of the clinical procurement review group

KS, LH, GMG Ongoing



27 November 2019

Audit Committee Report

The Audit Committee (AC) met on 24th September 2019 to consider and review the following important issues. The Chair of the AC welcomed Adam Sharples as a new member and Jenny Townsend, Chief Accountant who will be attending the AC. The Committee thanked Althea Efunshile for her sterling service to the Committee.

Summary of the Meeting of 24th September 2019Internal Audit (IA) – Progress Report

Implementation of recommendations

IA confirmed that progress in implementing recommendations was good. The ongoing work in relation to the MSK contracting process was flagged and the CFO agreed to provide a progress update as the Trust was reliant on other organisations to complete the process. Timeliness of response to complaints

This report received an amber/red rating (partial assurance with improvements required). Quality and Safety have agreed to implement the nine recommendations outlined in the report by the end of October 2019. These include structural change within the team and changes to the process. It was noted that the number of complaints had increased by 0.5% and that complaints were becoming more complex.

External AuditThe AC agreed the external audit plan for 2019/20 and noted that the scope was largely unchanged from prior years. Over and above the mandated risks, key local risks had been identified as the valuation of EHRS and Phase 5 programmes. The AC noted that a new Code of Audit Practice from the National Audit Office was out to consultation. There was discussion about the issues the Trust was experiencing following the implementation of Epic, relating to pharmacy costing via the Willow module of Epic and billing. The AC noted that a number of actions are in place to resolve these issues.

Board Assurance Framework (BAF)The CFO summarised the three main risks on the BAF as the implementation of Epic, the risk of EU exit and financial risk. There was a discussion as to whether risks were too heavily weighted towards financial and programme risks rather than to performance risks. It was agreed that the financial risk would be reworded to better reflect the impact of Epic and external reporting, along with operational performance issues.


Risk ReportThere was a discussion of both the quality and quantity of risks being captured. The AC was advised that a new recording system was being piloted for a month which would allow staff to express concerns rather than classing a concern as a risk. This will be evaluated. There is also a plan to put the risk register on “my UCLH” which will allow all staff to see it. The Epic risk register will be kept separate for now.

Business Conduct ArrangementsThe committee noted that 94% of staff required to complete a declaration of interest had done so. An awareness campaign will be run in mid-November to raise staff awareness of the need to declare any gifts and hospitality offered, even if these are not accepted.

Insurance ArrangementsIt was agreed that consideration needs to be given to directors’ liability, insurance of assets, clinical indemnity for private patient activity and insurance provisions within contracts. A plan and timescale was agreed.

Finance Metrics and ProcessesThe finance transformation and improvement plan was noted. Work streams and agreed metrics are in place with weekly and monthly review. Most of the issues identified related to compliance rather than to processes. The finance team would be considering greater automation of finance processes and would be visiting other sites to identify possible opportunities. The review of finance metrics showed that better payment practice compliance had fallen to 58% as a result of clearing old invoices which had been backlogged. The impact of Brexit on overseas patients was also discussed.

Rima MakaremChair of the Audit CommitteeNovember 2019



27 November 2019

Electronic Health Records System report

1 Achievements since last report

Since the last report to the Board in September, we have delivered two substantial projects. The first was the digital provision for the new Royal National ENT and Eastman Dental Hospital (“Phase 5” in Huntley Street) which opened on 1st October. This was made more challenging by a building commissioning period of only four weeks, meaning that many equipping tasks were being completed concurrently and in the final days before opening. Nonetheless, opening was smooth, with the provision of WiFi for staff and patients, introduction of check-in kiosks and patient call screens, building of new clinic templates, digital chairside dental imaging (for the first time) as well as connecting two cone-beam scanners, ultrasound and an MR, interfacing audiology software, and installing and testing a wide range of desktop and mobile workstations, many with label and wristband printers and bar code scanners. There are a few outstanding items which are being managed through to completion. After extensive learning in the main Epic Go-Live, the technical dress rehearsal of all equipment went very well and was managed by the in-house team. We are working through the potential to maintain the capacity and skills for this infrequent exercise by supporting other UK sites. It was encouraging to hear at the Leadership forum from a consultant who is working across both the new building and the RNTNE Hospital in Grays Inn Road, that Epic has made cross-site access to clinical information easy.

The second project was our first Epic Upgrade, completed on-time and with little and only transient disruption in the early hours of 14th November. We are now working with the May 2019 functionality, including the ability for clinicians to place “orders” on a mobile phone using the Epic Haiku application. We installed an upgrade of Hyland OnBase at the same time in order to correct a problem with imported document integration into Epic. We are about to review the lessons learned to apply to future Upgrades, which we will taking two at a time (the releases are quarterly), twice a year.

Both these projects required close working between our EHRS team, our technology specialists, Atos and Epic, as well as joint working with Medical Physics to integrate clinical devices and partnering with clinical and operational teams. Ever-closer working will be a key part of our future and a focus of my new role as Medical Director for Digital Healthcare, which I started on 7th October. This is a full-time Executive leadership role ensuring that we adopt digital technology to enhance the quality, safety and efficiency of care, empower patients, and harness the power of data to take forward our Research Hospital ambitions. The Health Service Journal has recently published a survey of Trust Board leadership of the digital agenda, highlighting gaps across the country. We were able to report positively on both Board-level leadership and the establishment of clinical informatics leadership (unusually we have Chief Medical, Nursing and Research Information Officers). The Board’s ongoing support is important and very much appreciated, particularly as we work through the “snagging” phase of our implementation.

