wµ o] } }( ] } p v of director… · a7(iii) corporate governance update ts attached 11.26 –...

Public Board of Directors

26 March 2020, 11:00 to 11:33Board Room, Culture Centre, RVI

Agenda

1Public Board of Directors Agenda

Attached

A0 BoD Public Agenda 26 March 2020.pdf (3 pages)

2Business Items 9 minutes

2.1Apologies for Absence and Declarations of Interest

Verbal

Chairman

2.2Minutes of the Meeting held on 30 January 2020 and Matters Arising

Attached

Chairman

A2 NuTH Public BoD Minutes 30 Jan 20 DRAFT.pdf (13 pages)

2.3Meeting Action Log

Verbal

Chairman

2.4Chairman's Report

Attached

Chairman

A4 Chairman's Report ‐ March 2020.pdf (4 pages)

2.5Chief Executive's Report

Attached

Chief Executive Officer (CEO)

A5 CEO Board report ‐ March 2020.pdf (8 pages)

3Pa ents 8 minutes

3.1Patient Story

Attached

Director of Quality and Effectiveness(DQE)

A6 (i) Patient story ‐ March 2020.pdf (3 pages)

3.2

Medical Director's Report, includingAttached

DQE

A6 (ii) Medical Director's Report ‐ March 2020.pdf (4 pages)

3.2.1Guardian of Safe Working Report

Board Reference Pack (BRP)

3.2.2Learning from Deaths

Attached

A6 (ii)b Board Learning from Deaths ‐ March2020.pdf

(6 pages)

3.2.3Consultant Appointments

BRP

3.3Executive Chief Nurse Report

Attached

DQE

A6 (iii) Executive Chief Nurse Update March 20.pdf (14 pages)

3.4Healthcare Associated Infections (HCAI) Director of Infection Prevention and Control(DIPC) Report Attached & BRP

DQE

A6 (iv) Healthcare Associated Infections ‐DIPCReport ‐ March 2020.pdf

(6 pages)

4Performance 9 minutes

4.1Integrated Board Report ‐ Quality, Performance, People & Finance

Attached

DQE & Finance Director (FD)

A7 (i) Integrated Report Cover Sheet ‐ March2020.pdf

(1 pages)

A7 (i) Integrated Board Report ‐ March 2020.pdf (26 pages)

4.2Update from Committee Chairs

Attached

Committee Chairs

A7 (ii) Update from Committee Chairs.pdf (4 pages)

4.3Corporate Governance Update

Attached

Trust Secretary (TS)

A7 (iii) Corporate Governance Update ‐ March2020.pdf

(8 pages)

A7(iii) Appendix 1 FT4 Self Certification Q3.pdf (2 pages)

A7(iii) Appendix 2 G6 Self Certification Q3.pdf (1 pages)

5People 2 minutes

5.1People Update

Attached

Director of HR (HRD)

A8 People Update ‐ March.pdf (7 pages)

6Items to Approve 2 minutes

6.1NIHR CRN NENC Annual Business Plan and Annual Financial Plan 2020‐21

Attached & BRP

TS

A9 CRN NENC Annual Business Plan ‐ March2020.pdf

(9 pages)

7Items to Receive 1 minutes

7.1Date and Time of Next Meeting:Public Board Meeting: Tuesday 26 May 2020 in the Board Room, Freeman Hospital Verbal

Chairman

7.2To resolve to exclude members of the press and public in accordance with the HealthService Act 2006 (Schedule 7 Section 18 (E)) (as amended by the Health and Social CareAct 2012) and in view of publicity being prejudicial to the public interest

Verbal

Chairman

PUBLIC TRUST BOARD OF DIRECTORS’ MEETING

Thursday 26 March 2020 in the Boardroom, Culture Centre, RVIStart time 11.00am

AgendaItem Lead Paper Estimated

TimingsPage No

Business ItemsA1 Apologies for Absence and Declarations

of InterestChairman Verbal

A2 Minutes of the Meeting held on 30 January 2020 and Matters Arising

Chairman Attached 4

A3 Meeting Action Log Chairman Verbal

11.00 – 11.02

A4 Chairman’s Report Chairman Attached 11.02 – 11.04

17

A5 Chief Executive’s Report CEO Attached 11.04 – 11.09

21

Patients

A6(i) Patient Story DQ&E Attached 11.09 –11.11

29

A6(ii) Medical Director’s Report, including:a. Guardian of Safe Working Reportb. Learning From Deathsc. Consultant Appointments

DQ&E AttachedBRPAttachedBRP

11.11 – 11.13

32

36

A6(iii) Executive Chief Nurse Report DQ&E Attached 11.13 – 11.15

42

A6(iv) Healthcare Associated Infections (HCAI) Director of Infection Prevention and Control (DIPC) Report

DQ&E Attached &BRP

11.15 – 11.19

56

Performance

A7(i) Integrated Board Report - Quality, Performance, People & Finance

DQ&E &FD

Attached 11.19 – 11.24

62

A7(ii) Update from Committee Chairs Committee Chairs

Attached 11.24 – 11.26

90

1/3 1/119

Item Lead Paper EstimatedTimings

Page No

A7(iii) Corporate Governance Update TS Attached 11.26 – 11.28

93

PeopleA8 People Update HRD Attached 11.28 –

11.30104

Items to Approve

A9 NIHR CRN NENC Annual Business Plan and Annual Financial Plan 2020-21

TS Attached & BRP

11.30 –11.32

111

Items to Receive

A10(i) Date and Time of Next Meeting:

Public Board meeting: Tuesday 26 May 2020 in the Boardroom, Freeman Hospital

Chairman Verbal

A10(ii) To resolve to exclude members of the press and public in accordance with the Health Services Act 2006 (Schedule 7 Section 18(E)) (as amended by the Health and Social Care Act 2012) and in view of publicity being prejudicial to the public interest.

Chairman Verbal

11.32 – 11.33

Key: BRP = document contained within a separate Board Reference Pack

2/3 2/119

THIS PAGE IS INTENTIONALLY BLANK

3/3 3/119

Agenda item A2

________________________________________________________________________________________________Minutes of the Trust Public Board Meeting – 30 January 2020Trust Board – 26 March 2020

DRAFT MINUTES OF THE BOARD OF DIRECTORS MEETING HELD ON30 JANUARY 2020

Part A: Public Session

Present: Professor Sir J Burn ChairmanDame J Daniel Chief Executive OfficerMr A Welch Medical Director/Deputy Chief

ExecutiveMr M Wilson Chief Operating OfficerMs M Cushlow Executive Chief NurseMrs A Dragone Finance DirectorDr V McFarlane-Reid Director of Enterprise & Business

DevelopmentMr D Stout Non-Executive DirectorProfessor K McCourt Non-Executive DirectorMr K Godfrey Non-Executive DirectorMr S Morgan Non-Executive DirectorProfessor D Burn Non-Executive DirectorMr J Jowett Non-Executive DirectorMs J Baker Non-Executive DirectorMrs P Ritchie Associate Non-Executive Director

In Attendance:

Mrs C Docking, Assistant Chief ExecutiveMrs D Fawcett, Director of Human Resources (HR)Mr G King, Chief Information OfficerMrs K Jupp, Trust Secretary Mrs F Darville, Deputy Trust Secretary [Minutes]Dr L Pareja-Cebrian, Director of Infection Prevention and Control (DIPC), Agenda item 20/02(iv) onlyMs J Gordon, Patient, Agenda item 20/02(i) onlyMs M Burnside, Nurse Specialist, Agenda item 20/02(i) only

Observers: Mrs P Yanez, Public GovernorMr D Black, Member of the PublicMr S Brice, Assistant Director of PharmacyMrs T Adegbie, Insight Programme ParticipantMr A Bailey, Outico Limited

Note: The minutes of the meeting were written as per the order in which items were discussed.

20/01 BUSINESS ITEMS

i) Apologies for Absence and Declarations of Interest

1/13 4/119

Agenda item A2


Apologies were received from Mrs A O’Brien, Director of Quality and Effectiveness and Mr R C Smith, Director of Estates.

The Chairman introduced Mrs Pat Ritchie, Chief Executive of Newcastle City Council, as a new Associate Non-Executive Director for the Trust.

There were no additional declarations of interest noted at this time.

It was resolved: to note the apologies listed and that no additional declarations of interest were made.

ii) Minutes of the Meeting held on 28 November 2019 and Matters Arising

The minutes of the meeting were agreed to be an accurate reflection of the meeting, subject to the following minor amendments: Page 9: In reference to the LEDER panel paragraph, the removal of the words

‘dedicated post’ and replacement with ‘lead consultant’. Page 11: The reference to ‘plastic’ surgeons be removed from the fourth bullet point.

Under Matters Arising, Mr Jowett queried whether any further actions had been taken following the establishment of the Trust Climate Change Group to which the Deputy Trust Secretary advised that a presentation had been scheduled for the June Board Development Session to brief Board members.

There were no additional matters arising from the previous meeting.

It was resolved: to (i) receive the minutes as an accurate record of the meeting, subject to the amendments outlined, and (ii) note the additional matter arising from the previous minutes.

iii) Meeting Action Log

It was agreed that all actions on the log were now complete.

It was resolved: to note the action log position.

iv) Chairman’s Report

The Chairman presented the report and noted the salient points.

It was resolved: to receive the report.

v) Chief Executive’s Report

The Chief Executive presented the report and outlined the following key points to note: The policy and priorities of the new Government had started to be communicated and

further detail was anticipated, particularly around the financial framework and

2/13 5/119

Agenda item A2


performance targets. The Trust was well represented nationally regarding the discussions in these areas.

The organisation continued to perform well despite winter pressures and increasing demand for services. Board members extended their gratitude to all staff for continuing to deliver safe and effective care to patients.

Work continues to develop the Flourish programme to engage further with front line staff. A further update would be provided to the Board in due course.

The Chief Executive became a member of NHS Expert Panel on Climate Change to advise on policy and guidance in reducing NHS organisations’ impact on the environment. This followed the climate emergency declaration made by the Trust in the summer of 2019.

The Trust recently welcomed a second visit by Dr Sam Roberts, the Chief Executive of the Accelerated Access Collaborative, who toured some of our innovative and pioneering services. The visit highlighted our translational research benefiting patients, and their development from ‘bench to bedside’. The Trust has been approached to be one of three test centres for innovation across the country.

Funding options through working with industry partners were being explored in relation to robotic surgery.

In relation to environmental sustainability, Ms Baker advised that the Trust’s Charitable Funds Committee was working with its investment fund managers to prioritise sustainable and ethical investment utilising the Environmental, Social and Corporate Governance (ESG) framework. It was suggested that this be extended to further Trust business where possible.


20/02 PATIENTS

i) Patient Story

The Executive Chief Nurse introduced Mrs Jenny Gordon, a former Trust patient, and Ms Melissa Burnside, Nurse Specialist.

Mrs Gordon relayed her experience to the Board, noting the following points: As a busy mum of two children, who was usually fit and well, Mrs Gordon advised that

she started to feel poorly and her condition deteriorated when she developed a cough and pain on her right side. Her husband persuaded her to attend a Walk in Centre and she was then referred to Ambulatory Care.

Following a short wait, she was triaged and was advised that she would be admitted overnight so she could be observed further. Mrs Gordon advised that she was administered oral antibiotics and had a chest x-ray following a diagnosis of pneumonia. Mrs Gordon extended her thanks to all of those staff who cared for her and made her feel safe, noting that due to their calm demeanour, she was initially unaware of how seriously ill she was.

3/13 6/119

Agenda item A2


Shortly after this, Mrs Gordon was transferred to the High Dependency Unit (HDU) and subsequently the Intensive Care Unit (ICU) due to the severity of her condition, which was diagnosed as sepsis two days later. Mrs Gordon advised that all staff who were involved in her care delivered high quality care and compassion that she hoped to deliver as a nurse.

The Chief Executive extended the thanks of the Board to Mrs Gordon for relaying her story and noted the continuing national focus on sepsis diagnosis and treatment.

Ms Burnside noted that the Trust’s management of patients with a suspected sepsis diagnosis had evolved significantly since Mrs Gordon was a patient in 2017, particularly regarding early diagnosis and the implementation of electronic rather than manual processes. Further, a pilot exercise was scheduled as part of a Quality Improvement Initiative to improve clarity of documentation for deteriorating patients and increase patient safety.

The Chairman noted the importance of staff expertise in those areas where patients enter the organisation in ensuring appropriate triage.


[Mrs Gordon and Ms Burnside left the meeting at 11.27am].

ii) Medical Director’s Report

The Medical Director/Deputy Chief Executive presented the report, with the following salient points noted: The challenges associated with the delivery of the Trust’s Cost Improvement

Programme (CIP) and the need to explore Quality Improvement (QI) initiatives to identify further efficiencies that also improved quality were noted.

[The Director of Infection Prevention and Control joined the meeting at 11:28am].

The challenges presented by the Junior Doctors contract changes in terms of compliance with working hours, rest and reflection time requirements were noted, particularly given the size of the organisation and increasing demand for services. Some Directorates were impacted more heavily than others were but all have been able to comply with the requirements through more innovative ways of working with Associate Nurse Practitioners and Allied Health Professionals.

Ms Baker queried whether any further detail was available regarding the priorities for the year within the Medical Director Group. The Medical Director/Deputy Chief Executive advised that the report detailed headline priorities and the Board would be kept informed of progress through the routine Medical Director reports. The Director of HR advised that a number of these priorities would be also be monitored as part of the work of the People Committee.

a. Learning from Deaths Report

4/13 7/119

Agenda item A2


The Medical Director/Deputy Chief Executive presented the mandated quarterly report demonstrating the position from October to December 2019. The report provided assurance that the Trust continued to review deaths where and when appropriate and ensure that lessons were learned through the Mortality Surveillance Group.

It was advised that the process would be further strengthened with the introduction of Medical Examiners within the Trust from April 2020. Ms Baker queried whether the Medical Examiner role would be a new or existing role within the organisation to which the Medical Director/Deputy Chief Executive advised the posts would be filled by existing staff. It was anticipated that there would likely be circa 15 staff who would undertake the role performing 1-2 sessions each.

b. Consultant & Honorary Consultant Appointments

The Consultant and Honorary Consultant Appointments were included in the Board Reference Pack (BRP) for information.

It was resolved: to (i) receive the reports and (ii) to note the inclusion of the supplementary report in the BRP for information.

iii) Executive Chief Nurse Report

The Executive Chief Nurse presented the report, noting the following points: The World Health Organisation (WHO) has designated 2020 as the International Year

of the Nurse and Midwife and the Trust will embark on an ambitious calendar of events starting with clinical research and the history of nursing in the Trust.

In relation to the Flu campaign, the Trust achieved the vaccination target of 80% of front line staff and 80% of staff in high-risk areas. Gratitude was expressed to Mr Steven Forster, Clinical Lead/Service Manager Occupational Health, as well as all of the Peer Vaccinators and other staff involved in the campaign. Vaccinations continue to be available and encouraged.

Section 3 of the report provided an update on Nursing and Midwifery staffing. No risks of note were raised with the Trust Board. A reduction in the fill rate for Health Care Assistants (HCAs) had been observed which was noted to be a direct result of the continued targeted work with wards regarding the utilisation of enhanced care, temporary staffing and the significant work undertaken to agree staffing numbers and demand templates.

The senior nursing team have commenced an in depth workforce review. This has a particular focus on the age demographic of the current workforce and predicting future workforce needs. It was expected that this would show some short-term workforce pressures which would necessitate consideration of further international recruitment. A formal paper would be submitted for executive consideration.

Section 4 of the report outlined the quarter 3 position for safeguarding, highlighting progress in areas such as safeguarding training and collaborative working, for example with neuroradiology to ensure appropriate adjustments were made for patients with a learning disability.

5/13 8/119

Agenda item A2


The Trust recently received a visit from Mr Rob Behrens, the Health and Safety Ombudsman, who observed a Trust Complaints Panel meeting and gave positive feedback on the work undertaken by the Trust in relation to complaints.

Board members were reminded that the Picker results from the National Maternity Survey were reported to the Trust Board within the Quarter 2 Patient Experience report in November 2019.

Mr Morgan acknowledged the commencement of recent construction work on the new Oncology Centre in Carlisle, a collaborative endeavour between the Trust and North Cumbria Integrated Care NHS Foundation Trust.

Professor McCourt commented positively on the increasing number of Filipino nurses in achieving the required assessment standards.

The Chief Executive complemented the Executive Chief Nurse on the depth and breadth of the report and assurance provided to the Trust Board in relation to nurse staffing. The importance of celebrating the International Year of the Nurse and Midwife was noted and reference made to the recent IPSOS Mori poll, which highlighted that Nurses were the most trusted profession.

The Executive Chief Nurse advised that NHS Improvement (NHSI) would be coming to visit the Trust in February following positive feedback received on the content of the Board reports in relation to Nurse staffing data. Professor McCourt added that a request had also been made by the Nursing and Midwifery Council to visit the Trust as part of the commonwealth celebration in March.


iv) Director of Infection Prevention and Control Report

The Director for Infection Prevention and Control (DIPC) presented the report and highlighted the following points: There were no cases of MRSA bacteraemia during the month of December 2019 with

no cases having been reported for 16 months. The Trust was on trajectory in relation to MSSA bacteraemia and C.difficile. In relation

to C.difficile, it was advised that the target was set by the Department of Health (DoH) and there had been a change in the criteria therefore it appeared that the Trust was closing the year with more cases than in the previous year but had observed a reduction. The Trust continued to monitor this closely and to progress with improvements in documentation and reviewing outcomes after 30 days.

Regarding Gram Negative Bacteraemia, focus continued on E.coli. A 10% reduction target had been set with good progress being made, albeit the Trust had reported two cases over the target. An increase had been observed in other Gram Negative Bacteraemia, which would continue to be closely monitored with a full review to be undertaken of each case.

Trust staff response to the Flu campaign was reiterated. It was advised that an increased number of patients with flu had been treated by the Trust earlier in the

6/13 9/119

Agenda item A2


year, which was as expected, and numbers had since decreased from the peak at the start of the flu season.

In relation to sepsis, the results of a number of audits had identified that both the awareness and management continued to improve in the Emergency Department and Assessment Unit. Further improvements were being supported.

In regards to antibiotic resistance, the focus remained on reducing unnecessary prescribing.

It was advised that since the report had been produced, one case of MRSA bacteraemia had been reported. The case would be fully reviewed to ensure that lessons would be learnt and shared.

The Director for Infection Prevention and Control provided an update regarding Coronavirus, noting that the Trust was one of the designated national High Consequences Infectious Diseases centres. Robust processes were in place and the Trust was prepared, as always, to respond as required.


[The Director of Infection Prevention and Control left the meeting at 11:52am].

v) Maternity CNST Incentive Scheme Year 2 Report

The Executive Chief Nurse presented the report, advising of the Trust’s progress. The following key points were noted:

The report provides assurance to the Board around the organisation’s ongoing compliance with the standards as set out by the scheme.

The Perinatal Mortality Review had been undertaken as detailed in section 2 of the report and had been completed with no further causes for concern.

The Trust remained compliant with the requirements around workforce planning. A concern regarding neonates staffing had been raised and actioned and would be

closely monitored. In addition, work was planned to mitigate estates concerns relating to the Trust’s

Maternity Assessment Unit.

The Executive Chief Nurse advised that the Director of Quality and Effectiveness continued to closely monitor the data associated to ensure that ongoing compliance with the standards be maintained. The Executive Chief Nurse asked for Board approval of the self-assessment to date which was granted.

It was resolved: to (i) receive the report and (ii) note Board approval of the self-assessment to date.

7/13 10/119

Agenda item A2


20/03 PERFORMANCE

i) Integrated Board Report – Quality, Performance, People and Finance

The Executive Chief Nurse presented the Quality element of the report, with the following salient points to note: Positive progress continued in all areas of Harm Free Care, with reductions observed

in relation to both Pressure Ulcers and Falls. Work to further improve compliance continued within ward teams across the organisation.

In relation to Serious Incidents (SIs) and Never Events, it was noted that the Duty of Candour was applied in all but one case, which was being reviewed and addressed. Lessons learned from SIs continued to be communicated and shared widely across the Trust.

The Trust continued to perform well in the results from the Friends and Family test.

The Chairman queried whether a pattern had been observed in the increase in formal complaints to which the Executive Chief Nurse advised that there had been no specific pattern identified however, work continued to review complaints both individually and as a whole. Further, the complaints process was being reviewed. The Chief Operating Officer presented the Performance element of the report, with the following salient points to note: The Trust’s Accident and Emergency (A&E) Department continued to see an increase

in demand for services but were performing well. The Trust was currently positioned highly for A&E performance however maintaining such a position was challenging. The Trust was experiencing pressure from neighbouring organisations through patient diversions and deflections in to Newcastle Hospitals, which was noted as having a detrimental impact on performance.

A reduction in the number of transfers into the Trust from neighbouring organisations had been observed more recently, which was anticipated to continue.

Trust performance was also impacted in other ways, such as delayed transfers of care, where there was a lack of beds available for patients to be transferred to their local District General Hospital or other care providers. It was noted that there had been a recent improvement in the capture of the data to assist in ensuring transfers occur in a timely manner to support patients in going home earlier.

Mr Morgan queried the level at which ambulance diverts had reduced to which the Chief Operating Officer advised such diverts reached their peak in December 2019 when they rose from 3 per week to between 20-25 per week. It was noted that there had been no diverts in recent days.

In relation to Referral to Treatment targets, particular challenges remained in relation to elective treatment with more referrals received than the Trust had capacity to treat. The Trust, along with national colleagues, awaited the outcome of the national review of clinical standards.

Regarding diagnostic waits, an increase in demand had negatively affected performance, particularly in radiology and endoscopy. In addition to an increase in

8/13 11/119

Agenda item A2


demand, technical advances and workforces shortages have had a contributory impact. Work was ongoing to attempt to remedy this to improve the position.

In relation to cancer, the Trust continued to work in collaboration with the Northern Cancer Alliance around its areas of risk, most notably regarding endoscopy and breast cancer. It was further advised that the national review may have an impact on cancer standards going forward.

The Chief Executive advised that the reset within the NHS in relation to these standards was under consideration nationally

The Director of Human Resources presented the People element of the report, with the following salient points to note: In relation to sickness related absence, following a regional benchmarking exercise in

September, the Trust was ranked highest with the lowest sickness absence. It was noted that targeted interventions were in place within directorates such as community services to assist in reducing sickness absence levels.

An update relating to sustainable workforce planning and progress on the reduction of bank staff utilisation was noted within the report.

Inclusion of an additional table detailing medical job planning was highlighted to provide greater assurance and transparency to the Board regarding Trust performance against the regulator’s standards.

In relation to education and training, it was noted that the Trust continued to be challenged regarding appraisal compliance however it was noted that a pilot utilising Robotic Process Automation (RPA) to aid in reducing the backlog of data to be input would soon commence.

Regarding mandatory training compliance, the Trust continued its regular national dialogue with Electronic Staff Record (ESR) regarding challenges staff face in completing the required national training modules.

The Finance Director presented the Finance element of the report, with the following salient points to note at the end of Month 9: It was anticipated that the Trust would meet all of its financial obligations and targets

by year-end. If this was achieved as predicted, the Trust would receive approximately £14m in Provider Sustainability Funding.

The areas of risk to the achievement of this were advised to be in managing income and expenditure and the delivery of the Cost Improvement Programme (CIP) on a recurrent basis. Shortfalls in CIP had been observed on some projects and therefore the use of non-recurrent funds would be required.

The risk rating was currently 1, which was due to the Trust’s continuing strong cash position.

The Trust has spent £36m of its capital programme.


ii) Update from Committee Chairs

The following updates were provided.

9/13 12/119

Agenda item A2


Audit Committee

Mr Stout, Chair of the Audit Committee, provided the following update: A PFI Energy Update was received. The Committee reviewed the Trust’s risk management processes and was able to

provide assurance to the Board that the management of risk continues to be fit for purpose.

The Committee considered and approved the Trust’s revised Risk Management Policy. The Committee agreed the revised Standing Financial Instructions, Scheme of

Delegation and Standing Orders. The Committee received updates from Internal Audit, External Audit and Counter

Fraud. The Committee also received a number of reports including financial statements

annual reports and debtors and creditors report.

Charitable Funds Committee Mr Godfrey, Chair of the Charitable Funds Committee, provided the following update: The Committee met once since the last meeting of the Board of Directors. An

extraordinary meeting would take place immediately after this meeting to consider two time sensitive grant applications.

The Committee agreed to move the current Newton’s portfolio into a Sustainability Fund.

The Committee considered and approved a number of grant applications including the approval of applications for a Database for Hip Surveillance in Children with Cerebral Palsy and a Clinical Cystic Fibrosis Fellowship.

The Committee received presentations from the two main Investment Fund holders. The Committee also received a number of reports including the Income Report, the

Target Spend Report and a summary of Grants received since the last meeting of the Committee.

Finance and Investment Committee

Mr Morgan, Chair of the Finance and Investment Committee, provided the following update: The Committee continues to be updated on the Trust’s financial performance

including the Income and Expenditure Position, Directorate Performance, the financial Forecast and areas of Risk. It was advised that the Trust was projected to meet its financial obligations at year-end.

The Committee reviewed areas of risk associated with the Trust’s finances, noting in particular the achievement of CIP.

The Trust’s cash balance continued to be strong and was pivotal to the Trust’s ongoing financial security.

The Trust’s future Financial Strategy was essential in delivering financial sustainability.

People Committee Mr Jowett, Chair of the People Committee, provided the following update:

10/13 13/119

Agenda item A2


The Committee received a Workforce Development update, which included a Learning and Education Group Update and the Medical Education Update.

A Flourish update was received which included details of the NHS Staff Survey results. The Committee discussed Mandatory Training and noted in particular the need to

ensure that the Trust remained complaint with Information Governance/Data Security and Protection Training.

The national pensions issue continues to be discussed at each meeting and would be a standing item until resolved.

The Committee continues to monitor Wi-Fi provision in the Education Centre.

Quality Committee

Professor McCourt, Chair of the Quality Committee, provided the following update: The Committee continues to receive updates from the management groups that are in

place in provide assurance. It was agreed that the Committee would consider its overall effectiveness prior to the next meeting of the Committee to ensure that adequate assurance was provided to Board.

The Committee was updated on the organisation’s management of sepsis diagnosis and treatment.

A full and robust discussion took place regarding estates challenges within the Maternity Assessment Unit, which was being addressed via the Trust’s Executive Team.

The Medical Director/Deputy Chief Executive detailed the process in place across the Trust for the approval of New Interventional Procedures.

The Committee received a number of updates including the Serious Incidents Bi-Annual Report and the Leadership Walkabouts Report.

iii) Corporate Governance Update

The Trust Secretary presented the report, advising that a number of updates pertinent to the Trust’s Corporate Governance were detailed in the report.

The Deputy Trust Secretary advised that since the circulation of the report, the date of the next Members Event had changed to Thursday 11 June 2020 and would be centred upon the History of the RVI.


20/04 PEOPLE

i) People Plan Update

The Director of HR presented the report and provided the following update: It was anticipated that the full People Plan would be published in March 2020

following the budget. The results of the Trust’s performance in the NHS Staff Survey were embargoed until

18 February 2020.

11/13 14/119

Agenda item A2


Work to improve the provision of Wi-Fi in the Trust’s Education centres had been agreed and would commence shortly.

The results of the Stonewall Workplace Equality Index had been released with the Trust in joint 40th position. This was an improvement of 109 places and realised the Trust ambition of placing in the top 100. The Board thanked Mrs Karen Pearce, Head of Equality, Diversity and Inclusion for her work in coordinating the submission. The Board of Directors also congratulated Newcastle City Council in achieving top position on the list.

The Trust’s Gender Pay Gap Report would be presented for approval at the February meeting of the People Committee and would be published in March 2020.

The Trust commissioned an Ethnic Pay Report, which was produced by Karen Pearce and Surash Surash, Consultant Neurosurgeon. The report has garnered much interest across the NHS and would be considered by the People Committee at its meeting in February 2020.

An update was provided regarding progress with the Education and Training review, leadership development and apprenticeships.

It was resolved: to i) receive the report and ii) provide delegated authority to the People Committee to review and approve the Trust Gender Pay Gap report prior to its publication.

20/05 ITEMS TO RECEIVE

i) Date and Time of Next Meeting:

The next meeting of the Board of Directors was scheduled for Thursday 26 March 2020 in the Board Room of the Freeman Hospital [subsequently moved to the Board Room, Culture Centre, RVI].

ii) Members of the press and public were excluded from the meeting in accordance with the Health Services Act 2006 (Schedule 7 Section 18(E)) (as amended by the Health and Social Care Act 2012) and in view of publicity being prejudicial to the public interest

The meeting closed at 12.33pm

12/13 15/119


13/13 16/119

Agenda item A4

TRUST BOARD

Date of meeting 26 March 2020

Title Chairman’s Report

Report of Professor Sir John Burn, Chairman

Prepared by Kelly Jupp, Trust Secretary

Public Private InternalStatus of Report

☒ ☐ ☐For Decision For Assurance For Information

Purpose of Report☐ ☐ ☒

SummaryThe content of this report outlines a summary of Chairman activity and key areas of focus since the previous Board meeting.

Recommendation The Trust Board are asked to note the contents of the report.

Links to Strategic Objectives

Patients – Putting patients at the heart of everything we do. Providing care of the highest standard focusing on safety and quality.Pioneers – Ensuring that we are at the forefront of health innovation and research.

Quality Legal Finance Human Resources

Equality & Diversity Reputation Sustainability Impact

(please mark as appropriate) ☐ ☐ ☐ ☐ ☐ ☒ ☐

Impact detail Provides an update on key matters.

Reports previously considered by Previous reports presented at each meeting.

1/4 17/119

Agenda item A4

____________________________________________________________________________________________________Chairman’s ReportTrust Board – 26 March 2020

CHAIRMAN’S REPORT

In years to come, we will look back on this time as a turning point in global society. The coming months will be a test of character and resilience at communal, institutional and personal levels. It is vital that we listen to the Government advice on hand hygiene and social distancing in order to keep everyone – our staff, patients and wider communities safe. The test will be to maintain some semblance of normality in the face of unprecedented disruption.

While radical change and difficult choices will be needed in some areas, we should continue to adhere to due process as best we can. With this in mind, our governance structures will be maintained in an adapted format. Our Board meeting that is normally held in Public will for the first time be held temporarily behind closed doors and with a minimum of members in the room. Our migration to more virtual meetings will be accelerated. The following is my usual report of recent weeks as we need to preserve as much of our day to day activity as possible, not least because we face what might be many months in this strange new existence.

We held our second Shadow Board session in January as part of a Leadership Development Programme for (New and Emerging) Senior Leaders. The session provided an overview of the role and responsibilities of a Trust Board as well as the processes involved in governance for a large teaching Trust. This was followed by an appearance at an interesting roundtable discussion organised by the Health Services Journal to discuss the deployment of precision medicine in oncology. This drew on my knowledge from my academic work and as a member of the NHS Genomic Leaders Forum. An edited version will be published in due course. I was also able to contribute a recorded interview as part of our online leadership training.

We held a successful Members Event on 6th February including presentations by Professors Stephan Schueler and Steven White on the world class work by our surgical teams in management of end stage heart failure with implanted cardiac pumps and treatment of pancreatic damage or disease using islet cell transplants respectively. At the Event we also held our first Governor ‘surgery’ to allow representatives from the Trust’s Council of Governors to talk with members from their constituents. Feedback was extremely positive.

I had the pleasure of announcing the Personal Touch awards on 24th February to recognise the excellence of the care we provide in so many areas and represented the Trust at a North East Chamber of Commerce event which included an interesting discussion on the political climate.

I visited our High Consequence Infectious Diseases Unit at the start of the current Coronavirus outbreak and saw first-hand the amazing services and care that they provide. I also spent time with our fantastic staff in the Eye Clinic at the RVI. I had the pleasure to introduce visitors to our Sustainability Team and had a fascinating behind the scenes look at the complex challenge of refurbishment of wards 26/26A in our Cardiothoracic Centre at the Freeman Hospital.

2/4 18/119

Agenda item A4

____________________________________________________________________________________________________Chairman’s ReportTrust Board – 26 March 2020

Our Board Development Session included training in the important area of cyber security, lessons driven home by one of my social media accounts being accessed due to a weak password which hadn’t been updated for many years. On the other hand, the benefit of social media was brought home by the response to my message after the meeting organised by the British Gastroenterology Society in honour of my friend and colleague Professor John Mansfield, who is soon to retire from his leadership role in academic gastroenterology In Newcastle. He will be greatly missed.

Report of Professor Sir John BurnChairman19 March 2020

3/4 19/119


4/4 20/119

Agenda item A5

TRUST BOARD


Title Chief Executive’s report

Report of Dame Jackie Daniel, Chief Executive Officer

Prepared by Caroline Docking, Assistant Chief ExecutiveAlison Greener, Executive PA to the CEOAndrew Edmunds, Principal Adviser




Summary

This report sets out the key points and activities from the Chief Executive. They include: An overview on the Trust’s response to the coronavirus. Summaries of the Trust’s current performance and financial position, and the planning for

the forthcoming financial year. Headlines from key areas, including Flourish, the work across our Integrated Care System,

and the Chief Executive Officer’s networking activities.

Recommendation The Board of Directors are asked to note the contents of this report.

Links to Strategic Objectives This report is relevant to all strategic objectives and the direction of the Trust as a whole.



(please mark as appropriate) ☒ ☐ ☒ ☒ ☐ ☐ ☐

Impact detail This is a high level report from the Chief Executive Officer covering a range of topics and activities.

Reports previously considered by Regular report.

1/8 21/119

Agenda item A5

____________________________________________________________________________________________________Chief Executive’s ReportTrust Board – 26 March 2020

CHIEF EXECUTIVE’S REPORT

1. CEO OVERVIEW

Over the last few days and weeks our response to the COVID-19 outbreak has risen to be the principal operational and strategic priority for the trust. It is likely, based on advice set out by HM Government, that this is likely to be the case for the forthcoming months.

On 3 March, Government published its COVID-19 action plan setting out the steps being taken to tackle the spread of the virus within the UK. It also provides important information on what we can all do to protect ourselves. This plan, the updates to advice within it, and how these apply to the trust through the national NHS and public health bodies will shape our response. Government is updating its response on a regular basis – sometimes daily – and the trust will always respond to the latest advice and guidance.

Following the publication of this plan, and the World Health Organisation’s declaration of the outbreak as a pandemic, on 11 March we activated our Pandemic Influenza Plan. This is a plan the trust is legally required to hold and keep updated in order to respond in situations of pandemic influenza. It applies also to other, similar respiratory diseases. The trust’s plan was last updated in December 2019, and its activation stands up a series of clear, operational processes to enable an effective response to the pandemic by the trust, including:

Minimising the impact on the trust’s services to patients and staff. Putting in place measures to maintain resources to support essential patient care. Promoting and participating in partnership working on an integrated local response,

planning locally, regionally and nationally as appropriate. Coordinating effective communication to staff, patients and visitors.

As you will be aware, as one five high consequence infectious disease (HCID) units in the UK, we have been treating patients who have tested positive for the virus since the first UK confirmed cases. Using our Pandemic Influenza Plan as a central guide, we are as well equipped to deal with this outbreak as we can be.

Professor Chris Whitty, Chief Medical Officer for England visited our unit on 19th February 2020 and saw first-hand how we are treating the infected patients and discussed the preparations we have in place as a specialist unit capable of dealing with this illness. He was extremely impressed with the facilities we have here and the quality of care we have been providing to patients.

In recent weeks I have regularly visited our HCID unit and have witnessed the exceptional treatment and care of our patients that has been taking place there. We are also the only organisation in the North East (at present) with a laboratory capable of testing for the coronavirus, which I visited on 5 March. The teams in both units have been doing an amazing job, and we are all incredibly grateful for their work.

2/8 22/119

Agenda item A5


The escalation of COVID-19 planning and our operational response has also taken place as we finish 2019/20 and prepare for 2020/21. As set out in the performance and finance section of this report, and later in item A7(i) we expect to end the year in financial balance. 2020/21 will, even without the COVID-19, be a difficult year financially for the trust – one of the most challenging that we have faced in recent memory. As a result, the Executive Team will be adopting an escalated, tighter process for quality, financial and operational performance management to ensure that areas where we are seeing slippage we are taking corrective action as soon as possible.