2 Areas of focus

Our areas of focus for Epic stabilisation remain the same as our previous report.


Willow Inventory

Epic are providing support to resolve Inventory-related issues that are currently impacting on allocation of drug costs to clinical services and high cost drug billing and making work onerous for the dispensary, pharmacy inventory management and income teams. Nine developments are planned for delivery in December, and a further set is being scoped. We have been working with GOSH who have experienced similar challenges and also Royal Devon and Exeter who will implement next Summer.

Supporting waiting list and activity management

The admin, billing and reporting governance group chaired by Simon Knight is overseeing a comprehensive set of actions to improve the processing of referrals, referral triage, booking, waiting list and activity management, which has been challenging since Go-Live - and indeed has been problematic in many EHR implementations in the UK. This includes focus on waiting list validation and patient booking, together with build changes where necessary and work with the administrative community through Henry Wilson’s Access and Patient Administration Programme. A pipeline of dashboards and reports for real-time management is in progress. Epic are providing additional support in this area and their lead technical developer for patient administration will be on-site at the beginning of December to assist. The Board should note that we have recommenced external reporting of the wait to acquisition of diagnostic tests (the national “DM01” return). We have continued to report RTT waiting times and performance is improving month on month as we work through data quality issues with the help of a supplementary validation team. Cancer reporting is securely established although not yet as streamlined as we would like. These targets are discussed in further detail in the Performance report.

Beacon protocols implementation

Beacon chemotherapy protocol implementation has been further delayed, with an expected rollout date of early 2020. It is important to achieve this timeline to ensure it does not extend into the period of intense planning for the Phase 4 move (amongst other reasons). The main constraint in the last month has been the pace at which the clinical pharmacists in the cancer team can check built protocols for any errors – an activity in which we cannot cut corners. We are also mindful of the adverse impact on patient experience should there need to be more than a very minimal level of just-in-time protocol completion.

Other activity

At the November programme board, good progress was reported by our Governance Groups on using Epic for patient flow management, the release of more new reports, completion of most of the 29 specialist variants on the WHO checklist, build of improved summary views of patient observations, and creation of a standardised clinic letter template to improve communication with GPs and facilitate greater automation of letter generation from information in Epic. A wide range of other actions are in progress.

4 Financial performance

The Board previously approved the release of £1m from the contingency budget. This is being used to meet a range of non-recurrent costs and has been fully allocated. Taking this into account, the programme remains broadly on budget for the current financial year as we evolve from project budgeting to business as usual financial management. In particular, pay expenditure is on budget. However, having implemented Epic, there is now a trust-wide appetite for more generous provision of end-user technology, rapid problem-solving and acceleration of new developments and rigorous prioritisation is essential to stay within our budget. We are now in the planning cycle for 2020-21.


5 Future planning.

We have our next work programme planning workshops in December. In addition to completing areas of stabilisation and planning for Phase 4 as our next major strategic project, we are increasing our focus on identifying and delivering cash-releasing initiatives. To date, we have achieved substantial reductions in the management of paper records and the cost of transcription of letters and we have agreed to support a project to step up electronic communication to patients as the default. We will be working with Yale University & Yale and New Haven Health System to learn from their longer Epic experience to create clinical improvements and efficiencies, building on the connections we have made on using Epic in research (reinforced during their participation in our BRC mid-term review process). A complex project is also underway to move data from a range of live or read-only legacy systems to a managed archive, which will release substantial savings on both licences and data centre costs.

We are also working on our plan to achieve Himss (Healthcare Information and Management Systems) accreditation of digital maturity at level 6. Amongst other things, this requires us to achieve a sufficient level of Bar-Code Medicines Administration compliance to reduce drug errors.

6 Developing our capability

We are holding a “Getting to know Epic” week in the first week of December and will be putting on webinars and masterclasses on key functionality. We are also pleased to have secured one year’s funding from the UCLH Charity to establish a programme to build up our community of Epic experts within our front-line teams, enabling them to support and teach colleagues, and learn to configure elements of the system alongside the full-time “professional” builders. We will also be establishing a seminar programme to learn from the wider digital and digital healthcare world. In addition, the charity has generously funded new data science fellowships and we aim that these programmes will be synergistic. We are starting to plan a programme of activities on the value and power of data to coincide our first anniversary of implementation.

In coming weeks we will appoint to a new Chief Technology Officer post and to a successor to David Kwo, as Head of Electronic Health Records, leading the EHRS team. David retires at the end of November and we will miss his commitment and expertise.

7 Growing our collaborations

The Epic UK users now comprise Cambridge University Hospitals, ourselves, GOSH and two sites in development: Royal Devon and Exeter and Cleveland Clinic London. A regular Epic-convened collaboration meeting has been established and the group will debate which Epic developments are of greatest priority in the UK, and how any development costs might be shared. GOSH and UCLH, having implemented the same version within three weeks of each other, have considerable common ground and we have joint meetings planned.

In addition, there are other UK sites at various stages of their procurement process, and we are now regularly asked to host their teams, as we have a recent version and a wide portfolio of services. This is not funded by the NHS Digital Global Exemplar programme, which is currently paused.