1.1 Other key headlines

NHS staff survey results

The NHS Staff survey results were published on the 18th February 2020 with around half of employees completing the survey. Newcastle Hospitals was ranked as one of the best places in the country to receive treatment with 90% of staff saying they would be happy with the standard of care provided to relatives and friends and 90% of staff agreeing that the care of patients is our organisation’s top priority. These are results that we can rightly be proud of.

However, there is still a lot of work to do around some of the indicators. This includes addressing the issues some of our black, asian and minority ethnic (BAME) staff had raised about the negative experiences of working here which indicated that bullying, harassment and discrimination from colleagues and managers had deteriorated. Whilst our overall rating for equality, diversity and inclusion benchmarked well against other organisations there are clear areas that we need to take action in. The entire Executive Team is committed to taking the actions necessary over the forthcoming weeks and months.

NHS Operational Planning and Contracting Guidance 2020/21

In light of the current situation regarding COVID-19, the operational planning process for 2020/21 has been suspended.

Marmot review

The Marmot Review 10 years on by Professor Michael Marmot was published in February 2020. The report revealed that life expectancy had failed to increase across the country and, for the poorest 10% of women, it had declined. There was also an increase in the north-south health gap with the largest decreases seen in the most deprived 10% of neighbourhoods here in the North East. This important publication is a clear reminder of how important the organisation’s role with our civic partners is in supporting and driving improvements in health, wealth and wellbeing across the communities we serve.

Great North Care Record (GNCR)

By the end of March we expect the Health Information Exchange (HIE) aspect of the Great North Care Record to go live. This provides the central underpinning of the GNCR’s digital capability and create the space for improved patient experience and outcomes by:

3/8 23/119

Agenda item A5


Providing better informed (clinical) decision making – including improved diagnoses, clarity around medication and allergy history, discharge summaries available to GPs and carers to action, and visibility around future appointments;

Minimising the gaps in a patient’s history; Preventing duplicate investigations or assessments; Reducing phone calls to third parties seeking information – which is especially

important out of hours; and Combining the above to lead to fewer onward referrals and unnecessary admissions.

As well as better access to consolidated patient records for individual patients and health and care professionals and carers, the GNCR also allows for vastly improved population health management, research and evaluation – records within the GNCR have an automatic opt-in for use in research.

This milestone is something that both the trust and its regional partners on the GNCR can be incredibly proud of. It is a huge step in providing real improvements to the health, wealth and wellbeing of the communities we serve, and ensuring that the decisions made on health and care are based on the best possible, joined-up information.

Integrated Care Partnership/Integrated Care System (ICS)/Integration

As previously mentioned, I meet with ICS partners on a monthly basis. Recent discussions have included colleagues from Local Authorities across the North East and North Cumbria. Discussions since the last Board meeting have focussed on developing an ICS-wide governance and operating model, which I will update on once it has been agreed.

Shelford Group

As part of my role as Chair of the Shelford’s Chief Executive Group, alongside other Shelford colleagues I met with William Warr, the Prime Minister’s Special Adviser for Health at 10 Downing Street to discuss a number of national issues including the clinically led review of standards, workforce planning, NHS finances and legislative change.

2. PERFORMANCE AND FINANCE

The latest performance position for the trust is as follows:

Achieved the 95% A&E 4hr standard in February 2020, at 95.9% - the 3rd best performer in the country compared to the 82.8% national average.

Did not achieve the 92% 18 week standard in February, at 87.0%. The national average for February was 82.8%.

Did not meet the 99% 6 week diagnostic standard in February, at 96.0%.

Did not meet 7 of the 8 Cancer Waiting Time (CWT) standards in January 2020.

4/8 24/119

Agenda item A5


The latest financial position – at 29th February – is as follows:

The Trust had an income and expenditure deficit of £74k and a forecast deficit of £0.9 million excluding Provider Sustainability Funding (PSF).

Achievement of the Control Total remains challenging. Since the last Board meeting a number of recovery mitigating actions have been put in place, and the Trust can now be more confident that the Control Total will be met.

The risks remain the non-achievement of recurrent CIP targets, shortfalls in the volume of activity delivered against Plan, cost pressures in waiting list activity drugs and estates, commissioning risks and the ongoing PFI dispute. In addition the measures the Trust needs to put in place to tackle Covid-19 may generate further cost pressures and risk income as activity will be delivered in a different manner. Guidance from NHS England and NHS Improvement on Covid-19 has been issued and is in the process of being worked through for March 2020 onwards.

The Balance Sheet remains strong with a cash balance of £120.0 million; £35.3 million above Plan. That is a higher cash balance than anticipated as it includes £12.4 million of PSF funding that was not included in Plan, and a number of other sums received in advance of expenditure.

Capital Expenditure to 29th January 2020 totals £44.2 million, which is £1.1 million behind Plan.

Further detail is included in the Integrated Board Report.

3. NETWORKING ACTIVITIES

We hosted a number of important visits during the past month. On 31st January 2020 we welcomed Simon Corben, Director and Head of Profession NHS Estates and Facilities, NHS England and Improvement to the Trust. He visited areas with some estate issues which included Maternity and the Emergency Department (ED), as well as the site for the new Paediatric Cardiology Unit and the proposed New Specialist Hospital Building site alongside Richardson Road.

On 11th February 2020 I visited our Great North Childrens Hospital and, in particular, the Paediatric Emergency Department and the Paediatric Emergency Asthma Unit. In the visit I was able to follow a patient pathway which demonstrated the challenges of frontline working and then viewed the patient experience asthma one-stop-shop. The team also demonstrated some of the innovative methods they are dealing with asthma and sepsis and how they are working across the region on this. This was an excellent visit to one of our most important units, and I am grateful for their time in hosting me.

I was asked to participate in the University seminar series on the 18th February 2020. “A conversation with…..” was a question and answer session around the opportunities for Newcastle University Faculty of Medical Sciences and Newcastle upon Tyne Hospitals to

5/8 25/119

Agenda item A5


work together for the benefit of patients, focussing on the Clinical Research and Advanced Therapies teams that are based in the Centre for Life.

As part of the Northern Health Science Alliance New Statesman event, I was part of a panel discussion on 27th February 2020 which looked at the strength of health collaboration within the North, and especially Newcastle, together with how health innovation can be combined with a more aggressive attraction of investment.

Amanda Pritchard, the NHS England and Improvement Chief Operating Officer, visited the Trust on the 4th March 2020. She was speaking at the Leadership Congress later on in the day but took the opportunity to visit the Great North Children’s Hospital – focussing in particular on paediatric oncology services there – as well as our Infectious Diseases Unit and Emergency Department. We highlighted areas within these units where there were issues of concern for her to reflect on how NHS England and Improvement can provide further assistance. She was extremely impressed with the teams she met, and the units and services she saw, and grateful to our staff for taking the time for her to visit. At the Leadership Congress she spoke alongside me about the role of anchor institutions, and we heard some fantastic examples of where our organisation is leading the way nationally in changing current practice to integrate and organise services for the benefit of patients.

4. AWARDS AND ACHIEVEMENTS

Our staff and teams continue to be recognised at both local and national level for the important work they do to enhance patient care and support our services – and staff - across our organisation, some of which I have listed below:

• Our maternity services were, once again, rated among the best in the country for the care provided to mums and babies in the Care Quality Commission’s national maternity survey. The Trust identified as performing ‘better than expected’, in three key areas – during labour and birth, staff caring for you and care in hospital after the birth – and it is a testament to the work of all our teams.

• The RVI and Freeman were ranked third and fourth in the Best UK Hospitals by Newsweek which, for the second year in a row, has partnered with a global data research company to rank the leading hospitals across the world.

• It was great to see Associate Director of Nursing Peter Towns at the NHS book launch of ‘My Daddy is a Nurse’ which aims to challenge gender stereotypes about men in nursing. Peter is one of a number of ‘men in nursing’ ambassadors who has helped to shape and design this book for four to seven-year-olds and the launch marked the beginning of International Year of the Nurse and Midwife 2020.

• The work of Ian Baxter and Cathy Lawson around sustainable anaesthesia and our climate emergency team have both been shortlisted for the BMJ Awards in Environmental Sustainability and Climate Action Team categories.

6/8 26/119

Agenda item A5


In addition, we are also finalists in the Workforce and Wellbeing Team Award for the work we have been doing in partnership with colleagues in the Association of Anaesthetists as part of the joint fatigue working group.

• Our team at the Great North Children’s Hospital has been shortlisted in the ‘Pharmacy and Medicines Optimisation Award’ category of the 2020 HSJ Value Awards for their KidzMedz project, which teaches children to swallow tablets. The awards showcase the most efficient and innovative projects that are helping their wider organisations deliver better services and improved outcomes.

• Occupational therapy assistant Becca Carlson was named ‘Apprentice of the Year 2020’ at the national Unsung Heroes Awards. Becca was put forward by her supervisor, Deb Gardner - an advanced occupational therapist (OT) who works at the RVI’s Great North Children’s Hospital.

Report of Dame Jackie DanielChief Executive 26 March 2020

7/8 27/119


8/8 28/119

Agenda item A6(i)

TRUST BOARD


Title Patient Story

Report of Ms Maurya Cushlow, Executive Chief Nurse

Prepared by Mrs Tracy Scott, Head of Patient Experience




Summary This story shares the journey of the Northern Centre for Cancer Perspectives Partnership Group.

Recommendation The Board of Directors is asked to read, discuss and acknowledge the experience shared in this paper.


Patients We deliver the best possible health outcomes for our patients.

Partnerships Our partnerships provide added value in all that we do. Patient pathways are streamlined through integration and collaboration.

Pioneers We lead the way in delivering world class, cutting-edge diagnostics, treatment and care,

research, education and innovation.



(please mark as appropriate) ☒ ☐ ☐ ☐ ☒ ☒ ☐

Impact detail Involving and engaging patients in research will help ensure we are at the forefront of health innovation and research.

Reports previously considered by This patient/staff story is a recurrent report.

1/3 29/119

Agenda item A6(i)

____________________________________________________________________________________________________Patient StoryTrust Board - 26 March 2020

PATIENT STORY

1. IMPROVING THE NATIONS HEALTH AND WELLBING THROUGH PUBLIC INVOLVMENT IN RESEARCH

Every day, thousands of patients and the public go the extra mile to help make research happen in the UK. Individual researchers or organisations who apply to the National Institute for Health Research for funding will be expected to have a robust plan for patient and public involvement that lay reviewers will scrutinise.

The Northern Centre for Cancer has established a ‘Perspectives Research Partnership Group’ which brings together people affected by cancer to influence cancer research activities and contribute a consumer perspective to research being conducted within the Centre.

‘Perspectives’ are a group of lay volunteers who all have personal experience of cancer. The group, established in June 2014 meets at Maggie’s’ Centre on a regular basis with the overall objectives to:

Promote, provide, monitor and evaluate effective public involvement across various stages of the research process and act as an advisory group for researchers.

Provide a forum for researchers and the public and patient community to formally engage with each other.

To identify training needs and to deliver and evaluate training for group members. To raise awareness of the benefits of public and patient involvement in research. To raise awareness of cancer research.

The Newcastle Upon Tyne Hospitals have a worldwide reputation for the high quality of healthcare provision; however are also well-known for the quality of research. Achieving local and global reach through compassionate and innovative healthcare, education and research forms one of the five core values of the Trust.

Evidence shows that patients do better in hospitals that carry out research – even if they don’t actually take part in a study themselves. Research helps patients to benefit from potentially life-saving treatments in the future, and has a positive effect for patients now.

Members of the Perspectives Group would like to share their diverse range of experiences and successes in supporting and co-developing cancer research in The Newcastle Upon Tyne Hospitals.

Report of Ms Maurya CushlowExecutive Chief Nurse26 March 2020

2/3 30/119


3/3 31/119

Agenda item A6(ii)

TRUST BOARD


Title Medical Director’s Report

Report of Andy Welch, Medical Director/ Deputy Chief Executive Officer

Prepared by Andy Welch, Medical Director/ Deputy Chief Executive Officer


☒ ☐ ☐

For Decision For Assurance For InformationPurpose of Report

☐ ☒ ☐

Summary The Report highlights issues the Medical Director wishes the Board to be made aware of.

Recommendation The Board of Directors is asked to note the contents.


Putting patients at the heart of everything we do and providing care of the highest standard focusing on safety and quality.



(please mark as appropriate) ☒ ☐ ☐ ☐ ☐ ☐ ☐

Impact detail Detailed within the report.

Reports previously considered by This is a regular report to the Board. Previous similar reports have been submitted.

1/4 32/119

Agenda item A6(ii)

____________________________________________________________________________________________________Medical Director’s ReportTrust Board – 26 March 2020

MEDICAL DIRECTOR’S REPORT

1. COVID-19

Preparations are well advanced for the Covid-19 pandemic. There is a daily control group meeting and a daily Operational Executive Control Group Meeting chaired by the Medical Director. Collaborative work is ongoing with the ICP and Primary Care providers. Further details will be presented verbally.

The major priorities relate to expansion of the Intensive Care Unit (ICU) bed base, with plans for further expansion, staff training and staff health and wellbeing.

2. EMERGENCY DEPARTMENT TARGETS

The Trust continues to perform extremely favourably with increasing pressure relating to potential Covid-19 patients and the requirement for Personal Protective Equipment (PPE).

3. EXTERNAL ICS PRESSURES

The Trust continues to be supportive, as far as is possible, of other ICS Trusts whose services are under pressure. Specialities involved include Cancer Services, Neuroradiology, Interventional Radiology, Stroke and Paediatrics. This support is facilitated at Directorate and Executive levels.

4. QUALITY IMPROVEMENT

This remains a priority for the Medical Directors Group. It was intended that this report would provide comprehensive details of Quality and Patient Safety Governance processes, specifically detailing the involvement of the Medical Director and Chief Nurse Teams alongside CGARD. This will be deferred to a future meeting.

5. BOARD REFERENCE PACK DOCUMENTS

Included within the Board Reference Pack are the following documents: a) Guardian of Safe Working Report; and b) Consultant Appointments.

6. RECOMMENDATION

The Board is asked to note the contents.

2/4 33/119

Agenda item A6(ii)

____________________________________________________________________________________________________Medical Director’s ReportTrust Board – 26 March 2020

A R Welch FRCSMedical Director20 March 2020

3/4 34/119


4/4 35/119

Agenda item A6(ii)b

TRUST BOARD


Title Learning From Deaths (October – December 2019 Serious Incidents)

Report of Mr Andy Welch, Medical Director

Prepared by Mrs Clare Casson, Quality and Assurance Lead




SummaryThe content of this report outlines the process in place to provide the Board with assurance that unexpected deaths, including those deaths with potentially modifiable factors are reviewed, and that mechanisms are in place to ensure lessons are learned and shared.

Recommendation The Board of Directors is asked to (i) receive the report and (ii) note the actions taken to further develop the mechanism for sharing learning across the Trust.


Putting patients at the heart of everything we do. Providing care of the highest standard focusing on safety and quality.

- We deliver the best possible health outcomes for our patients. Maintaining our ‘Outstanding’ CQC rating



(please mark as appropriate) ☒ ☐ ☐ ☐ ☒ ☒ ☐

Impact detail Provision of assurance that patient outcomes are reviewed and lessons learned to include deaths of people with learning disabilities.

Reports previously considered by This is a recurrent report, provided quarterly.

1/6 36/119

Agenda item A6(ii)b

____________________________________________________________________________________________________Learning from DeathsTrust Board - 26 March 2020

LEARNING FROM DEATHS

1. INTRODUCTION

The objective of this report is to provide the Quality Committee and Trust Board with assurance that there is a robust process in place to review unexpected deaths, as well as those deaths with potentially modifiable factors. Further that mechanisms are in place to ensure lessons are learned and shared.

For the purpose of this paper ‘modifiable factors’ are defined as factors identified that may have contributed to the death and which by means of locally or nationally achievable interventions could be modified to reduce the risk of future deaths.

2. BACKGROUND

The Care Quality Commission (CQC) report ‘Learning, candour and accountability’ published in December 2016 detailed concerns about the way NHS trusts investigate and learn from deaths of people in their care, and the extent to which families of the bereaved are involved in the investigation process.

The guidance released in March 2017 by the National Quality Board (NQB) set clear expectations for how trusts should engage meaningfully and compassionately with bereaved families and carers at all stages of responding to a death, and described trust boards’ responsibilities for ensuring effective implementation of this guidance. The Trust implemented the Learning from Deaths (LFD) guidance by the September 2017 deadline and has the required framework in place to facilitate learning from deaths within the Trust.

The NQB report ‘Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers’, published in July 2018 consolidated the existing guidance and provided perspectives from family members who have experienced bereavement within the NHS. This additional guidance set out how organisations should support and engage families after a loved one’s death in their care but has been written with the intention of being a resource which families can also refer to. This guidance aims to align with the CQC’s approach to assessing the ‘well-led’ domain which includes assessing how trusts have implemented the guidance published in 2017 by using appropriate Key Lines of Enquiry.

The introduction of medical examiners was proposed nationally from April 2019. This process aims to ensure that all deaths are reviewed independently by the Medical Examiner giving relatives of the deceased an opportunity to ask any questions relating to their loved ones care. In order to progress the start-up of this service within the Newcastle upon Tyne Hospitals NHS Foundation Trust the Medical Examiner Steering Group have proposed a pilot using the suggested National model and funding which is expected to commence in Spring 2020.

2/6 37/119

Agenda item A6(ii)b


3. MORTALITY REVIEW DATABASE – DATA SUMMARY

Current Morbidity and Mortality (M&M) meetings provide a robust forum for multidisciplinary discussion of each death. The mortality review database was launched in June 2017 and has improved the ease at which lessons identified within M&M meetings can be shared between Directorates. The database captures all mortality reviews and centralises the findings in one place for all level 2 reviews.

Level 1: The reviewer reviews the cause of death and discusses with the certifying doctor.Level 2: In addition, the reviewer also considers documents and health records associated with the death.

Since January 2019 this has included learning from Paediatric Mortality reviews as the Children’s Services Directorate has commenced use of the database to record all child death reviews. In addition, the Learning Disability Team (LDT) also uses the database to record their investigations.

The National Learning Disabilities Mortality Review (LeDeR) Programme was established as a response to the recommendations from the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD 2013). CIPOLD reported that people with learning disabilities are three times more likely to die from causes of death that could have been avoided with good quality healthcare. In the past 12 months 17 patients died who were identified as having a learning disability and had reviews undertaken for each case according to the LeDeR guidelines.