Closer to home, we are active members of the North Central London Digital Board and are working towards sharing patient records across patients’ healthcare teams in the wider systems through the centrally funded “Health Information Exchange” programme. In addition we have our own Epic tools which


are used to share patient data between Epic sites (e.g. for neonates transferring between UCLH and GOSH) and to offer access to GPs for their patients.

Finally, various members of the Digital Healthcare team are now working closely with our data science colleagues in Research Hospital workstreams.

Gill Gaskin, Medical Director, Digital Healthcare.


Board of Directors

27 November 2019

Mortality Surveillance Report Quarter Two 2019/20

1.0 IntroductionThis paper is the report on deaths and learning to the Board for the period July 2019 to September 2019. This report provides the:

Numbers of deaths in the period Number of deaths due to be reviewed according to UCLH criteria (based on NHSI guidelines) Number of deaths actually reviewed and whether they are more likely than not to be due to

problems in care.

It also includes the Women’s Health Perinatal Mortality Surveillance Report for quarter two.

Deaths have been reviewed either by existing processes such as complaints and serious incident investigations or using the structured judgment review (SJR) process. The paper sets out the learning from those reviews.

2.0 About this report Appendix A is an update on learning from deaths reported in quarter two 2019/20 and an update on actions and learning from deaths previously reported. Appendix B is a detailed breakdown of deaths for review according to the UCLH Mortality Surveillance and Learning from Deaths policy. Appendix C is a breakdown of how deaths are reviewed including SJR and existing processes. Appendix D is an overview of the overall SJR scores for quality of care for the year to date and for the quarter. Appendix E is a breakdown of the cases reported under the Perinatal Mortality Review Tool.

3.0 Overview quarter two July to September 2019The total number of deaths in Q2 July to September 2019 was 207. See appendix C for more details.

Table 1 Overview April 2019 to September 2019Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sept 19 Total

Total No. of deaths reportedExcluding Private Patients

79 68 87 62 68 77 441

E NE E NE E NE E NE E NE E NE E NE7 72 11 57 15 72 5 57 8 60 9 68 55 386

Total eligible for SJR 5 9 10 7 14 5 2 7 4 7 4 16 39 51SJR exclusion criteria

Inquest 1 2 2 5Palliative Care 2 1 3 2 3 11

SJR criteriaSepsis 8 6 1 7 4 15 41AKI 1** 1 1 3Out of trust death 1 1 1 3Other* 4 1 5

Completed reviewsNumber of SJR completed for month(Percentage)

6/1443%

12/17(70%)

9/19(47%)

2/9(22%)

1/11(9%)

0/20(0%)

30/90(30%)

E = Elective NE = Non-Elective*Other – may include referral from M&M, sampling of non-elective.**Included in Sepsis figure


Table 1 shows the number of deaths to be reviewed according to our criteria (data correct as at 12/11/19). This shows that the trust has only reviewed 30% of deaths eligible for review.

4.0 Structured Judgement Reviews undertaken to date and training The overall number of SJRs completed has increased since last quarter, however there continues to be a lack of SJR reviewers and the trajectory planned for improvement following the review in February 2019 has not been realised. In quarter two, 38 SJRs were completed (28 for 19/20 and 10 for deaths in 18/19); in total to date from April 2017 to September 2019 over 140 SJRs have been completed.

Training is provided on a monthly basis and takes approximately 2 hours to complete. In quarter two 2019/20 we put on three training sessions in which four further staff have been trained. Going forward we have added the SJR training to the learning portal and have set training dates for 2020 which will be advertised in the Quality and Safety bulletin. Work continues to recruit SJR reviewers.

Figure 1: Number of SJRs completed by quarter and number of staff trained in quarter

2017/18 Q12017/18 Q22017/18 Q32017/18 Q42018/19 Q12018/19 Q22018/19 Q32018/19 Q42019/20 Q12019/20 Q20

5

10

15

20

25

30

35

40

45

Total SJRs completed in quarter Number of staff given SJR training

Number of SJRs and number of staff trainedQ1 17/18 - Q2 19/20

5.0 Themes and learning noted in SJRsOf 38 SJRs completed in Quarter 2, 31 (82%) were rated 3 (adequate) or above for all phases, and were not eligible for a second review.

Of the 31 rated adequate or above, good communication with and involvement of the patient’s families was noted in 13 (42%) reviews.

7 SJRs completed in Quarter 2 were eligible for second review as they were rated 2 (poor) for one or more of the phases.

Of the 7 SJRs eligible for second review, 4 were rated 2 (poor) overall.

Of the 4, 2 overall assessments mentioned poor discharge planning, and other reasons for scoring poor care included lack of involvement of specialist services, lack of awareness of deterioration, poor communication with family related to active management versus palliative care. The second reviews are pending.


3

Appendix A: Learning from deaths reported in quarter two 19/20 and updates on learning and actions from deaths previously reported for serious incidents and complaints

April - September 2019 Quarter 2 updateSource Description The learning and actions from the investigation Outcome

Structured Judgement ReviewsThemes related to end of life care identified from SJRs

This SJR highlighted a theme which is that discussions with patients about their end of life care can occur too late and patients may continue to receive invasive care for too long.

See below under complaints

Serious IncidentsSI535 SI 535 Missed small bowel obstruction resulting

in aspiration and cardiac arrest

Missed diagnosis and treatment in a patient with small bowel obstruction resulting in aspiration and cardiac arrest, with unsuccessful resuscitation. The missed diagnosis was due to lack of recognition of the significance of symptoms of pain and persistent vomiting in the context of reassuring National Early Warning System (NEWS) scores and apparent initial response to treatment

As a result of this incident the new guidelines for the management of small bowel obstruction have been completed; these guidelines require minor amendments. Processes for recognition and treatment will then be embedded into local assessments and practice.

Training in the diagnosis and initial treatment of acute surgical conditions and the new guidelines on the management of small bowel obstruction will be included in the rolling educational programmes of the multidisciplinary team on the Acute Medical Unit.

Agreed death not likely to be due to problems in care (MSG 03/06/19)

ComplaintsThemes related to communication identified from complaints

A theme identified from the MSGs review of complaints was the communication between clinicians and bereaved families.

As a result of this theme, which is also seen in some of the SJRs, the End of Life team attended the Quality and Safety Committee to share how junior medical staff are trained and the plans for the service. The SWAN model of care has been launched trust wide SWAN stands for ‘Sign Words Actions and Needs’ and is a model which aims to promote dignity respect and compassion at the end of life. For example a swan symbol is used to alert others that the patient is expected to die.

18/2014 Complainant raised concerns about the care and treatment provided to her mother prior to her death. The concerns detailed in the complaint were delays in transfer, a second CT scan and operation, lack of communication from surgical team, the perception there was no emergency/out of hours interventional radiology cover and why the patient was not put on a ventilator when in ITU.

The complaint response gave a detailed account of the concerns raised relating to delays in transfer, a second CT scan and operation and no additional learning was identified in relation to these concerns. However, learning was identified relating to communication and an action has arisen to address this.

Action:Reinforce with ward sisters and nursing staff the importance of effective communication with relatives.This importance of providing relatives with accurate and up-to-date information has been reiterated at daily staff meeting attended by all medical and surgical Ward Sisters.

Discussed at MSG 10/07/19 and judged death not likely to problems in care


4

Source Description The learning and actions from the investigation Outcome

Serious incidentsSI541 Fall with harm

An 80 year old gentleman was admitted tohospital with diarrhoea, dehydration and pain.

He was mobile on the ward with a walking stickand had previously had no history of falls.

He fell on the ward sustaining a hip fracture. Hereported to the staff that he fell after moving anobservation machine which was blocking thebathroom door.

He went to theatre for a repair of his hip fractureand unfortunately his condition deteriorated andhe died several days after his operation.

It was noted that the patient was transferred between wards late at night and further information was requested from the patient flow team.

Equipment for monitoring patients was plugged in to charge and obstructed the toilet door causing a patient with a walking stick to lose his balance and fall as he moved the machine out of the way. The ward staff were focused on charging the monitoring equipment at the most convenient point on the ward and did not consider the position of the equipment in relation to the toilet door.

Actions include:1. All wards to be reminded to maintain a clear environment allowing clear access to

toilets/bathrooms in line with the Inpatient Falls policy and to ensure that allequipment plugged into wall sockets to charge are positioned so as not to blockdoors or patient walkways. This will be communicated in the October/November issueof the Quality & Safety bulletin.

2. Introduce peer review walk around specifically for observing and reviewingenvironmental hazards, such as clutter and positioning of equipment, and also toreview practice and documentation relating to falls.

Other actions:A new patient flow policy and ‘Ward Rhythm of the Day’, both of which support the improvement work to reduce movements of patients late at night (particularly the elderly frail) has been implemented.

Work in development includes:A weekly flow dashboard from Epic is planned which will monitor timeliness of patient admissions, discharges, transfers and outlier repatriation and track improvements. QSC will receive a follow-up report in six months (April 2020).

Discussed at MSG 10/07/19 and agreed that death was likely to be due to problems in care.


5

Appendix B: UCLH Mortality Surveillance quarterly monitoring report April 2017 to September 2019

Please be aware that the data is updated quarterly to reflect the number of SJRs completed in subsequent monthsKEY A/B/CA = Number of deaths to be reviewed B = numbers reviewedC = Death judged more likely than not to be due to problems in care by MSGPlease note: complaints are logged when received and are reviewed by MSG when closed. There is usually a delay between date of death and receiving a complaint, and a further period of time for the review – this is why there can be a discrepancy between the table on page 2 and this table.

Number of deaths to be reviewed /Numbers reviewed/Death judged more likely than not to be due to problems in care by MSGQuarter Stillbirths

Neonatal deaths

Childhood deaths

(under 18)Maternal deaths

Where the coding was

elective admission or eligible for review

under criteria as set out in the policy

(SJR)

Following hospital acquired

thrombosis

With a learning disability

(All referred

to LeDeR)

With severe mental illness/ whilst

detained under the

MHA

Mortality outlier

notification

Subject to serious incident

investigation

Where a complaint has been received

Where bereaved families

and carers, have

raised a significant concern

about the quality of

care provision

In the community within 30 days of

discharge

Not under UCLH care at the time

of death but where another organisation

suggests that the trust should

review the care provided to the

patient in the past

2018/19Q1 12/12/0 23/23/0 0/0/0 1/0/tbc 1/0/tbc 0 2/2/0 4/4/0 0/0/0 0/0/0 1/1/0Q2 17/17/0 25/23/tbc 0/0/0 2/1/tbc 0/0/0 0 3/3/0 5/5/0 0/0/0 0/0/0 1/1/0Q3 13/13/0 24/24/0 0/0/0 0/0/0 0/0/0 0 1/1/0 6/6/0 0/0/0 0/0/0 0/0/0Q4 15/15/0 27/22/tbc 0/0/0 0/0/0 0/0/0 0 2/2/0 6/5/0 1/0/tbc 0/0/0 2/2/0