A summary of the data for the past 12 months is shown below:

The Q3 mortality data was presented to the Trust Board in January and has not yet been updated as Q3 data is collected in April. The Q4 mortality review summary, review by Hogan score and key learning points will be reported to the 22nd May 2020 Quality Committee and

3/6 38/119

Agenda item A6(ii)b


to the 26th May 2020 Trust Board. The sequencing of the Quality Committee and Trust Board meetings has meant that the reporting of the data is slightly out of sync however this is being reviewed as part of the annual review of Committee effectiveness.

4. OUTCOME OF INVESTIGATIONS LINKED TO SERIOUS INCIDENTS (SI)

All unexpected deaths, or deaths with possible modifiable factors, are routinely escalated as potential SI via the Trust incident reporting system (Datix). Deaths of this nature are subject to a detailed review facilitated by a Clinical Director and usually involve members of the clinical team directly involved in the patients care. The review process includes an analysis of the care provided and determines whether any modifiable factors contributed to the death. Key learning points are identified and action plans generated. A summary of outcomes of investigations linked to SIs is shown below:

During October 2019 - December 2019 there were 42 SI reported to Commissioners via the Strategic Executive Information System (STEIS).

Of these 42, there were five patient deaths which were subject to a SI investigation. Three investigations are now complete and two investigations are ongoing.

The incidents and learning from the three deaths are summarised below:

2019/22513 Absconded patient (joint learning with Mental Health Trust) Enhanced education provided in order to increase staff understanding of the

Deprivation of Liberty Safeguards (DoLS) Ongoing staff education opportunities to ensure the appropriate assessment of

Mental Capacity Assessment is understood and clearly documented Improve the documentation of clinical decision making across mental health and

acute care teams to ensure clear communication

2019/25598 Delayed recognition of deterioration Reinforcing escalation procedures for deteriorating patients through enhanced

education and awareness-raising across all clinical teams Review of clinical shift patterns in order to improve senior support to junior staff

2019/26672 Delay in Treatment Review of multi-disciplinary handover and Consultant ward round practices in order

to improve support for junior staff Review electronic patient record functionality in order to improve alerts and

escalation prompts for staff Enhanced education for deteriorating patient Champions to further embed practice

across clinical teams Provide further mentoring and support for junior leaders to develop leadership skills

4/6 39/119

Agenda item A6(ii)b


2019/21634 Misconnection of medical device Investigation in progress

2019/21443 Delay in reversal of anticoagulation therapy Investigation in progress

Q2 (2019/20) Investigation update

Following on from the previous report submitted in September 2019, the outstanding incident investigation from Q2 (2019) remains in progress.

2019/20921 Delayed CT scan Investigation in progress

5. RECOMMENDATIONS

To (i) receive the report and (ii) note the actions taken to further develop the mechanism for sharing learning across the Trust.

Report of Mr Andy Welch Medical Director11th March 2020

5/6 40/119


6/6 41/119

Agenda item A6(iii)

TRUST BOARD


Title Executive Chief Nurse Report

Report of Maurya Cushlow, Executive Chief Nurse

Prepared by Maurya Cushlow, Executive Chief NurseElizabeth Harris, Deputy Chief Nurse




Summary

This paper has been prepared to inform the Board of Directors of key issues, challenges and information with regard to the Executive Chief Nurse areas of responsibility. The content of this report outlines:

Year of the Nurse & Midwife – Big Event – Making History Nursing & Midwifery Staffing Clinical Assurance Toolkit (CAT) Patient Experience update quarter 3 (Q3) Patient-Led Assessment of the Care Environment (PLACE) 2019 End of Life and Specialist Palliative Care Freedom To Speak Up Guardian (F2SUG)

RecommendationThe Board of Directors is asked to:

i) Note and discuss the content of this report.ii) Note the actions taken.


Putting patients at the heart of everything we do. Providing care of the highest standard focusing on safety and quality.

We will be an effective partner, developing and delivering integrated care and playing our part in local, national and international programmes.

Being outstanding, now and in the future.



(please mark as appropriate) ☒ ☒ ☒ ☐ ☒ ☐ ☐

Impact detail Detailed within the main body of the report.

Reports previously considered by

The Executive Chief Nurse update is a regular detailed comprehensive report bringing together a range of issues to the Trust Board.

1/14 42/119

Agenda item A6(iii)

____________________________________________________________________________________________________Executive Chief Nurse reportTrust Board – 26 March 2020

EXECUTIVE CHIEF NURSE REPORT

1. INTRODUCTION/BACKGROUND

This paper aims to provide members of the Board of Directors with a summary of key issues, achievements and challenges within the Executive Chief Nurse portfolio.

As part of the 2020 International Year of the Nurse and Midwife, a strategy has been commissioned which will be representative of Nurses, Midwives, Allied Health Professionals and team members in Newcastle Hospitals. The event which was facilitated by Helen Bevan, Chief Transformation Officer, NHSiE and Bev Matthews, National Delivery Lead, NHS Horizons, invited staff to develop individual and collective actions to help shape the strategy.

Over 400 staff attended the day which consisted of two fast paced consecutive workshops discussing journeys through healthcare, the future we want for Nursing, Midwifery and AHP’s, actions to take forward, barriers and challenges to overcome and support needed for our ‘big ideas’.

To document the day, we had writers who captured what was happening throughout the event in real time, as well as artist Josie Brooks who did live drawings to visually present the collective voice of all who attended.

Key themes which emerged from the day included:

Communication and involvement of staff. Staff indicated there was a need for improved communication, involvement in decision making and the ability to influence changes in their own clinical areas.

Team cohesion, effectiveness and efficiency. Staff advised of the requirement of an improved understanding and appreciation of the different roles across disciplines. Increasing awareness of the contribution each make and working together to improve patient care and outcomes.

Investment in Training and Development. Staff wanted investment in their training and development, as well as allowing time out to work in collaboration with their team members.

Leadership capacity and capability- ensuring leaders are present, visible and accessible.

Plans to take forward

YEAR OF NURSE AND MIDWIFENEWCASTLE BIG EVENT – MAKING HISTORY

On Thursday 5 March, we made history by holding the very first big room ‘Big Event’ for Nurses, Midwives and Allied Health Professionals at St James Park, Newcastle.

2/14 43/119

Agenda item A6(iii)


Over the course of the next year we will work with the teams to develop the strategy and work streams which will respond to the themes which emerged on the day. We know that there is much underway in relation to the themes but there is much more that we need to do to further strengthen and develop these.

2. NURSING AND MIDWIFERY STAFFING

This regular Board update presents the review and analysis of staffing levels across the Trust and complements the six month deep dive report presented at the Trust Board in November 2019. The next in depth review will be presented in May in line with national guidance.

The Nurse Staffing and Clinical Outcomes Operational Group reviews all wards where there is a staffing or clinical outcome risk on a monthly basis based on a risk adjusted dashboard. Once reviewed, the Wards are classified as requiring low, medium or high level support. Any ward requiring medium support for two consecutive months or any ward requiring high-level support will be highlighted to the Board in this report. This provides assurance and transparency of ‘ward to board’ escalation and reporting. It is noted that since its inception, the group has started to recognise early trends in metric variations. This has supported either early action (such as staff movement or bed closures) or increased surveillance promoting early discussion with Matrons and clinical teams to mitigate risk.

In the January 2020 meeting, nine wards required review. Two wards (FRH 13 &14) required review following medium level support previously. This was due to significant staffing gaps in the previous months. Up to date data demonstrated that two wards required continued medium level support and in-line with the escalation criteria analysis is noted below:

Ward Metric Review Action OutcomeFreeman Ward 13 1) Nursing fill rate above

85% but concern regarding skill mix

2) Acuity profile in line with establishment

3) RN 43%: HCA 57%. Higher percentage largely due to enhanced care

4) CHPPD 5.75) Ward occupancy remains

above 95%6) Vacancies 8.6% 7) Sickness 12.5%8) Increase in Falls noted9) 3 Pressure ulcers10) IPC no concerns 11) No medication errors

noted12) No rostering issues noted

1) Associate Director of Nursing to meet with Matron and review actions already in place.

2) Validation of acuity and dependency data planned to ensure it is accurate

3) Associate Director to review sickness data

Vacancies have been filled but awaiting deployment

Planned CHPPD is 5.91 at 100% occupancy

Actual CHPPD in line with national average

Sickness largely short term and managed in line with policy

Validation of acuity still to be undertaken

Expected improvement of metrics in February

Freeman Ward 14 1) Nursing fill rate below 85%

2) RN 38%: HCA 62%. Higher HCA rate due to enhanced care. RN fill rate against plan was 78%

1) Associate Director of Nursing to meet with Matron and review actions already in place.

2) Validation of acuity

High utilisation of enhanced care in month requiring increased HCA above plan (118%) which altered skill mix.

3/14 44/119

Agenda item A6(iii)


3) Ward occupancy 95% 4) Vacancies 10.6%5) Sickness 12.1% 6) No increase in falls noted.7) Three Pressure ulcers8) No IPC concerns, 9) 1 formal complaint

received10) No rostering issues noted

and dependency data planned to ensure it is accurate

3) Associate Director to review sickness data

4) Senior Nurse for Nursing and Midwifery Staffing to review fill rate metrics with Matron

Delivered 78% of planned RN shifts and mitigated with responsive movement

Future rosters reviewed and staffing improving

Vacancies now filled with only 1wte left to appoint

No reduction in bed capacity required

Sickness largely short term and managed in line with policy

It was noted that Ward 33 NCCC had seen a small increase in healthcare acquired

infections and was therefore subject to a full metric review by the group. No concerns were noted in any other staffing or outcome metrics and it was agreed to review the outcome of the RCA meetings. Low level support was agreed and for review next month. The other five wards (three in Internal Medicine, one in EPOD and one in Neurology) were agreed as requiring low level support and managed appropriately.

In the February 2020 meeting, ten wards required review. The two wards requiring medium support outlined above were deemed as requiring low level support due to the execution of the action plans and an improvement in metrics.

Ward 12 at the RVI was asked to be reviewed by one member of the group. After a full metric review there were no noted outcome concerns and staffing and skill mix was in line with guidance. No further action was required. The other seven wards (one in MSK, four in Internal Medicine and two in Surgery) were deemed as requiring low level support and will be reviewed on the 16 March.

The group is working with the Chief Nursing Informatics Officer to see how data from the new e-record system can be integrated to further improve analysis and intelligence monitoring.

The on-line dashboard has been finalised and is in the process of being shared with Matrons and Ward Leaders.

However, it is important to note that, whilst this group provides oversight, high level monitoring and assurance, there is a robust leadership and management framework led by the matron team who manage the wards staffing ensuring safety every day.

Trust Level Fill Rates

The Trust level fill rates for the previous 3 months are as follows:

Month RN day fill rate %

HCA Day fill rate %

RN Night fill rate %

HCA Night fill rate %

Trust fill rate %

Dec 2019 91.39% 96.28% 92.87% 108.17% 94.06%January 2020 93.52% 90.81% 97.26% 112.03% 95.86%February 2020 93.37% 92.30% 100.30% 112.67% 97.02%

The nursing fill rates for February are comparable to February 2019.

4/14 45/119

Agenda item A6(iii)


The marginal increase in HCA fill rate on nights against plan in January and February is due to the increase in medical bed capacity to support winter. As this is a short-term change, the baseline plans are not altered and therefore will appear as an increase against plan. It is expected this will reduce in April and May.

Recruitment and International Recruitment

The current Trust Band 5 vacancy rate sits at 8.9%, which is 1% lower than the same period last year. This is due to improvement in recruitment in Medicine and Older Peoples Medicine and Theatres following recent international recruitment.

There are currently approximately 150wte Band 5 RN/Operation Department Practitioner (ODP) vacancies in the Trust. There is a Band 5 open day planned for the 28th March to attract those students due to qualify in September 2020.

Due to the changes in undergraduate programmes the March intake of RN students was dropped after 2017 and there are no March 2021 students due to graduate. To compensate there is an increase in September 2020 graduates and we are expecting around 130-150 Band 5 applicants in the next three months. To ensure we maximise recruitment, all directorates have been asked to validate and update their active RCG’s and ensure over recruitment agreements are in place where applicable.

In addition to the figure above, there are currently 65wte external Band 5 RN/ODP who have been appointed and are currently in the recruitment process. The vast majority are due to be deployed in March and April 2020. There are 36wte external candidates who have commenced in post since mid-December 2019 to date.

With turnover we expect and average of 75wte Band 5 vacancies per month due to staff going through the vacancy process or awaiting deployment. This equates to 3% of the Band 5 workforce.

There are currently 8wte Healthcare Assistants in the recruitment process with approximately 38wte residual posts to fill. Interviews are planned for March 2020.

The five international nursing recruits from the Philippines, who were required to undertake a partial resit of their Objective Structured Clinical Examination (OSCE) in January 2020 all passed and are registered with the NMC.

At the end of January, five international nursing recruits were welcomed to the Trust and a final two are expected in April.

A paper for future international recruitment will be presented to the Executive Team in the coming weeks for consideration.

The Nursing and Midwifery Recruitment and Retention Group continues to provide oversight on this work-stream. There are eight projects being overseen by the group. These include work on pre-deployment engagement, later career development, qualified rotational posts, career clinics and maximising the Newcastle brand and advertising.

Nursing and Midwifery Finance Position

In line with agreed process, an in-depth analysis of the Nursing and Midwifery spend position was undertaken at the end of Q3 and reviewed by the Executive Chief Nurse Team.

5/14 46/119

Agenda item A6(iii)


Key points to note:

At the end of Q2, there were three directorates who had been flagged as being overspent based on the criteria outlined in the Nursing and Midwifery financial escalation process. All directorates were communicated or met with as per protocol with actions agreed and documented.

All 3 directorates showed an improvement in the spend positon at the end of Q3 Q3 analysis demonstrates that the total N&M budget is £400,647 underspent, inclusive

of the trust apportioned vacancy factor. This is comparable to the end of Q2 which demonstrated a £362,135 underspend position.

No new directorates are demonstrating an overspend position when taking into account the trust apportioned CVF.

There has been a 43% reduction in agency use compared to the previous year. Spend at month 10 of 2018/19 was £1,444,072 and is £825,435 for month 10 2019/20.

There has been a 4% reduction in bank spend compared to the previous year. Spend at month 10 of 2018/19 was £7,131,574 and is £6,821,974 for month 10 2019/20. This equates to an average reduction of 25wte Band staff per month and corresponds with the success of our efforts around recruitment and retention.

3. CLINICAL ASSURANCE TOOLKIT (CAT)

CAT is a way for clinical staff to continuously self-assure standards of high quality care for patients and forms part of the overall Trust assurance. This is a biannual review analysing trends in the results of the CAT.

The table below demonstrates the trends from the last 7 CAT reports and as can be seen, scores have been consistently above 91%. Staff Knowledge scores have remained above 91% and the scores on Environmental Cleanliness continue to demonstrate high standards across the Trust. Formal Hand Hygiene Audits remain variable and are ongoing.

Less than 91%Between 91% and 97.9%98% or more

6/14 47/119

Agenda item A6(iii)


As always, the scoring criteria are extremely rigorous, commensurate with the high standards in the Trust therefore, any area that has a red score (less than 91%) for the whole of the CAT or for Matrons cleanliness checks will appear on escalation reports within Business Objects. Matrons are aware of their areas with lower scores and are encouraged to analyse results, act upon them and share with clinical teams. These numbers are very small and issues identified are acted upon immediately. Overall, the small numbers of areas with lower scores gives reassurance that issues identified on CAT are being dealt with by the Directorates as they arise. As additional checks, biannual Matron Peer Reviews are carried out (March and September) to demonstrate assurance in the results received.

Since it commenced in 2011, CAT has provided the Trust with a ward and department based audit tool owned by Clinical Leaders. The advent of electronic documentation will fundamentally change CAT (e.g. questions have now been amended to accommodate the start of Paperlite) and therefore the senior nursing team work plan for this financial year includes an update and refresh of CAT. Future Clinical Assurance Tool reporting will be via the reviewed Quality Governance Structure and Patient Safety Committee with exceptions only escalated to the board of directors.

Historically the Trust has been very successful in reporting a number of key factors including, medication errors, harms, safety thermometer, safer staffing, infection prevention and control and of course CAT. This has provided wards and department’s assurance of the quality of care delivered and the ability to provide safe and effective care to patients. Other key factors that could affect the delivery of care, such as compliance with documentation and key nursing factors, have necessitated long time consuming audits that are impractical to undertake on a frequent basis.

Since the implementation of our Electronic Patient Record, data has been entered by nursing and other clinical staff, which will allow us to extract data from the new data warehouse, with a delay of only 15 minutes. This will change how we as a Trust will begin to examine data and change from a retrospective audit to a number of predictive indicators, which could affect care, and how it is delivered on our wards.

The current plan is to implement a ward dashboard for ward sisters, Matron’s and the senior Nursing team by July 2020. This dashboard will incorporate all of the current quality indicators that we currently utilise and implement a number of new reporting datasets that will assist staff in the assessment of care. Correlation between non-compliance of key care tasks, could provide valuable predictive information for ward managers where early intervention could be taken in the form of training or additional senior support. This is a radical change in reporting that will provide real-time information to our staff allowing them to make changes to planning or delivering high quality effective care to our patients. It is also only the start as we progress towards the implementation of Artificial intelligence, assisted decision making and predictive interventions, we will set the Trust on a path to be truly revolutionary in reporting.

7/14 48/119

Agenda item A6(iii)


4. PATIENT EXPERIENCE UPDATE Q3

Patient Surveys - CQC and Ipsos MORI mixed method pilot

The Trust has recently taken part in a pilot project led by Ipsos MORI, to help trial new methods of delivering the National Survey Programme. Evidence suggests different survey approaches appeal to different people, therefore the aim of the pilot was to test the uptake of patients completing an online questionnaire using either letters containing a URL or via an SMS invite.

The results were received by the Trust on 4 March 2020, which shows the response rate for those offered a mixed method (56.1%) is higher than those only offered the postal survey (49.8%). Patient feedback is currently being analysed and we expect results to be shared early April.

The Trust is currently working in partnership with the CQC in the redevelopment of the 2020 Inpatient survey, as the current survey would need to be shortened to allow for an online version.