2019/20Q1 9/9/0 28/25/tbc 0/0/0 tbc/tbc/tbc 0/0/0 0 3/3/0 1/1/0 0/0/0 0/0/0 0/0/0Q2 5/5/0 42/3/tbc 0/0/0 tbc/tbc/tbc 0/0/0 0 2/2/1 6/4/tbc 0/0/0 0/0/0 0/0/0


6

Appendix C

Breakdown of how deaths are reviewed including SJR and existing processes

3.1 Stillbirths, neonatal deaths, childhood deaths (under 18) maternal deathsThese are investigated by the Women’s’ Health division via the multidisciplinary Clinical Incident Review Group (CIRG) and/ or the Child Death Panel where a child is involved. The trust also reports perinatal mortality to a national database using the Perinatal Mortality Review Tool (PMRT). Any serious incidents are investigated according to the Trust framework. For quarter two, there were six cases eligible for notification and a breakdown of these can be found in Appendix D.

3.2 Deaths where the coding was elective admission (SJR) These deaths were reviewed using the structured judgement review template. Case record reviews can identify problems with the quality of care so that common themes and trends can be identified, which can help focus our quality improvement work. Review also identifies good practice that can be spread (see section 5 for more information). This also includes a sampling of those deaths where a patient had sepsis and AKI.

3.3 Deaths where the coding was AKI and/or Sepsis (SJR)A sample of these deaths are reviewed where the patient may have had Sepsis or AKI or an additional concern may have been raised and the death was not included in the elective coding. These deaths are reviewed using the structured judgement review template.

3.4 Deaths following Hospital Acquired Thrombosis (HAT) (SI)For quarter two 2019/20 there were no recorded deaths following hospital acquired thrombosis. Such deaths would normally be investigated as a serious incident.

3.5 Cardiac Arrests Rapid Review (CARR)For quarter two 2019/20 no deaths were reported following a cardiac arrest for which a Cardiac Arrest Rapid Review (CARR) was eligible. This excludes cardiac arrests in the critical care unit and patients admitted to the Emergency Department with a cardiac arrest.

3.6 Deaths of patients with a learning disability (LD) (SJR)All LD deaths should be referred to the Learning Disability Mortality Review Process for Adults. However it is not possible currently to identify patients with learning disabilities who have died from Epic and other options are being explored.

3.7 Deaths of patients with severe mental illness/whilst detained under the Mental Health Act (SI)For quarter two 2019/20 there were no deaths noted for a patient coded for severe mental health illness. Such deaths would normally be investigated as a serious incident

3.8 Mortality outlier notification (SJR)For quarter two 2019/20 there were no notifications received for mortality outliers.


7

3.9 Deaths subject to serious incident investigationSerious incident investigations are more in-depth than case record review as they gather information from many additional sources and are subject to root cause analysis and individualised action plans are developed where appropriate. No SJRs led to a serious incident investigation. There were two serious incidents declared in quarter two that related to a patient who has died. There was one serious incident completed in quarter two.

3.10 Complaints received in July 2019 to September 2019 in which clinical care concerns were raised For quarter two 2019/20 two complaints were received from next of kin of deceased patients raising concerns about clinical care.MSG has reviewed 8 closed complaints over the meetings in quarter two;

Four deaths were judged not to be due to problems in care. Two deaths that were reviewed are to have an SJR which have not yet been

completed Two complaints raised a concern that did not relate to the circumstances of the death

of the patient.

3.11 Significant concerns raised via bereavement - end of life care survey/letterConcerns can be raised by relatives via the bereavement team, using the end of life care survey or directly with the trust. If concerns are not able to be addressed by the clinical team, families are advised how to formalise their complaint.

3.12 Deaths which occurred in the community within 30 days of discharge Currently we rely on these being notified informally and we have not received any notification for the period of July 2019 – September 2019.

3.13 Deaths which occurred where at the time of death the patient was not under the care of UCLH but where another organisation suggests that that the trust should review the care provided to the patient in the past.We have not received any notification for the period of July 2019 – September 2019


8

Appendix D

Overview of the overall SJR scores for quality of care

Poor6%

Adequate17%

Good67%

Excellent10%

1 (Very Poor)

2 (Poor)

3 (Adequate)

4 (Good)

5 (Excellent)

Overall SJR scores April - September 2019

Poor10%

Adequate8%

Good61%

Excellent21%

1 (Very Poor)

2 (Poor)

3 (Adequate)

4 (Good)

5 (Excellent)

Overall SJR scores for SJRs completed during Q2 2019/20

There were four SJRs rated as poor for overall score for this quarter. Any SJR that highlighted poor care was subject to a second review as per the quality assurance process and if agreed was put forward to the Mortality Surveillance Group (MSG) for discussion.

Currently there are four SJRs that have identified sub optimal care; three which are currently undergoing a second review, and one was discussed at MSG where there were no problems in care identified that led to the patient’s death

Very poor (1)Poor (2)

Adequate (3)

Good (4)

Excellent (5)

0 4 3 23 8Very poor (1)

Poor (2)

Adequate (3)

Good (4)

Excellent (5)

0 2 5 20 3


9

Appendix EPerinatal Mortality Review ToolA brief synopsis of the eligibility of cases suitable for Perinatal Mortality Review Tool (PMRT) review is as follows: https://www.npeu.ox.ac.uk/pmrt

Reported cases should be notified, surveillance completed and PMRT commenced with a draft report available within 4 months of the date identified / notified to the system.

The PMRT has been designed to support the review of the following perinatal deaths: Late fetal losses between 22+0 and 23+6 weeks of pregnancy showing no signs of life All stillbirths (24+0 weeks gestation and above) Fetal losses where the gestation is not known and birth weight is over 500g All neonatal deaths from 22+0 weeks’ gestation where death occurs up to 28 days after birth All neonatal deaths where the gestation is not known and the birth weight is over 500g Post-neonatal deaths where the baby is born alive from 22+0 but dies after 28 days following

neonatal unit care.

The PMRT is not designed to support the review of the following perinatal deaths: Termination of pregnancy at any gestation Babies who die in the community 28 days after birth or later who have not received neonatal

care Babies with brain injury who survive

Parental input into PMRT review:With the introduction of the PMRT process a generic information letter was produced by the Women’s Health Safety Team and bereavement teams. This letter is given to women and families following a loss to support the verbal conversation about the PMRT review process and reminding them that their input is valuable.

100% of women in this report who suffered a loss were given the letter outlining how they can input into the review of their and their baby’s care.

Summary of cases eligibleFor Q2 2019/2020 there were 7 eligible cases identified:

2019 July August September TotalLate miscarriage 0 0 0 0Stillbirth 1* 1 0 2NND 2 0 1 3Post-neonatal death 0 0 2 2Total 3 1 3 7

All 7 cases (100%) had MBRRACE notification and surveillance completed within 1 month of the death occurring.

1 of the cases was referred to HSIB for investigation – denoted by * (intrapartum stillbirth); the PMRT will be completed following completion on the investigation report as a joint exercise between UCLH and HSIB.

All 6 non-HSIB cases have PMRT reviews commenced within four months of the death occurring with a draft report on file. All are scheduled for an external review to complete the PMRT process at the end of October 2019.


https://www.npeu.ox.ac.uk/pmrt

10

Appendix E continuedBrief overview of completed case reviews

Brief description of cases

Case review – Summary of outcome, learning Actions

Case 1Intrapartum term stillbirth

A patient expecting her fifth child called the hospital in labour and was invited for review at the Maternal Fetal Assessment Unit where the midwife heard what she thought was a very slow fetal heart rate. The patient was escalated and transferred to the Labour Ward where an ultrasound scan of the fetal heart saw no movements. The Consultant Obstetrician undertook a ventouse delivery with consent for neonatal resuscitation. Despite advanced resuscitation no heart rate was regained.

This case was reviewed at CIRG and no contributory care issues identified.

Referred to HSIB.

Case 2IUD / stillbirth

A woman arrived in the hospital reporting contractions at 35 week’s gestation. On arrival no fetal heart could be identified. The woman was induced in line with guidance. NB this woman speaks no English and discussions were supported by language line.

This case was reviewed at CIRG and no contributory factors identified.

There were some safeguarding concerns which were referred appropriately but no actions required.

PMRT review only.Case 3Neonatal deathKnown congenital anomalies

A patient was booked with a twin pregnancy, each with their own separate placenta with its own separate inner and outer membranes (dichorionic diamniotic twins). The twin had multiple congenital abnormalities found antenatally and further abnormalities were identified postnatally. Twins delivered by elective caesarean section this twin was intubated at birth but had severe underdevelopment of the lungs. In spite of ventilating on high pressures and 100% oxygen, the baby was not saturating well. The baby’s clinical condition meant that escalating of care or surgical care was not appropriate. With parental consent (and following discussion) intensive care was re-directed. Baby was extubated at 18.30 hrs and he died peacefully with parents at 0245hrs on 15/7/2019.

This case was reviewed at CIRG and no contributory factors or service delivery issues identified.

PMRT review only.

Case 4Neonatal deathKnown congenital anomalies

A woman booked with UCLH and at her anomaly scan, large echogenic kidneys were identified with no liquor around the baby. The woman was referred to and monitored by the fetal medicine clinic and counselled extensively. The woman and team opted for elective caesarean section because of the likelihood of pulmonary hypoplasia and poor prognosis.

At birth the team were unable to ventilate the baby to maintain saturations and care was redirected; the infant was extubated and spent time with his parents before dying at 39 minutes of age.

This case was reviewed at CIRG and no contributory factors or service delivery issues identified.

PMRT review only.


11

Brief description of cases

Case review – Summary of outcome, learning Actions

Case 5Neonatal deathCongenital CMV infection

Booked at another hospital; transferred to UCLH with severe early onset growth restriction. Investigations showed no identifiable reason. Delivered at 26+6 due to ongoing concerns about growth. Died at 27 days of age from CMV (cytomegalovirus) pneumonia.

NB the woman had tested positive for CMV in pregnancy and the sample was sent to the National Reference Laboratory who said the sample was negative for CMV. Investigations after the death showed the reference laboratory had mislabelled another sample with the woman’s details and the result given therefore was not for this baby’s mother.Review of care, incident notified to reference laboratory who have undertaken an investigation. Because of the early onset growth restriction and CMV infection of the lungs, it was considered that this baby had a very poor prognosis.