The Trust is also taking part in a similar pilot within Maternity Services, which is currently underway.

Same Sex Accommodation

The Trust are working towards embedding the updated guidance on delivering same-sex accommodation for Trans people and gender variant children. Key points are:

Trans people should be accommodated according to their presentation: the way they dress, and the name and pronouns they currently use.

This may not always accord with the physical sex appearance of the chest or genitalia. It does not depend on their having a gender recognition certificate (GRC) or legal

name change. It applies to toilet and bathing facilities (except, for instance, that preoperative Trans

people should not share open shower facilities). Views of family members may not accord with the Trans person’s wishes, in which

case, the Trans person’s view takes priority.

Complaints Activity

The Trust has received a total of 159 formal complaints in Q3, which is a similar number to complaints received in Q2 (160). The Trust is currently receiving on average 54 formal complaints per month, which is a 20% increase from the previous year, however no obvious trends or themes are emerging.

There has been a significant increase in the number of complaints (102) up to the end of Q3 compared with the previous financial year. A large proportion of this increase is with ePOD and Cardiothoracic Services, which have collectively seen an increase of 33 complaints, equating to a combined 53% increase across the 2 services. Contrastingly, there has been a reduction of complaints received for Medicine, Patient Services and Cancer Services.

8/14 49/119

Agenda item A6(iii)


The Trust closed 175 complaints in Quarter 3. 30 of those complaints were upheld, 40 were partially upheld and 105 were not upheld. The table below demonstrates the breakdown of upheld complaints across directorates.

Complaint activity, themes and trends continue to be scrutinized at the monthly complaint panel with a strong emphasis on learning and service improvement.

5. PATIENT-LED ASSESSMENT OF THE CARE ENVIRONMENT (PLACE) 2019

The Patient-Led Assessments of the Care Environment (PLACE) are an annual assessment of the non-clinical aspects of the patient environment to determine how it supports patients’ privacy and dignity and its suitability for patients with specific needs e.g. disability or dementia. PLACE aims to promote the principles established by the NHS Constitution and focus on areas that matter to patients, families and carers. The Trust’s PLACE audits were undertaken during the month of October 2019. There were 37 Wards/Out-Patient Departments, three communal areas, three external areas assessed and 10 food tasting sessions undertaken.

A crucial component of the assessment process is the involvement of patient assessors i.e., Trust Governors, patient committees, community engagement networks, volunteers, patient advocates. There is no maximum number of patient assessors in a PLACE team however, as a minimum patient assessors should make up 50% of the team.

Patient Assessors comprised of representatives from the Advising on the Patient Experience Group, the Governor’s Council, Patient Advice and Liaison Service, Trust Volunteers and Tyneside Kidney Patient Association. Staff Assessors comprised of representatives from the Executive Chief Nurse team, Infection Prevention and Control, Estates and Hotel Services.

The PLACE assessment tool provides a framework for assessing quality against common guidelines and standards. The environment is assessed using a number of question depending on the services provided by the facility. Cleanliness; Food and Hydration; Privacy, Dignity and Wellbeing; Condition, Appearance and Maintenance of healthcare premises;

9/14 50/119

Agenda item A6(iii)


Dementia; Disability (the extent to which premises are able to meet the needs of people with

disability against a specified range of criteria).

The Trust again scored well this year. The table Appendix 1 below shows the Trust’s scores in comparison to the Shelford Group scores and the National Average.

Overall, the Trust results are positive; the exceptions to this are the Disability and Dementia assessments. The Disability domain focused on issues around access, signage, hearing loops. The Dementia domain focused on flooring, décor, signage, availability of handrails, appropriate seating. The aforementioned represent some key issues for providing for the needs of patients with a disability and/or dementia. We will work through those issues that can be readily resolved but acknowledge that much of this work must be incorporated in the Trust ward refurbishment programme recognising that it is important that healthcare premises create a safe and secure environment for patients with dementia.

6. END OF LIFE AND SPECIALIST PALLIATIVE CARE

National Audit of Care at the End of Life 2019

The Newcastle Hospitals Specialist Palliative Care and End of Life teams provide a liaison service offering advice and support to patients with specialist palliative care needs. They also provide support for patients at the end of life, their loved ones, and staff caring for them.

The Trust took part in the 2019 National Audit for Care at the End of Life in Hospitals 2019 (NACEL). Initial results were circulated for information in February 2020. Formal results will be published nationally in coming months. The report demonstrated above national average scores in all domains, which is an improvement on last year’s outcome. Scores of note include 9.0 (National average 7.2) for use of an individualised plan of care, and 8.1 for families and others experience of care (national average 7.2). This is particularly encouraging given that the trust was not scored in this domain last year due to insufficient carer responses. Timely recognition of dying appears to have improved (51% in comparison to 46% national average recognised dying 48 hours or more before death). Despite a positive report, there are areas for improvement, including discussion of risks and benefits of hydration & nutrition and indications and side effects of medication with both patients and carers. An Action Plan will be created to address these areas, this plan will be presented at both the Trust Audit and Patient Experience and Engagement groups.

End of Life Care Peer Review

An internal peer review was carried out on 21st February 2020. Following data submission and interview of the End of Life leads, the team visited wards and community settings where patients were known to be at end of life to evaluate the quality of care received. The inspection team also visited members of the palliative and end of life care teams, bereavement officers and mortuaries. We expect to receive formal feedback and results of the review during March 2020.

10/14 51/119

Agenda item A6(iii)


The RVI Haven

The RVI Haven was officially opened by Sir John Burn on 27th November 2019. Since then it has provided much needed respite for the families of 30 dying patients, allowing them a space to rest and relax, make a hot drink, or have a shower. Evaluation of this service has been universally positive, including: “Thank you for providing our family with a place to be when we really needed it. It really is a Haven! God bless” & “A private space to refresh and just be- deepest gratitude.” We continue to explore plans for a similar space at the Freeman site.

Legacare

Legacare is a legal charity that provides specialist professional legal advice for patients with life limiting illness. In November the Charities Board granted charitable funding for legal advice for about 90 patients. Patients who are able to pay are asked for a voluntary donation. The agreement is that patients must have life limiting illness and be referred by the Palliative Care Team. This has provided an important service for 42 patients so far. Services provided have included support with wills, Lasting Power of Attorney, guardianship, housing & probate advice. The service will be evaluated towards the end of the year & the results of this will be shared with the Charities Board to aid decisions on future funding.

Flourish ‘Dying Matters’ month

May 2020 will be Newcastle Hospitals Flourish ‘Dying Matters’ month. A variety of talks, tours, information, films in the Medicinema, and marketplace events are being planned with the support of the Communications Team. This is aimed at helping staff to be more comfortable in discussing & planning for end of life.

7. FREEDOM TO SPEAK UP GUARDIAN (F2SUG)

The aim of this report is to provide the Board with information about the activity undertaken by the Trust’s Freedom to Speak up Guardian (FTSUG) over the past six months.

Activity

During the period September 2019 – March 2020, 36 concerns were raised with the FTSUG which required intervention, maintaining the level of activity seen in the previous 6 month period (37). A further 30 concerns were raised which required only an initial conversation / support / advice or signposting to alternative, more appropriate services.

Concerns continue to focus on interpersonal relationships; issues with line managers are increasingly common, particularly a lack of support, perceived unfair disciplinary action and over-zealous implementation of policy with no consideration for the individual’s needs or well-being. There have also been allegations of bullying and discrimination raised against line managers. For the first time during my tenure as FTSUG, staff have raised concerns about direct discrimination by managers; one in relation to race and two regarding mental health conditions.

11/14 52/119

Agenda item A6(iii)


Directorate Management teams continue to take all allegations which are escalated to them seriously and has consistently engaged in meaningful investigations. Lines of communications have been improved to ensure that those raising concerns feel supported throughout the process and findings / learning shared with them, and where appropriate, more broadly in teams.

The 36 concerns raised which led to further action were raised by a range of staff: 9 Admin & Clerical 8 Nurses 7 Anonymous 5 Scientists / Technicians 2 Auxiliary 2 HCAs 2 Junior Docs 1 Doctor

Encouragingly, there has been a significant increase in the level of engagement from Junior Doctors. This may be a result of the work to promote the FTSUG service and improved links with the education and induction processes.

All staff raising concerns were asked to complete a satisfaction surveys. Response rates remain lower (approx. 20%) but positive with 100% rating the service as 5/5 and all stating that they would recommend it.

8. RECOMMENDATIONS

The Board of Directors is asked to:i) Note and discuss the content of this report.

ii) Note the actions taken.

Report of Maurya CushlowExecutive Chief Nurse26 March 2020

12/14 53/119

APPENDIX 1

13/14 54/119


14/14 55/119

Agenda item A6(iv)

TRUST BOARD


Title Healthcare Associated Infections (HCAI) Director of Infection Prevention and Control Report

Report of Maurya Cushlow, Executive Chief Nurse

Prepared by

Dr Lucia Pareja-Cebrian, Assistant Medical Director, Director of Infection Prevention & Control (DIPC), Consultant MicrobiologistMrs Elizabeth Harris, Deputy Chief NurseMrs Angela Cobb, Matron Infection Prevention & Control (IPC)



Purpose of Report☐ ☒ ☐

Summary

This paper is the bi-monthly report on Infection Prevention & Control (IPC). It complements the regular Integrated Board Report and summarises the current position within the Trust to the end of February 2020. Trend data can be found in Appendix 1 (HCAI Report and Scorecard February 2020), enclosed in the Board Reference Pack, which details the performance against targets where applicable.

Recommendation The Board of Directors is asked to (i) receive the briefing, note and approve the content and (ii) comment accordingly.


Achieving local excellence and global reach through compassionate and innovative healthcare, education and research.Patients - Putting patients at the heart of everything we do. Providing care of the highest standards focussing on safety and quality.Partnerships - We will be an effective partner, developing and delivering integrated care and playing our part in local, regional, national and international programmes.Performance - Being outstanding, now and in the future.


Equality & Diversity Reputation SustainabilityImpact

(please mark as appropriate) ☒ ☒ ☐ ☐ ☐ ☐ ☐

Impact detailFailure to effectively control infections may lead to patient harm, litigation against the Trust and loss of reputation.There are no specific equality and diversity implications from this paper.

Reports previously considered by This is a bimonthly update to the Board on Healthcare Associated Infections (HCAI).

1/6 56/119

Agenda item A6(iv)

____________________________________________________________________________________________________Healthcare Associated Infections (HCAI) – DIPC ReportTrust Board – 26 March 2020

DIRECTOR OF INFECTION PREVENTION & CONTROL (DIPC) REPORT

1. INTRODUCTION / BACKGROUND

This paper provides bimonthly assurance to the Trust Board regarding Healthcare Associated Infections (HCAIs). It is an exception report and identifies actions and learning. An overview of HCAI rates is covered in the Integrated Board Report and trend data can be found in Appendix 1 entitled HCAI Report and Scorecard February 2020 (located within the Board Reference Pack).

2. KEY POINTS FOR JANUARY/FEBRUARY 2020

2.1 Coronavirus (COVID-19)

In December 2019 several cases of pneumonia were linked to a market in the city of Wuhan, in China. Subsequent testing identified a newly described coronavirus, 2019-nCoV, and the illness that it causes has been named COVID-19.

Coronavirus are a family of viruses that are widely distributed among several species of animals, causing a wide range of infections. There are six species that cause infections in humans: four are responsible of “common cold”; the other two are SARS-CoV and MERS-CoV, causative agents of severe respiratory syndrome outbreaks in China and Middle East respectively.

The World Health Organisation declared a Pandemic in response to COVID-19 on 11th March 2020. Since that the time this Trust has enacted our Emergency Planning Resilience and Response plans using the framework of the Trust influenza Pandemic plan. Due to the rapidly evolving situation, a verbal update will be provided to the Board of Directors.

2.2 C. difficile Infections

Figures are not comparable to previous years as previously reported, due to the change in the reporting criteria from NHS Improvement (NHSI). At the end of February 2020 there were an additional 27 cases assigned to the Trust. Overall, C. difficile infections are below the 113 trajectory with 105 cases to date. A total of 24 cases have been successfully appealed.

2.3 MRSA / MSSA Bacteraemias

By the end of January 2020, the Trust had its first Healthcare Associated MRSA bacteraemia for over 16 months; lessons learnt from this case have been shared with all Directorates.

The Trust continues to see a reduction in MSSA bacteraemia cases in line with our internally set objective of 10% reduction from last year. A total of 66 cases were reported by the end of February 2020 in comparison with 86 cases in the previous year. The main source of infection continues to be intravenous devices and work is ongoing to promote effective

2/6 57/119

Agenda item A6(iv)


device management. This remains a priority therefore remains a standard item in Directorate Serious Infection Review Meeting (SIRM) Action Plans so that risks can be identified and assurances provided to inform standards of practice.

2.4 Gram Negative Bacteraemias (E. coli, Klebsiella, Pseudomonas)

Similarly to MSSA bacteraemias, an internal reduction target of 10% has been set for all reported gram negative bacteraemias from last year’s position, working towards the nationally set ambition to reduce gram negative bloodstream infections (GNBSI) by 25% by 2021/22 with the full 50% reduction by 2025.

There has been an overall reduction of E. coli bacteraemia in comparison to this time last year however, the Trust is above the 10% reduction trajectory by 4 cases. Since January 2020 the Infection Prevention and Control Nurses have been undertaking detailed patient reviews in order to identify areas of good practice and any lessons to be learnt. From analysis of the first month’s data, device management remains a theme which mirrors the observations from MSSA bacteraemia. There is ongoing work also running in parallel to the Antimicrobial framework aiming to optimise the management of the most common causes of bacteraemia which are urinary tract, gastrointestinal and line related.

Klebsiella and Pseudomonas bacteraemia rates have significantly increased this year. Pseudomonas rates are 4 cases over trajectory, but Klebsiella has had a marked increased with rates of 29 cases over internal trajectory. Directorates receive data on individual cases and it is included within their SIKRM action plans. Early indication suggests commonalities between Klebsiella and E. coli bacteraemias and we are finalising a reduction strategy for next year.

2.5 Outbreaks and Periods of Increased Incidence (PIIs)

In January 2020 3 outbreaks were declared, 2 of which due to diarrhoea and vomiting; no organism was confirmed with an impact upon patient flow of 92 lost bed days. The other outbreak was respiratory in origin and confirmed as Respiratory Syncytial Virus (RSV) resulting in an additional loss of 9 bed days. In February only 1 outbreak was declared for symptoms of diarrhoea with minimal impact on patient flow with a total of 2 lost bed days.

There were no PII for C. difficile infection (CDI) during January however in February there were 3 cases of PII CDI. PII meetings have been arranged along with environmental screening.

2.6 Sepsis

Trust wide new ‘Failure to rescue’ education sessions are being delivered to all clinical staff who complete observations in all Directorates to raise awareness of recognising deteriorating patients and the appropriate escalation according to the patients Risk/Trust policy. Education strategies are continuing to be developed to improve compliance with the sepsis screening process and treatment. The electronic deterioration alerting process commenced its pilot phase on 3rd March 2020 within a busy medical/surgical ward within the RVI. This will highlight deteriorating patients with sepsis at ward level within eRecord.

3/6 58/119

Agenda item A6(iv)


The results of this pilot will inform the rollout to all clinical areas which is hoped to be rolled out from 1st April 2020. This will also be incorporated into a dashboard of deteriorating patients, which is part of a patient safety project in the Trust.

The sepsis video on the Trust’s You Tube channel from 2015 is currently being updated. Once this is completed we will put a link onto Twitter and update the trusts website. This will also help with sepsis education.

We are still awaiting the final part of our safety netting to be printed for the Trust to comply with NICE guidance.

The management of sepsis audit shows a slight improvement in Quarter 3.The introduction of the sepsis alert is likely to lead to an improved position also. Gathering data has had a significant impact on time and workload. There is a current business case being progressed to obtain further support in gathering the required data.

2.7 Antimicrobials

Antimicrobial Stewardship remains essential in order to reduce the risks associated with developing antimicrobial resistance (AMR). Improvements in some areas of prescribing are the focus of this year’s antimicrobial CQUIN. It is anticipated that similar initiatives will continue in the next 5 years.

Urinary Tract Infection (UTI) CQUIN goals are to achieve 90% of antibiotic prescriptions for lower UTI in older people meeting National Institute for Health and Care Excellence (NICE) guidance (NG109) and Public Health England (PHE) Diagnosis of UTI guidance in terms of diagnosis and treatment. Q3 data has now been finalised and is showing as 42% compliance. This CQUIN has been challenging across the board, with similar challenges being reported by many organisations.

Colorectal CQUIN goals are to achieve 90% of antibiotic surgical prophylaxis prescriptions for elective colorectal surgery (in >18s) being a single dose and prescribed in accordance to local antibiotic guidelines. Q3 data has now been finalised and showing at 88% compliance.

The CQUINS for 2020/21 have now been identified and will be:

Antifungal CQUIN - aim to reduce inappropriate use of anti-fungal agents. Appropriate antibiotic prescribing for UTI in all admissions of patient’s adults aged 16+

(excluding patient’s prescribed antibiotic prophylaxis for the treatment of recurrent UTI; pregnant women; chronic tubulo-interstitial nephritis)

Treatment of community acquired pneumonia in line with British Thorathic Society (BTS) Care Bundle, for all admissions. The care bundle includes performance of a chest x-ray within 4 hours of hospital arrival time; diagnosis of pneumonia severity score (CURB65); receive antibiotics within 4 hours of hospital arrival time and antibiotic prescription is concordant with severity score and in line with local guidelines.

Antimicrobial Stewardship relies on ongoing education, guideline updates and real time

4/6 59/119

Agenda item A6(iv)


intervention to patients’ antibiotic treatment and it is guided by NICE quality standards. A self-assessment exercise on such standards has been undertaken and support for some of the gaps identified will be sought through a business case for further resources.

2.8 Water Safety

No exceptions to report.

2.9 Ventilation

No exceptions to report.

3. RECOMMENDATIONS

The Board of Directors is asked to (i) receive the briefing, note and approve the content and (ii) comment accordingly.