PMRT review only.

Case 6Post-neonatal deathKnown congenital anomalies

Infant born at 39+2 week’s gestation by elective caesarean section at term. Diagnosis antenatally with multiple congenital abnormalities:

Dandy Walker malformation (structural brainanomaly)

Possible hypoplastic left heart Abnormal kidneys

The baby was confirmed with a number of anomalies post-delivery and had a rupture of one eyeball; the reviewing ophthalmologist felt that it was likely due to anterior segment dysgenesis, possible in the context of dandy walker syndrome.

The infant died at 7 weeks of age, the death certificate records the cause of death as:1a Chromosome 6p deletion1 b Dandy walker syndrome1 c Co-arctation of aorta2 Rupture of left eye

MBRRACE surveillance completed and awaiting completion of PMRT.


1

AUDIT COMMITTEE (AC)

Minutes of the meeting held on Tuesday 16th July 2019

Present:Audit Committee Members Rima Makarem Non-Executive Director and Chair (RM)Althea Efunshile Non-Executive Director (AE)Harry Bush Non-Executive Director (HB)Non-MembersVicky Clarke Deputy Director of Finance (VC)Tim Jaggard Finance Director (TJ)Craig Wisdom Deloitte, External Audit (CW)Neil Thomas KPMG, Internal Audit (NT)Jack Stapleton KPMG, Internal Audit (JS)Erin Sims RSM, Counter Fraud (ES)Cathy Mooney Director of Quality and Safety (CM), for items 4.4, 4.5 and 5Matthew Hall Head of Information Governance (MH)Denise Cheung Finance Analyst, Minutes (DC)Pia Larsen Director of Procurement (PL), for item 4.1Adrian Buckingham Deputy Director of Procurement (AB) for item 4.1Jane Foley Head of ICT records and Information Governance for item 4.7Rachel Stoukas (for Karin Roberts) Trust Administrator

Matters Covered

1. Apologies for AbsenceJane Collins

2. Minutes of the Meeting held on 21st MayThe minutes were agreed.

3. Matters Arising

AC agreed to close the following MA as complete: MA 477, 478

4. Other Reports

4.1 Waivers report

PL presented the latest report on waivers. PL noted that the waiver process was being reviewed and improved and that a document is being created which provides guidance on waivers and providing further details regarding the public procurement requirements. The intention is for the process to make it easier for users to take the right steps in the procurement process to reduce the need for waivers. A new smart form is being


2

Matters Covered

developed which will act as a screening step to filter out purchases that do not require a waiver but where a different procurement process is required.

RM asked if the new form would make it more difficult for users. AB responded that the new process will make it easier for users and allow procurement to recommend different options, giving them the right advice before any work on a waiver is progressed.

HB asked if the same process would have to be followed for a repeat waiver and queried whether or not a fast-track option was possible. PL confirmed that procurement apply a sensible logic for these cases and that for ongoing annual requirements, e.g. rent, end users are encouraged and coached to complete the waiver for a period of time.

AE asked how the new form will deal with repeat waivers. AB confirmed that they will need to complete the form to cover a length of time but will have to top this up after the period or value is exceeded. PL added that it is important to see the repeat waivers to identify areas where issues are not being solved at source. TJ added that the form needs to be user-friendly and designed to distinguish between ongoing contractual agreements and one-offs.

AB stated that guidance had nearly been completed that would provide more guidance on waivers, details regarding the public procurement requirements and the process to undertake when completing a waiver.

4.2 Finance metrics and finance process improvement

VC presented the report. She highlighted that there had been some focus on aged debtors. She highlighted that meetings needed to be arranged with other parties to negotiate exchanges (of payables and receivables) to clear some of the large balances.

With regards to creditors, targets are not being met. This is partly due to issues in the accounts payable team where there is a backlog since the implementation of Cloud and where time is being spent on escalations, diverting from the day to day invoice processing.

Agency spend is fairly stable, albeit at a higher level than in 2017/18.

VC also introduced an overview of a proposed finance process improvement programme and requested that the Audit Committee supports and provides scrutiny of the progress and pace of the programme. HB asked if the trust had considered why this had not worked before. TJ said that processes can have a far reach across teams but that there is currently a culture whereby individual teams follow the process they think best, or have inherited from predecessors. He said there is a need for standardisation. HB asked if this could be delivered without additional resource. VC responded that it was difficult to assess any resource requirements without having completed an exercise of process mapping and identifying issues and resolutions. Some blockages in the processes can be overcome with little cost, for example, electronic invoicing whereas


3

Matters Covered

others, such as automation of parts of processes would inevitably have an investment requirement. The key would be in reducing the escalations to allow the team to feel that they can make progress on the day to day, BAU work.

RM asked if the slow system was a temporary issue. VC responded that other Trusts who have implemented the system have the same issues and that the Trust is in contact with NEP and other NEP Trusts to look for ways to mitigate this.

RM agreed that the process improvement programme should be a standing agenda on the audit committee agenda.

4.3 Raising concerns annual update

BM introduced the report. He highlighted that there had been an increase in the use of the Guardian service which was very positive and that it has been good value for money. He noted that as the contract was due to end soon, it was important to evaluate and consider options which he considered to be:

1. In-house or2. A hybrid model of an external guardian service but with the system function in-

house. This model has been used in many Trusts that have been identified as adopting best practice by the CQC.