Report of Maurya CushlowExecutive Chief Nurse26 March 2020

5/6 60/119


6/6 61/119

Agenda Item 7(i)

BOARD OF DIRECTORS


Title Integrated Board Report – Quality, Performance, People & Finance Report

Report of Martin Wilson – Chief Operating Officer

Prepared by Stephen Lowis – Senior Business Development Manager - Performance


☒ ☐ ☐

For Decision For Assurance For InformationPurpose of Report

☐ ☒ ☐

SummaryThis report provides an integrated overview of the Trust’s position across the domains of Quality and Performance, People and Finance in order that the Board can be appropriately assured that the organisation is, and will continue to be, an outstanding healthcare provider.

Recommendation To receive the report, noting the key challenges and the actions being taken to improve quality and performance where required.


Patients – Putting patients at the heart of everything we do. Providing care of the highest standard focussing on safety and quality.Performance – Being outstanding now and in the future.



(please mark as appropriate) ☒ ☐ ☒ ☒ ☐ ☒ ☒

Impact detail

Details compliance against national access standards which are written into the NHS standard contract.Details compliance against key quality targets.Has financial implications through penalties and activity.Reports on HR and finance metrics.

Reports previously considered by Regular report to the Quality Committee and Trust Board.

1/1 62/119

Integrated Board ReportQuality, Performance, People and Finance

March 2020

Agenda item A7(i)

1/26 63/119

Purpose• This report provides an integrated overview of the Trust’s position across the domains of Quality & Performance, People and Finance in order that the Board can be appropriately assured that the organisation is, and will continue to be, an outstanding healthcare provider.

Executive Summary

1. Staff across the Trust are working very hard to ensure the continued provision of high quality services in a context of increasing demand and capacity shortfalls for some clinical staff groups.

2. At the end of February 2020, the Trust had no cases of MRSA bacteraemia leaving the total YTD as 1; lessons learnt from this case have been shared with all Directorates. To the end of February, C. difficile infections are now slightly above the Trust trajectory with a total of 105 cases against the end of year ambition of 113.

3. The Trust achieved the 95% A&E 4hr standard in February 2020, at 95.9%. In February the Trust was the 3rd best performer in the country (excluding access standard pilot sites), with achievement of 95.9% vs 82.8% national average.

4. The Trust failed to achieve the 92% 18 week standard in February at 87.0% compared to 82.8% nationally (February). The Trust has a total waiting list of 76,545 which is above the end of year trajectory of 72,960 but a reduction from the previous month. Performance continues to decline across a number of specialties, with 6 individual specialties plus the ‘X01 bucket specialties’ below 92% during January.

5. The Trust did not meet the 99% 6 week diagnostic standard in January at 96.0%, having last been compliant in November 2018. The most significant pressures exist within Endoscopy, Audiology and Sleep Studies.

6. The Trust met 1 of the 8 Cancer Waiting Time standards in January 2020; 31 day subsequent treatment (Radiotherapy). The Northern Cancer Alliance met 2 standards in January, 31 day subsequent treatment (Radiotherapy) and 31 day first treatment.

7. Two Week Wait (2WW), 2WW Breast Symptomatic, 31 day first treatment, 31 day subsequent treatment (Drugs), 31 day subsequent treatment (Surgery), 62 day screening and the 62 day Urgent standards were not met in January 2020.

8. The Trust has an Income & Expenditure deficit excluding PSF of £74k at Month 10 (£12.8 million surplus including PSF) which is consistent with Plan. To date the Trust has delivered £24.8 million savings in relation to the Trust efficiency requirement, with the balance covered by non-recurrent measures.

9. The cash balance is £120 million and well above Plan by £35 million.

10. The Trust is currently heavily involved in the national and regional planning rounds.

Executive SummaryA7(i)

2/26 64/119

Contents: March 2020A7(i)

Quality & Performance

Finance

• Healthcare Associated Infections• Harm Free Care• Incident Reporting• Serious Incidents & Never Events• Mortality• Friends and Family Test and Complaints• Health and Safety• Clinical Audit

• Monthly Performance Dashboard• A&E Access and Performance• Delayed Transfers of Care and Stranded Patients• 18 Weeks Referral to Treatment• Diagnostic Waits• Cancer Performance• Other Performance Standards

• Overall Financial Position• Financial Risk Rating

• Key issues

People• Health and Wellbeing• Sustainable Workforce Planning

• Excellence in Training and Education

3/26 65/119

Quality and Performance: Healthcare Associated InfectionsA7(i)

At the end of February 2020, the Trust had no cases of MRSA bacteraemia attributed to us.The Trust continues to see a reduction in MSSA bacteraemia cases and has set an internal 10% reduction from last year’s position. At the end of February we were on trajectory to achieve this with 66 cases reported. The same internal reduction has been set for E. coli bacteraemia cases and whilst there are fewer cases this year in comparison to the same period last year, we are currently over trajectory to achieve a 10% reduction. Klebsiella and Pseudomonas bacteraemias continue to see an increase in cases. To the end of February C. difficile infections are slightly above Trust trajectory to achieve the nationally set target of under 113 cases.

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

010203040

-10

MSSA per 100,000 bed days

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

10

20

30

40

C. difficile per 100,000 bed days

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

10

20

30

40

50E. coli per 100,000 bed days

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

10

20

30

40Klebsiella per 100,000 bed days

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

1

2

3 MRSA per 100,000 bed days

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

5

10

15

20Pseudomonas per 100,000 bed days

4/26 66/119

Quality and Performance: Harm Free CareA7(i)

The Trust reported a statistically significant reduction in Trust acquired pressure ulcers between March – September 2019. Although October showed a significant increase, there were 45 and 53 incidents of Trust acquired pressure ulcers reported in January and February respectively, bringing the Trust back below the 18 month average for this period. It was acknowledged in a previous Integrated Board Report that it would be a challenge to sustain the significant reduction over the Winter months, however the last quarter has shown a reduction which may also have been a result of the world wide stop the pressure ulcer day. In relation to inpatient falls, the statistically significant reduction achieved between July and December 2018 has not been sustained throughout 2019/20 but the rate and total number of falls remain within normal levels of variation. There has been success in relation to reducing serious harm from falls as the Trust have reported 30% less incidents resulting in serious injury compared to the same period last year (a total of 26 incidents 2019/20 Vs. 37 incidents 2018/19 April – September inclusive). The incidents and rates of falls and PU are monitored closely and any serious incidents undergo a robust Root Cause Analysis (RCA) process which assists in the identification of quality improvement work streams which to date have been successful.

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

50

100

150Inpatient Acquired Pressure Ulcers

Pressure ulcers 18mth Ave. -2SD +2SD

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

100

200

300All Patient Falls

Falls 18mth Ave. -2SD +2SD

sep...okt...

nov...des...jan-...

feb...

ma...

apr...

mai...

jun-...

jul-19 au

g...sep...okt...

nov...des...jan-...

feb...

3

4

5

6

7Patient Falls per 1000 Bed Days

Falls per 1000 bed days 18mth Ave. -2 SD

+ 2SD Trust target National Target

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0,0

0,5

1,0

1,5

2,0

2,5Pressure Ulcers per 1000 Bed Days

Pressure ulcers per 1000 bed days 18mth Ave. -2 SD + 2SD

5/26 67/119

Quality and Performance: Incident ReportingA7(i)

The percentage of incidents that resulted in severe harm or death reported in February 2020 is 0.5%. Nationally we report fewer incidents that result in severe harm or death than other similar providers. This data is subject to change in future reports as severity grading is modified following investigation.

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

25

30

35

40

Patient Incidents per 1000 Bed Days

Patient Incidents by 1000 Bed Days 18mth Ave. -2SD +2SD

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0,00,10,20,30,40,50,60,7

% of Patient Safety Incidents Resulting in Severe Harm or Death

18/19 19/20

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

12001300140015001600170018001900

Total Patient Incidents

Patient Incidents 18mth Ave. -2SD +2SD

6/26 68/119

Quality and Performance: Serious Incidents & Never EventsA7(i)

Duty of Candour (DoC) applies to patient safety incidents that occur when providing care and treatment that results in moderate harm, severe harm or death. It is a statutory requirement for the Trust to be open and transparent ensuring that patients/their families are informed about patient safety incidents that affect them, receive appropriate apologies, are kept informed of investigations and are supported to deal with the consequences.

In February there were 5 cases reported as SIs. The Duty of Candour process has been initiated in all cases.

• One delayed diagnosis – DoC in progress• Two falls resulting in harm – DoC in progress in both cases• Two pressure ulcers – DoC in progress in both cases

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

5

10

15

20

25Number of Serious Incidents Reported

Serious Incidents 18mth Ave. -2SD +2SD

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0

1

2

3

0

1

0

2

1 1

0 0 0

1

0 00 0 0 0 0

1

2

1 1

0 0

Total Number of Never Events Reported

18/19 19/20

7/26 69/119

Quality and Performance: Mortality IndicatorsA7(i)

In-hospital Deaths: In total there were 153 deaths reported in February 2020 ,which is higher than the amount of deaths reported 12 months previously (n=142). Learning from Deaths: In February 2020, 153 deaths were recorded within the Trust and to date, out of the 153 deaths, 40 patients have received a level 2 mortality review. These figures will continue to rise due to ongoing M&M meetings over the forthcoming months. The figures will continue to be monitored and modified accordingly.SHMI: The most recent published SHMI data from NHS Digital shows the Trust has scored 96 from months October 2018 – September 2019, this continues to be lower than the national average and is within the "as expected" category. The latest monthly SHMI data retrieved from external database CHKS is currently published up to September 2019. HSMR: The HSMR data shows a 12 month rolling HSMR score by quarter as well as monthly data. Quarterly HSMR data is available up to December 2019 and is below the national average. Monthly data is also available until December 2019. This number may rise as the percentage of discharges coded increases.

sep-18okt-18

nov-18

des-18jan-19

feb-19

mar-19apr-19

mai-19jun-19

jul-19

aug-19sep-19okt-19

nov-19

des-19jan-20

feb-20

0

50

100

150

200

250In-Hospital Deaths

In-hospital Deaths 18m Ave. -2 SD +2 SD

sep-...

nov-...

jan-19

mar-...

mai-...

jul-19

sep-...

nov-...

jan-20

0

1

2

3

4 100%

80%

60%

40%

20%

0%

Learning from Deaths

Deaths with identified learning disability Deaths considered potentially avoidable % Deaths reviewed

04/15...

07/15...

10/15...

01/16...

04/16...

07/16...

10/16...

01/17...

04/17...

07/17...

10/17...

01/18...

04/18...

07/18...

10/18...

85

95

105Quartlery SHMI

SHMI Average -2SD +2SD National Average

01...

04...

07...

10...

01...

04...

07...

10...

01...

04...

07...

10...

01...

04...

07...

10...

01...

80

100

120Quartlery HSMR

HSMR 18m Ave. -2SD +2SD National Average

8/26 70/119

Quality and Performance: FFT and ComplaintsA7(i)

Friends and Family Test

There were 2,674 responses to the Friends and Family Test in January 2020.

The figures opposite show the proportion of people that would recommend or not recommend these services to a friend or family member if they needed similar care or treatment.

National results are shown in brackets.

Trust Complaints 2019-20

The Trust received a total of 555 formal complaints up to the end of January 20, with 65 complaints received in January. The Trust is receiving an average of 56 new formal complaints per month, which is on average of 11 complaints per month higher than the 45 per month average for the last full financial year.

Taking into consideration the number of patients seen, the highest percentages of patients complaining up to the month of January are within Surgical Services with 0.08% (8 per 10,000 contacts) and the lowest are with Dental Hospital, ePOD and Cancer Services all with 0.01%.

‘All aspects of clinical treatment’ remains the highest primary subject area of complaints at 76% of all the subjects Trust wide. ‘Communication’ and ‘Attitude of staff’ are the next two largest subject areas with a combined 13% of all subjects raised within complaints.

9/26 71/119

Quality and Performance: Health and SafetyA7(i)

OverviewThere are currently 1050 health and safety incidents recorded on the Datix system from the 1st February 2019 to 31st January 2020, this represents an overall rate per 1000 staff of 71.01. Patient Services reported the highest number of health and safety incidents over this period (153). Directorate rates per 1000 staff for the highest reporting services are Peri-operative and Critical Care (102.4), Directorate of Medicine (93.4), Women's Services (89.8), Musculoskeletal Services (74.3), Integrated Laboratory Medicine (71) and Patient Services (70.6).

Incidents of Aggression on StaffIn addition to the health and safety incidents, there are 752 incidents of physical and verbal aggression against staff by patients, visitors or relatives recorded on the Datix system from the 1st February 2019 to 31st January 2020; this represents an overall rate per 1000 staff of 52.9. Directorate rates per 1000 staff over this period for the highest reporting services of aggressive behavior are Directorate of Medicine (168.2), Neuroscience (118.8), Community (111.8), Musculoskeletal Services (99) and Urology/Renal Services (84).

Sharps IncidentsThe average number of all sharps injuries per month is 27.6 between 1st February 2019 to 31st January 2020 based on Datix reporting, with 17.4% of the reports relating to clean or non-medical sharps incidents. The average number of dirty sharps incidents over the period is 21.3 per month.

Slips, Trips and fallSlips on wet surface, fall on level ground and tripped over an object collectively account for 53.5% of falls between 1st February 2019 to 31st January 2020. Fall as a result of a faint, fit or other similar event, collision with an object and falls from a chair account for 19.4% of the incidents recorded.

RIDDORThe most common reasons of reporting accidents and incidents to the HSE within the 1st February 2019 to 31st January 2020 are Slips and fall (11) and Physical Assaults (2). These account for 56.5% of reportable accidents over the period.

feb-19 mar-19 apr-19 mai-19 jun-19 jul-19 aug-19 sep-19 okt-19 nov-19 des-19 jan-200

1

2

3

4

5

RIDDOR

RIDDORS 12mth Ave. -2SD +2SD


5

10

15

20

25

Slips, Trips and Falls

Slips, Trips, Falls 12mth Ave. -2SD +2SD


10

20

30

40

50

Needlestick Injury or Sharps Incident

Needlestick injury or Sharps incident 12mth Ave. +2SD -2SD

10/26 72/119

Quality and Performance: Clinical AuditA7(i)

Audit / NCEPOD

Date of Release

Areas of Good Practice Recommendations for improvement Action Plan Developed

Sentinel Stroke National Audit Programme

Quarter 3 2019/20

Crude mortality rate after 30 days of admission, better than the national average 10% v 14%.

Brain scans were undertaken within one hour of arrival with the Trust scoring 70% and the national average at 50%.

The Trust scored 95% in terms of the percentage of time (requirement of 90%) patients spent on the stroke unit.

The target for all patients receiving thrombolysis is set at 20% and whilst the Trust scored 17-18%, this was well above the national average.

The Trust performed well against the swallow screen being undertaken within four hours of arrival.

The Trust was achieving the Therapy modalities i.e. (physiotherapy, SALT and Occupational Therapy) of 45 minutes therapy five days per week. The Trust currently offers seven days.

The Trust was well above the national average in terms of early supported discharge (attend MDT as part of discharge planning). Fewer patients required respite care with reduced readmission rates.

In terms of patients being assessed at six months, the Trust scored 70% against the national average of 31% and well within the target standard of 50%.

As the Trust has direct admission to the ward rather than going through ED, the Trust fares very well in terms of the time parameters.

The audit aim is to have 10% of patients with acute stroke having thrombectomy and the Trust performance scored 1.4%. To become compliant Trust would need to provide a 24/7 service.

There was a need for increased clinical psychology provision.

Discussed at February 2020 Clinical Audit and Guidelines Group

National Joint Registry

Sept 2019 All data relating to hips, ankles and knees is reported to the Registry.

The Trust did have revision rates lower that the national average with the Trust 0.3% and the national average 0.6%.

The Trust’s infection rates were half that of the national average with the Trust 0.2% and the national average 0.5%.

The Trust was an outlier in terms of PROMs with less than 25% completion. The Trust had looked into this and from the administration log kept within Musculoskeletal Services there appeared to be an error at the Registry.

The national average for length of stay was one day better than the Trust’s performance.

Discussed at February 2020 Clinical Audit and Guidelines Group

11/26 73/119

Quality and Performance: Monthly Performance Dashboard

A7(i)

12/26 74/119

Quality and Performance: A&E Access and PerformanceA7(i)

• In February, performance improved again to its highest level of the year, with the Trust meeting the monthly A&E 4hr standard with excellent performance of 95.9%. This was the 3rd best performance in the whole of England out of 118 Trusts (NHSE data excludes 14 Trusts piloting the new A&E metrics) and Trust performance was significantly higher than the national average of 82.8%. NuTH has consistently performed very strongly in comparison to other Trusts, having been in the top 10 highest performing Trusts in each of the past 14 months.

• Diverts to the Trust have increased again in February, following a sharp decrease in late January. The level is however still not currently as high as in December/early January - diverts are coming particularly from Durham and NSECH. 44% of diverts YTD have been from NSECH.

• Type 1 attendances per day rose from January, but were lower than February 2019’s level (22 less per day). This trend was also seen in Walk-in Centre attendances as the number seen per day rose from January but remained below 2019 levels.

• Bed closures due to D&V / Norovirus were much lower in February with only 44 bed days lost compared to 251 in January and 460 in December.

• Beds unavailable to DTOC patients reduced in February to an average of 50 from 59 in the previous month.• Winter measures including the use of a discharge vehicle and extended Same Day Emergency Care opening hours remain in operation until mid April, these have been seen to have a positive impact on patient flow and bed occupancy.

• From January (inclusive) Emergency Care performance data now includes approx. 600 monthly attendances at walk in centres from 111. In February there were 585 attendances with 0 breaches.

• March performance is currently 95.4% as at 16/03, with strong performance continuing. The 4 hour standard has been met in 11 of the first 15 days of March, although on 14/03 performance dipped below 90% for the first time since early January. Additionally, the number of medical boarders has continued to fall significantly and ambulance arrival levels remain similar to January which was lower than in November and December 2019. The Trust has been at OPEL Level 2 throughout March barring 01/03 and was at Level 2 for the majority of February.

• The Trust is currently responding to the coronavirus pandemic with new testing pods set up and a clear protocol established should patients require further investigation or treatment. Currently the Trust is coping with the level of related attendances and is responding accordingly. Additional measures continue to be devised and enacted as appropriate.

• The Trust received 30 ambulance diverts in February, a drop from January (52) and December (78) but higher than every other month in the year. 14 of these were from NSECH, 9 from North Durham with the remainder split between Gateshead, Sunderland and South Tyneside.

13/26 75/119

Quality and Performance: Delayed Transfers of Care and Stranded PatientsA7(i)

• The number of bed days delayed due to Delayed Transfers of Care (DTOCs) increased in February to 1,036, which is above the average monthly level of 819 seen over the past 12 months. Factors which have contributed to the higher levels of DTOCs include:

• Difficulties repatriating patients to their local hospitals due to high bed occupancy levels across the region, this is particularly prevalent within Neurosciences due to Walkergate Park capacity.

• 54% of the delayed discharges were within Medicine, with Neurosciences seeing the second highest number of delays (24%). The Medicine Directorate saw the biggest increase from the previous month (+25%).

• Following a decrease in delays in January, NHS delays in February have increased to 936 which above the monthly average of 755 seen over the past 12 months. The increase in February has predominantly come from patient choice (31%) and issues with care packages (16%), both these areas are at the highest level over the last 12 months.

• Overall the 2019/20 YTD position has seen an increase on 2018/19, with December 2019 to February 2020 seeing the number of delayed bed days increase by 36% compared to the same 3 month period in the previous year.

• During 2018/19, NuTH achieved a 21% reduction in the number of its 21 days+ Length of Stay (LoS) patients, with NHSE setting a target of a further 17% reduction during 2019/20. As at 16th March the Trust is currently slightly above its submitted trajectory, with a weekly average of 228 vs the ambition of 215. This metric excludes certain patient groups such as rehabilitation patients and pediatrics.

• The number of 7 days+ LoS patients reduced during February from the high of 839 at week ending 2/2, to 754 by week ending 23/2. The number of 21 days+ LoS patients also reduced in February from a high of 434 at week ending 2/2, to 389 by week ending 23/2. This metric does not have the exclusions applied and reflects the overall Trust level position.

• Length of Stay remains an area of focus throughout the Trust, with a task and finish group having been established which is championing the refreshed “There’s No Place Like Home” campaign. This campaign is particularly looking at patients who no longer require acute clinical care, with a LoS of 21-26 days.

Bed Da

ys Delayed

Daily bed delays

mar-19

apr-19

mai-19

jun-19

jul-19

aug-19

sep-19

okt-19

nov-19

des-19

jan-20

feb-20

0200400600800

1 0001 2001 400

051015202530354045

NuTH DTOC Bed Days

NHS Delays Social Care Joint Responsibility Daily Bed Delays

WE 01/12

WE 08/12

WE 15/12

WE 22/12

WE 29/12

WE 05/01

WE 12/01

WE 19/01

WE 26/01

WE 02/02

WE 09/02

WE 16/02

WE 23/02

0200400600800

1 0001 200

7 day+ and 21 days+ LoS Patients

Number of LoS Patients (>7) Number of LoS Patients (>21)

14/26 76/119

Quality and Performance: 18 Weeks Referral to TreatmentA7(i)

• The RTT Incompletes Performance in February has deteriorated further to 87.0% against the 92% standard. Latest national performance is 83.5% (January).

• The overall waiting list size reduced again slightly for the fourth month in a row although the number of patients waiting longer than 18 weeks for treatment has increased for 9 successive months. Overall demand outstrips capacity across many specialty areas and the impact of Covid-19 is likely to have a very challenging impact on both outpatient and inpatient activity over the coming months.

• As part of the Trust’s focus on recovery and patient care, activity forecasts are being monitored. In line with this, from March onwards additional measures have been implemented including activity at weekends in pressured specialties such as Ophthalmology (76.3%).

• There are some specialties which have consistently failed the target in recent months and in February 6 specialties and the Bucket (X01) failed the RTT Incomplete standard with the associated financial penalty shown; Ophthalmology (£522.3k), ENT (£185.7k), Trauma & Orthopaedics (£93.6k), Dermatology (£62.7k), Urology (£28.8k), General Surgery (£5.4k), Bucket - X01 (£315.6k). The total penalties that would have been applicable for 18 week breaches if the Trust had not agreed a financial Control Total would be £1,214,100 for February.

• For the fourth month in a row, the Trust reported a number of >52 week RTT waiters for Spinal Surgery (Orthopaedics). For February this figure rose to 19. Internal and external discussions continue on plans to relieve service pressure and recover the position. 52 week breaches will continue for the medium term with no short term solutions available to avoid 52 week breaches. The longest waiter on the PTL is currently 68 weeks.

• There are now 718 over 36 week waiters, which is a sharp rise again from January’s level and more than double the total 6 months ago. The biggest contributor to this position remains Spinal Surgery (Orthopaedics) (212).

• For the February 52 week breaches described above there is an overall financial penalty of £47.5k (£5k per breach, split equally by NuTH and commissioners), this penalty still applies despite the agreement of a Control Total.

* The table above contains only specialties with 10 or more > 36 week waiters

mar-19

apr-19

mai-19

jun-19

jul-19

aug-19

sep-19

okt-19

nov-19

des-19

jan-20

feb-20

50 000

60 000

70 000

80 000

90 000

76%80%84%88%92%96%100%104%

Trust RTT Incompetes Performance

Under 18 weeks Over 18 weeks Compliancy % Compliancy % Target

mar-19

apr-19

mai-19

jun-19

jul-19

aug-19

sep-19

okt-19

nov-19

des-19

jan-20

feb-20

0200400600800

243 217 226 243 290 360 355 430 438 495 584 718RTT - Total Number of Over 36 Week Incompletes

RTT Incomplete Pathways

18/19 Qtr 4

19/20 Qtr 1

19/20 Qtr 2

19/20 Qtr 3 Jan-20 Feb-20

Total 214,096 218,278 229,920 235,142 77,314 76,545

> 18 weeks 15,380 17,082 20,914 24,887 9,087 9,925

Overall Compliance 92.8% 92.2% 90.9% 89.4% 88.2% 87.0%Incomplete Penalty £606.6k £835.5k £1,727.4k £2,426.6k £1,027.3k £1,261.6k

Agreed Reinvestment £606.6k £835.5k £1,727.4k £2,406.6k £994.8k £1,214.1k

> 36 Week Waiters 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 54 55 56 57 58 59 62 68 Grand

Total108 - Spinal Surgery Orthopaedics

24 21 26 10 16 13 12 26 6 9 16 6 4 1 3 1 1 2 4 1 5 1 2 1 1 212

130 - Ophthalmology 29 28 14 10 14 5 4 2 4 110

107 - Vascular Surgery 7 10 11 5 7 10 7 5 5 4 3 2 2 2 80

101 - Urology 7 12 13 5 6 6 6 3 3 1 3 65110 - Trauma & Orthopaedics 6 7 9 6 5 4 1 3 41

120 - ENT 6 9 6 5 3 2 2 1 1 2 1 38320 - Cardiology 11 10 1 3 2 2 1 1 1 2 1 2 37502 - Gynaecology 6 1 2 1 1 4 3 2 1 21

100 - General Surgery 5 4 2 2 13

10801 - Spinal Surgery Neurosurgery

2 1 3 3 2 1 12

104 - Colorectal Surgery 2 3 2 1 1 1 1 1115/26 77/119

Quality and Performance: Diagnostic WaitsA7(i)

• February saw performance improve to 96.0% against the 99% standard, the highest level for 7 months. This followed a reduction in the waiting list size from January’s level and a 5% rise in the total number of tests undertaken compared to February 2019. Despite this progress the Trust failed the diagnostic target having last achieved in November 2018.

• The overall number of patients on the waiting list (WL) is 14% higher than at this stage in 2019. This reflects a trend seen across the North East and North Cumbria, as diagnostic performance within the ICS has dramatically worsened during 2019.

• The biggest increases in WL size compared to February 2019 levels were seen within Audiology Assessments, MRI, CT and Ultrasound.

• Endoscopy is the biggest area of challenge due to workforce capacity constraints linked to the retirement of nurse endoscopists, the timescales associated with recruiting and training new specialist staff and a reduction in flexible sessions from senior clinicians linked to pensions issues.

• Waiting list size and breaches both fell in February across all areas of Endoscopy; this followed increased weekend clinics and outsourcing of activity.• Despite the progress, Endoscopy still had 261 six week breaches with the majority of these having a TCI by the end of April.

• Overall endoscopy compliance is at 61.1% against the 99% standard which also places additional pressure on to Cancer and RTT performance.• Particular pressures exist within Colonoscopy, which has the greatest number of patients waiting >13 weeks (74).

• Radiology performance in February improved dramatically with breaches falling to their lowest level since April 2017. This represented particular progress within MRI, where breach numbers fell from 137 to 15. Additionally, for the first time in 2019/20 there are now no patients waiting over 13 weeks for a radiological diagnostic test.

• Despite the progress, there continues to be long-standing workforce shortages in Radiology, which significantly impacts on diagnostic test and reporting times, particularly when combined with demand for MRI and CT having grown considerably in the past year.

• The service is implementing agreed short, medium and long term measures to minimise waits for patients, including outsourcing of activity. Service capacity and demand for both scanning and reporting is subject to constant measure and review.

• A new monthly report is now in distribution to better inform Directorates of the current scanning and reporting waits.

• Due to continuing capacity issues, Sleep Studies still has a very high number of patients waiting >13 weeks (56). Although this is the lowest level for 4 months, this means that 60% of all patients on the Sleep studies’ waiting list have waited >13 weeks, and compliance against the 6 week diagnostic standard has deteriorated again to 22.6% A business case to expand capacity has recently been approved and performance is expected to recover once recruitment is complete.

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

93%94%95%96%97%98%99%100%

Diagnostic Waits (% under 6 weeks)

2018/19 2019/20 Target

DM01 Diagnostics Performance Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20

Number of Breaches 524 461 427 302 472 534 485 606 569 714 445

Number of ‘Excess’ Breaches 419 357 322 208 373 434 378 495 466 598 335

Performance (99% Standard) 95.0% 95.6% 95.9% 96.8% 95.2% 94.6% 95.5% 94.5% 94.5% 93.8% 96.0%

Penalty (£200 per breach) £83.8k £71.4k £64.4k £41.6k £74.6k £86.8k £75.6k £99.0k £93.2k £119.6k £67.0k

Number of Patients Waiting 10,487 10,368 10,439 9,374 9,869 10,070 10,736 11,068 10,288 11,521 11,026

Total Patients Treated 17,828 19,591 18,576 20,049 18,612 18,552 20,922 19,258 16,953 19,326 17,96816/26 78/119

Quality and Performance: Cancer Performance (1/2)A7(i)

• The Suspected Cancer Two Week Wait (2WW) standard was not achieved for January. NuTH reported 80.9% against the 93% standard. Lower GI performance continues to be significantly under standard at only 5.3%, this decline is despite seeing nearly 10% more patients YTD than at this point in FY 2018/19 - increased referrals and endoscopy capacity remain the core issues, with significant work going on to address both of these issues.

• Significant work continues to address the 2WW Breast Cancer pathway within the Trust and the region, with a project manager appointed by the Cancer Alliance to work with Trusts across the region and additional managerial resource implemented within the Trust.

• NuTH failed the Breast Symptomatic standard in January with performance of 19.6%, this is largely because appointment priority in Breast is being given to those with suspected cancer and by comparison the 2WW performance for suspected Breast was 89.2%.

• Amongst other measures NuTH have successfully appointed an additional Breast Radiologist (0.6 WTE) who will help to relieve pressure within the service from the end of January, efforts are also underway to establish a Breast Surgeon led ultrasound service.

• The 31 Day first treatment standard (96%) in January was not achieved at 93.0% against the standard.• The 31 Day Subsequent Treatment standard for Radiotherapy (94%) in January was achieved at 97.1%.• The 31 Day Subsequent Drug standard (98%) was not compliant with 92.9% compliance, staffing pressures exist within the service.• The 31 Day Subsequent Surgery (94%) standard reporting 89.6% for January.

The 62 Day position is post breach reallocation, following the application of Inter Provider Transfer (IPT) rules:

• Overall 62 Day performance for January was 68.2% against the 85% standard, a significant decline from December (83.0%)• All providers within the Northern Cancer Alliance failed the 62 day target in January and experienced significantly lower performance, this is partly due to the effect of the Christmas and New Year gap causing delays to patients who were treated in January.

• The most challenged groups were Lung (31%), Lower GI (44%), Upper GI (38%), Urology (51%)

• The Trust did not achieve the 62 Day Screening Standard (90%) at 83.8% in January.• The Trust achieved 1 of the 8 Cancer Waiting Time standards this month.

• The Northern Cancer Alliance will be funding a project manager to look at Urology pathways during 2020/21, this post is currently working with Breast pathways across the region until 31st March.

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

70%

75%

80%

85%

90%

95%

100%Cancer 2 week wait performance

2018/19 2019/20 Target

Please see additional charts on the next page

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

10%20%30%40%50%60%70%80%90%100%

Cancer Breast Symptomatic 2 week wait performance

2018/19 2019/20 Target

17/26 79/119

Quality and Performance: Cancer Performance (2/2)A7(i)

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

86%88%90%92%94%96%98%100%

Cancer 31 Day First Treatments

2018/19 2019/20 Target

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

30%40%50%60%70%80%90%100%

Cancer 62 Day Urgent Performance

2018/19 2019/20 Target

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

30%40%50%60%70%80%90%100%

Cancer 62 Day Screening Performance

2018/19 2019/20 Target

Breast

Lung

Gynae

Upper GI

Lower GI

Urological

Haem

Head & Neck

Skin

Sarcoma

Brain/CNS

Other

20%30%40%50%60%70%80%90%100%

Cancer 62 Day Urgent Performance by Tumour Group

Dec 2019 (%) Jan 2020 (%) Target

Apr

May

Jun Jul Aug

Sep

Oct

Nov

Dec

Jan Feb

Mar

65%70%75%80%85%90%95%100%

Cancer 31 Day Subsequent Treatment Surgery

2018/19 2019/20 Target

From 1st April 2020 the 28 Day Faster Diagnosis standard will come into effect. The aim of this standard is to inform patients earlier on in their care plan of their cancer diagnosis as well as speed up the time from referral to diagnosis and is in addition to the current Cancer Waiting Time standards.

The standard is to inform 75% of patients with 28 days of their diagnosis (cancer or non-cancer), this standard is enforceable through the NHS Standard Contract.

18/26 80/119

Quality and Performance: Other Performance Requirements

A7(i)

• The Trust reported 51 ‘last minute’ cancelled operations in February 2020, which was a slight increase from January’s level but still below the monthly average seen in 2019/20 so far of 62 cancellations per month. The patient being unfit was the most commonly recorded reason for cancellations in February. Across the Trust there have been 675 hospital cancellations in 2019/20 to date, a 24% increase on the corresponding period in 2018/19.

• The Trust reported 3 breaches in February against the standard to treat within 28 days following last minute cancellations, 2 of these were within the Surgical directorate and 1 was in MSU. The Trust does not receive payment for these rescheduled procedures.

• In relation to Dementia, the Trust continues to consistently perform below the national standard for 2 of the 3 metrics, but the referral metric has been met in each of the past 8 months and remains at 94%. Actions are being taken to improve compliance with the Trust’s Specialist Dementia team working alongside the IT department to further develop the screening tool. The team has proposed some amendments following a review of the screening tool against new evidence based practice and feedback from clinical staff. It was hoped this would increase compliance with screening completion to 70% by the end of March 2020, it currently stands at 55% in February, a reduction from 61% in both December and January.

• In February 2020 the ‘moving to recovery’ standard for IAPT was not met for the thirteenth month in a row, although performance has improved slightly to 46.6% against the 50% standard. An audit of ‘unrecovered patients’ has been completed with a corresponding action plan focusing on patients nearly at recovery, offering patients the most appropriate intervention and the most appropriate outcome measures.

• The increased monthly target of 1.58% of people who have depression and/or anxiety receiving psychological therapies is still yet to be met in 2019/20, February’s performance was 1.26%. Cumulatively performance in 2019/20 year to date is 14.59%, which is below the target of 18.96%. Positively, the targets for seeing patients within both 6 and 18 weeks have been met consistently every month since September 2016, with 94.9 % seen within 6 weeks and 100% seen within 18 weeks in February. Notice has been served on this contract by commissioners and the Trust is due to cease delivery on 31/03/2020. As a result, staff recruitment and retention is proving difficult which is having an adverse effect on the achievement of the performance targets. Discussion with commissioners continue re the future of the service post April 2020.

Reportable Cancelled Operations

Apr-19

May-19

Jun-19

Jul- 19

Aug-19

Sep-19

Oct-19

Nov-19

Dec - 19

Jan - 20

Feb – 20

Last minute cancelled operations

56 74 65 79 63 73 54 60 52 48 51

Number of 28 day breaches 1 5 9 3 13 2 4 1 4 5 3

Urgent operations cancelled for a 2nd or subsequent time

0 0 0 0 0 0 0 0 0 0 0

Penalty Amount * * * * * * * * * * *

Standards Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec- 19 Jan-

20 Feb-20

% asked the dementia case finding question within 72 hours of admission.

90% 34% 37% 45% 52% 50% 45% 39% 36% 36% 36% 35%

% reported as having had a dementia diagnostic assessment including investigations.

90% 76% 88% 60% 44% 59% 52% 57% 59% 61% 61% 55%

% who are referred for further diagnostic advice in line with local pathways.