An options paper and recommendations would be taken to the Board.

BM continued by providing an overview of the cases outlined in the Appendix to the paper. RM asked if there had been a visible impact of the service. BM responded that awareness of the service had increased, that the service supported a good relationship with the unions and that it was good value for money at £200 per case.

AE asked if the pattern of referrals had changed. BM said that the referrals pattern was reflecting an awareness that staff could use the service to help with difficult relationships at work and that the guardian service is able to refer individuals to psychology services, unions or occupational health. He said that the Trust is working on gathering better data from the Guardian service in terms of referral type whilst maintaining the important independence of the service. HB noted that the hybrid model risks detracting from being perceived as independent. BM agreed but said that a fully independent service would cost much more recurrently as the current service is at a heavily discounted rate. He noted that the CQC were interested in how many guardians we had and that we should seek to understand best practice.

4.4 Learning from deaths (MA 467)

CM presented the report. She outlined that the Trust needs to develop an M&M template to record activity and send to the centre. She said that the issue is not that teams are not undertaking the learning, rather that this is not being recorded for Trust level or external oversight. CM said that the team will attend current M&M reviews to see how they currently work with the aim of developing a Trust-wide, rather than local


4

Matters Covered

process.

4.5 Review of never events (MA 476)

CM presented the report. 12 never events had occurred during 2018/19 and the team was in the process of getting to the root cause of these to identify themes and trustwide actions. Examples of such themes included the need to re-embed the surgical pause as part of normal practice and team work and multi-tasking.

4.6 DSP Toolkit update (MA 479)

MH confirmed that the trust is on course to meet the improvement plan by September 2019 but that it is not currently compliant. A number of policies that were due to be approved in June will now be approved in August.

RM asked if the new version of the toolkit increased the requirements for compliance. MH responded that there are more essential requirements with regards to cyber-security and GDPR requirements are more robust. He confirmed though that this did not place additional requirements on the trust as the trust is already compliant.

AE noted that compliance with Information Governance training is 83% with a toolkit target of 95% by March 2020. MH said that this training is in the process of being updated and is expected to be ready by the end of August. As such, he wasn’t encouraging staff to complete this training at this stage. He noted that 95% compliance will be challenging but possible and that it is embedded into the appraisal process.

4.7 2018/19 Audit Update – Missing Patient Notes

JF provided an update on issues that had arisen as part of the 2018/19 Quality Audit. She highlighted that the team were not aware of the audit and that a request for notes went directly to the A&E department general manager who was relatively new. This GM did not escalate so the medical records team were not aware. CW noted that multiple requests were made in March and April before this was reported in May. He said that they were happy to add a step to engage directly with the medical records team.

4.8 Audit Committee Annual Report

RM provided an outline of the report and agreed that if there were not amendments, this could be submitted to the Board.

5. Quarterly risk report

CM presented the report. She noted a high amber risk on training in EPIC, a recurring risk relating to mobile phone signal in areas of the building and a new risk on patients in the cancer pathway where cancer had been identified but no follow through appointment had been made. She confirmed that a task and finish group had been deployed to understand what had happened.


5

Matters Covered

RM asked for a progress update on the washers. TJ said that there are two issues (in endoscopy and in the sterile service unit) but that resolution is on track and that he expected both risks to be cleared by 1st November.

6. Internal Audit

JS summarised the progress report. As no fieldwork had been completed, the report was an update on recommendations and a summary of next steps. The report also included a summary of best practices at other trusts with regards to recruitment, as requested by the Audit Committee. It was agreed that these practices should be reviewed by the new Workforce Committee.

7. Counter Fraud progress

ES introduced the report. She outlined that there had been 8 new referrals since the last committee. RM asked what proactive exercises were occurring. ES said that data analytics work was being undertaken for accounts payable and there was a focus on three key areas of recruitment, invoicing and procurement.

8. Audit Committee Work Programme 2019-20

The Committee reviewed the proposed schedule of reports for 2019/20. CW asked that the item ‘receive/consider the annual audit letter’ be removed as this is no longer relevant.

CW noted that IFRS 16 would be introduced soon so a technical briefing would be needed. RM asked about the need for the committee to understand the requirements of the committee with regards to climate change and sustainability. She suggested it would be helpful to understand best practice before this becomes mandatory. CW said that Deloitte have specialised teams who can help with this. Action: CW to arrange for the Audit Committee to be briefed on how to gain assurance on climate change/sustainability (MA Ref 480)

9. Committee assurance

9.1 Audit committee self-assessment

The self assessment survey results were reviewed.

In response to the responses regarding the timeliness of papers, RM asked that papers be distributed by the Tuesday before Audit Committee (one week before).

With regards to training and development needs, HB suggested that training be provided for members on the more commercial side of the accounts, for example, impairments, changes in accounting policy, provisioning and judgement. RM suggested this be arranged for the last quarter before the final accounts.


6

Matters Covered

9.2 Annual effectiveness of external audit

The committee reviewed the feedback on external audit. RM noted that there was a lot of positive feedback. HB noted that there were many ‘agree/disagree’ which wasn’t easy to interpret. RM suggested that a new category be added for the future such as ‘n/a’.

Date of Next Meeting

9am, Tuesday 24th September 2019, Chairman/CEO Meeting Room, 2nd floor Central, 250 Euston Road


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