90% 33% 46% 81% 100% 100% 100% 100% 100% 100% 94% 94%

19/26 81/119

Cumbria, Northumberland, Tyne an...Tees, Esk and Wear Valleys

County Durham & DarlingtonNorth Tees & Hartlepool

South Tyneside and SunderlandSouth Tees Hospitals

Northumbria Health CareGateshead Health

Newcastle Upon Tyne Hospitals

5,61%5,28%

4,93%4,76%4,75%

4,52%4,52%4,42%

4,25%Sickness Absence for Local Trusts

People: Health and WellbeingA7(i)

• Year to year comparison for sickness :

• Cost of absence £16.7m compared to £16.3m in February 2019

*COO Directorate includes Outpatients / ABC Service

*Period 1/1/2019 to 31/10/2019

Medical and Dental

Healthcare Scientists

Allied Health Professionals

Add Prof Scientific and Technic

Administrative and Clerical

Nursing and M

idwifery Registered

Estates and Ancillary

Additional Clinical Services

010 00020 00030 00040 00050 00060 00070 00080 000 10%

8%

6%

4%

2%

0%

Sickness Absence by Staff Group

FTE Days Lost% Time Lost 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Community ServicesChief Operating Officer

Women's ServicesClinical Research FacilityMusculoskeletal ServicesUrology & Renal Services

Peri-operative & Critical Care - FHCardiothoracic

Internal Medicine - GeneralChildren's Services

Peri-operative & Critical Care - RVIPatient Services

ENT, Plastics, Ophthalmology &...Radiology

EstatesNeurosciences

Medical PhysicsInformation Management & TechnologyCancer Services/ Clinical Haematology

Regional Drugs & TherapeuticsInternal Medicine - Urgent Care

Dental ServicesSurgical Services

SuppliesIntegrated Laboratory Medicine

FinanceHuman ResourcesMedical Director

Business & DevelopmentPharmacy

Chief Executive

Sickness Absence (% Time Lost) by Directorate

mar-19

apr-19

mai-19

jun-19

jul-19

aug-19

sep-19

okt-19

nov-19

des-19

jan-20

feb-20

1,00%

2,00%

3,00%

4,00%

5,00%

6,00%

Sickness Absence (% Time Lost)

Long term Short term12m Ave (total sickness) Target (total sickness)-2SD +2SD

Feb-19 Feb-20 Long-term 2.93% 3.07% éShort-term 1.34% 1.23% êTotal 4.27% 4.29% é

20/26 82/119

People: Sustainable Workforce PlanningA7(i)

• Staff in post at February 2020 is 12,800 wte compared to 12,576 in February 2019.

• Staff turnover has increased slightly from 8.65% in February 2019 to 9.08% in February 2020, against a target of 8.5%.

• The total number of leavers in the period March 2019 to February 2020 was 1,454.

• Staff retention for staff over 1 year service stands at 88.8%, an increase from 87.5% in February 2019.

*Vacancy data provided by Finance based on staff in post v budgeted establishment position

0 50 100 150

Nursing & Widwifery Registered

Nursing & Widwifery Unregistered


Scientific, Professional and Technical

Admin and Clerical

Medical and Dental

108

106

86

76

51

9

Vacancies by Staff Group (by FTE)

0 1 000 2 000 3 000 4 000

Nursing and Midwifery Registered



Medical and Dental





4249

2312

2096

1179

999

762

611

592

Staff in Post

Medical and Dental





Nursing and M

idwifery Registered



10%8%6%4%2%0%

Turnover by Staff Group

Turnover

Target

0 50 100 150 200 250

Voluntary Resignation - Relocation

Retirement Age

Voluntary Resignation - Work Life Balance

Flexi Retirement

Voluntary Resignation - Promotion

Top Five Leaving Reasons

0% 20% 40% 60% 80% 100%

Over 1 year service

Less than 1 year service

Staff Retention

21/26 83/119

People: Sustainable Workforce Planning A7(i)

• Comparing the periods March 2018 - February 2019 to March 2019 – February 2020), overall bank utilisation has fallen from 319 wte to 276 wte and agency from 150 wte to 146 wte.

• 9% Total Nursing vacancy rate as at 1st February 2020

Admin & Clerical

Ancillary

Estates

Nursing & Midw

ifery (Registered)

Nursing & Midw

ifery (Unregistered)

Professional & Technical

0

50

100

150

200

Bank and Agency Utilisation by Staff Group (FTE)

Bank (18-19) Bank (19-20) Agency (18-19) Agency (19-20)

Admin & Clerical

Ancillary

Estates

Nursing & Midw

ifery (Registered)

Nursing & Midw

ifery (Unregistered)

Professional & Technical

£6 000 000£5 000 000£4 000 000£3 000 000£2 000 000£1 000 000

£0

Bank and Agency Utilisation by Staff Group (Cost)

Bank (18-19) Bank (19-20) Agency (18-19) Agency (19-20)

mar-19

apr-19

mai-19

jun-19

jul-19

aug-19

sep-19

okt-19

nov-19

des-19

jan-20

feb-20

25

20

15

10

5

0

Internal Medical and Dental Bank Utilisation

Consultant Non-consultant Career Grade Trainee Grades

22/26 84/119

People: Excellence in Training and EducationA7(i)

• The appraisal compliance rate at February 2020 is 79.1% (83.7% at February 2019), against an end of year target of 95%.

• Mandatory training stands at 89.7% against a Q3 target of 90% and end of year target of 95%. The February 2019 position was 89.3%.

19-20 Apprenticeship Starts (Progress towards target in year)

Apprenticeship Starts Since 1 April 2017 (Progress towards estimated 4 year target)

0

200

400

600

800

1 000

1 200

1 400

129349

201

971

Apprenticeship starts

Achieved To Achieve

Medical and Dental

Senior Staff (Band 8c and above)



Nursing and M

idwifery Registered





0%10%20%30%40%50%60%70%80%90%100%

Mandatory Training by Staff Group

Compliance

Target


Nursing and M

idwifery Registered




Medical and Dental


Managers (Band 8c and above)


100%

95%

90%

85%

80%

75%

70%

Appraisals

Compliance

ANTT

Local Induction

Paediatric Basic Life Support

Fire Safety

Adult Basic Life Support

Infection Prevention and Control

Moving and Handling Level 2

Inform

ation Governance

Moving and Handling Level 1

Conflict Resolution

Safeguarding Children Level 1

PREVENT

Safeguarding Adults Level 1

Equality and Diversity

Health and Safety

Anti-Bribery and Corruption

Trust Induction

Prevention of Patient Falls

100%90%80%70%60%50%40%30%20%10%0%

Mandatory Training by Topic

Compliance

Target23/26 85/119

Finance: Overall Financial PositionA7(i)

This paper summarises the financial position of the Trust for the period ending 29th February 2020.

At Month 11, the Trust has delivered to the year to date an Income and Expenditure deficit of £0.074 million before Provider Sustainability Funding (PSF).

24/26 86/119

Finance: Financial Risk RatingA7(i)

The NHS Improvement Use of Resources (UoR) metric considers five aspects of performance; liquidity and ability to service debt from revenue, underlying performance, variance from the Trust’s Plan and agency expenditure compared to Plan. The metrics consolidate into a single Risk Rating which rates an organisation on a scale of 1 to 4, where ‘1’ reflects a low Financial Risk and ‘4’ reflects a Trust with high financial risk. Based on these metrics the Trust would attain an overall Risk Rating of ‘1’ which is a strong outcome. The profile is as follows:-

0 1 2 3 4

Liquidity

Debt Service Cover

I&E Surplus Margin

I & E Surplus Margin Achieved vs Plan

Agency Spend

Overall Risk Rating - Override

Financial Risk Rating

Actual Plan

25/26 87/119

Finance: Key issuesA7(i)

i. Operating income for the period ending 29th February 2020 is £1,036.1 million (excluding PSF) £43.6 million ahead of Plan.ii. Total operating expenditure for the period to Month 11 is £1,037.8 million, £43 million more than Plan.iii. The Trust has an Income & Expenditure deficit excluding PSF of £74k at Month 11 (£12.8 million including PSF) which is

consistent with Plan.iv. To date the Trust has delivered £24.8 million savings in relation to the Trust efficiency requirement, with the balance

covered by non-recurrent measures.v. The Capital Expenditure to January was £44.2 million and is running slightly behind Plan.vi. The Cash balance is £120 million and well above Plan by £35 million.

£ms

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12-4

-2

0

2

I&E Surplus 2019/20 (excluding PSF)

Plan Actual

26/26 88/119

Agenda item A7(ii)

TRUST BOARD


Title Update from Committee Chairs

Report of Non-Executive Director Committee Chairs

Prepared by Fay Darville, Deputy Trust Secretary




Summary

The report includes updates on the work of the following Trust Committees: Charitable Funds Committee - 30 January 2020 (extraordinary) and 28 February 2020. People Committee - 18 February 2020. Finance Committee - 27 February 2020 (extraordinary) and 25 March 2020. Quality Committee - 20 March 2020.

Recommendation The Board of Directors are asked to (i) receive the update and (ii) note the contents.

Links to Strategic Objectives Links to all.



(please mark as appropriate) ☒ ☒ ☒ ☒ ☐ ☒ ☒

Impact detail Impacts on those highlighted at a strategic level.

Reports previously considered by Standing verbal agenda item.

1/4 89/119

Agenda item A7(ii)

____________________________________________________________________________________________________Update from Committee ChairsTrust Board – 26 March 2020

UPDATE FROM COMMITTEE CHAIRS

1. INTRODUCTION

This report provides an update to the Board on the ongoing work of the Trust’s Committees for those meetings that have taken place since the last meeting of the Board of Directors in January 2020.

2. CHARITABLE FUNDS COMMITTEE

An Extraordinary Meeting of the Committee took place on 30 January 2020. This meeting considered two bids that required timely discussion and decision.

A formal meeting of the Committee took place on 28 February 2020. During the meeting, the main areas of discussion to note were: The Donation of Money Policy was ratified. The Committee received the Statement of Financial Accounts and Balance Sheet,

demonstrating the position to 31 January 2020. The Committee received a number of Grant Applications and approved a number of

applications, including those for a 12 Month Fellowship in Paediatric Cancer, NCCC Complementary Therapy 3 Year Grant and a GNCH Outreach worker.

The Summary of Grants was received detailing the position since the last meeting of the Committee.

The Target Spend Report and the Income Report were received. The Summary of Investments from both Newton’s and CCLA were received.

The next meeting of the Committee is scheduled to take place on 1 May 2020.

3. PEOPLE COMMITTEE

A formal meeting of the People Committee took place on 18 February 2020. During the meeting, the main areas of discussion to note were: Reports on both ethnic pay and gender pay were received. A Workforce Development Update was received. A staff experience update was received which included both the NHS Staff Survey

results and the Trust’s Flourish programme. The People Dashboard was reviewed. Key risks relating to the People agenda were highlighted, particularly those relating to

employment relations, recruitment and retention, workforce systems development and mandatory training and appraisal.

The next meeting of the Committee is scheduled to take place on 21 April 2020.

2/4 90/119

Agenda item A7(ii)

____________________________________________________________________________________________________Update from Committee ChairsTrust Board – 26 March 2020

4. FINANCE COMMITTEE

An extraordinary meeting of the Committee took place on 27 February 2020 which was convened to discuss the year end position.

A formal meeting of the Committee took place on 25 March 2020. During the meeting, the main areas of discussion to note were: The Month 11 Finance Report was received which included the Income and

Expenditure position, the current Directorate performance, the Forecast End of Year delivery and Control Total position and any risks to achieving these.

The Month 11 Directorate Activity Summary and Forecast Year-End Activity and Contract Position was received.

The Month 11 Transformation and Financial Improvement Update was received. The Estates Capital Projects position was received. The Financial Plan, Budget and Cost Improvement Position for 2020/21 was discussed. The 2020/20 Budget Controls and Contracts Update positions were received and

discussed.


5. QUALITY COMMITTEE

A formal meeting of the Committee took place on 20 March 2020. During the meeting, the main areas of discussion to note were: A report relating to the delivery of Research and Development within the Trust was

delivered by the Assistant Medical Director for Research and Development. Updates from the Management Group Chairs were received. The Medical Director, Chief Operating Officer and Executive Chief Nurse provided an

update on the Trust’s response to the COVID-19 pandemic. A number of reports were received including:

o End of Life and Palliative Care Report;o Learning from Deaths Report;o Patient Experience Quarterly Report;o Safeguarding Quarterly Report; ando Infection Prevention and Control Report.

The CQC Action plan was received and discussed.


6. RECOMMENDATIONS

The Board of Directors are asked to (i) receive the update and (ii) note the contents.

Report of Fay DarvilleDeputy Trust Secretary20 March 2020

3/4 91/119


4/4 92/119

Agenda item A7(iii)

TRUST BOARD


Title Corporate Governance Update

Report of Dame Jackie Daniel, Chief Executive

Prepared by Kelly Jupp, Trust Secretary, and Fay Darville, Deputy Trust Secretary



Purpose of Report☒ ☐ ☒

Summary

The report includes an update on the following areas: Risk Management Policy; Information Governance; Council of Governors Update, including:

o Council of Governors Elections;o Lead Governor Arrangements; ando Governor Working Groups.

Non-Executive Director Recruitment; Gatenby Sanderson Insight Programme; Annual Report 2019/20 Preparations; Members Events; and NHSI Quarterly Declarations

Recommendation The Board of Directors are asked to (i) receive the update and (ii) note the contents. The Board is also asked to approve the quarterly declarations.

Links to Strategic Objectives Performance – Being outstanding, now and in the future.



(please mark as appropriate) ☒ ☒ ☒ ☒ ☐ ☒ ☐

Impact detail Impacts on those highlighted at a strategic and reputational level.

Reports previously considered by Standing agenda item.

1/8 93/119

Agenda item A7(iii)

____________________________________________________________________________________________________Corporate Governance UpdateTrust Board – 26 March 2020

CORPORATE GOVERNANCE UPDATE

1. INTRODUCTION

This report provides an update on ongoing work in relation to the governance arrangements within the Trust to date.

2. RISK MANAGEMENT

Over the last year, a full review and refresh of risk management has been undertaken across the whole organisation. A new risk management policy has been written, and approved, detailing the Trust’s new approach to risk management with refreshed processes and procedures for the management of risk within the Trust.

The new risk management policy is now available to all staff through the policy database on the Trust intranet.

To support the application of this policy, a series of risk management awareness sessions will be made available to all staff.

3. INFORMATION GOVERNANCE

3.1 Data Security and Protection Toolkit (DSPT)

In response to the COVID-19 pandemic, the deadline for the completion of the DSPT has been delayed to 30 September 2020. At this stage, it is currently unclear how this will impact other elements of the process such as the mandatory implementation of Cyber Essentials Plus.

At the time of writing, the Trust currently has a ‘Standards not met’ status as it was unable to complete the agreed improvement plan put in place for the baseline submission in October 2019. There are two areas of current non-compliance being:

NDG 3 Training: 95% of all staff complete their annual data security awareness training in the period 1 April 2019 to 31 March 2020.

NDG 4 Managing Data Access: The organisation does not allow users with wide ranging or extensive system privilege to use their highly privileged accounts for high-risk functions, in particular reading email and web browsing.

To assist with training compliance, the Information Governance team have undertaken a significant programme of awareness raising which includes contacting all staff who have not completed their training to provide assistance and the use of intranet banners and screen savers. In addition, a series of face to face training sessions were undertaken in early March intended to increase compliance.

2/8 94/119

Agenda item A7(iii)


In relation to dual access, it was noted that the process would be revisited following completion of the full Paperlite programme.

The Trust’s DSPT was audited by the Trust Internal Auditors in December 2019 with the final report providing a good level of assurance and a high level of compliance with the control framework. Some minor remedial action points were noted, relating to policies, patch management and induction, which have been incorporated into the action plan for future ongoing compliance.

3.2 Secure Email Update

The Trust’s migration to NHSMail continues, with circa 12,000 staff having migrated over to NHS.net email accounts. The process to migrate these accounts to NHSMail continues with an anticipated completion expected within six months.

3.3 National Data Opt-Out

As highlighted in previous reports, the Trust has assembled a Task and Finish group to consider the organisation’s compliance with this national standard with representatives from a number of areas likely to be impacted by the requirements such as Information Services, Research, Regional Medical Physics Department (RMPD) and Information Governance.

The group has discussed areas of compliance, noting that the opt out is not applicable for health data used for direct care and only applies to (identifiable) data which would be utilised for a secondary purpose.

The group highlighted a number of methods to be undertaken to aid ongoing compliance such as the dissemination of posters and leaflets and staff training.

Due to the COVID-19 pandemic, the deadline for compliance with the National Data Opt-Out has been extended from 31 March 2020 to 30 September 2020.

4. COUNCIL OF GOVERNORS

4.1 Council of Governors Elections

4.1.1 Public and Staff Governors

As outlined in the last report to Board, the Trust undertook a supplementary round of Council of Governor elections in late 2019/early 2020. This was due to both a small number of seats remaining vacant following the spring 2019 round of elections and vacancies arising in the interim.

The Board of Directors extends its thanks to Barbara Goodfellow (Staff – Nursing & Midwifery) and Derek Thompson (Public Governor) for their service to the Trust as Governors.

3/8 95/119

Agenda item A7(iii)


The results of the vote were received on 5 February 2020, following verification by UK Engage, the Trust’s election provider. The results of the vote were as follows: Staff

o Medical and Dental: John Hill, Consultant Otolaryngologist, was elected. There was a tie in the vote and the successful candidate was chosen following the drawing of lots as per the Trust’s Constitution. There was an 18.06% turnout.

o Nursing and Midwifery: Glenda Bestford, Nurse Practitioner, was elected Governor with a 9.11% turnout.

o Volunteers: Steve Connolly was elected Governor with a 20.37% turnout. Public

o Northumberland, Tyne and Wear (excluding Newcastle): John McDonald was elected Governor with a 19.66% turnout.

The newly elected Governors were notified of their successful appointments and attended their first meeting of their three year appointments on 20 February 2020.

Newly appointed Governors receive an induction with the Trust Chairman and Trust Secretary and are required to complete mandatory training modules. As a result of the COVID-19 pandemic, training for new and existing Governors has been postponed therefore, a review as to how these sessions can be delivered differently; such as through electronic learning, is underway.

4.1.2 Appointed Governor for Charity

In addition, the Council undertook a ballot at the January 2020 Council of Governor workshop, following the receipt of expressions of interest from two local charitable organisations.

The successful candidate was Norah Turnbull from the League of Friends. Norah was notified of her successful appointment and attended her first meeting of her three year appointment on 20 February 2020.

4.1.3 Governor Elections 2020

Preparations have commenced to undertake an election for those seats of the Council of Governors that will be vacated on 31 May 2020.

Seats in the following constituencies will be included in the election:

Constituency Number of Seats

Newcastle upon Tyne [1] 2Northumberland, Tyne and Wear (excluding Newcastle) [2] 5North East [3] 2

There are no vacant staff seats.

4.2 Lead Governor Arrangements

4/8 96/119

Agenda item A7(iii)


As highlighted in the January report, the Lead Governor arrangements were formally approved by the Council of Governors at their meeting on 20 February 2020. This included the revised Lead Governor role description and proposed appointment process.

It was further agreed that the process to appoint a Lead Governor would take place in August 2020.

4.3 Governor Working Groups

The revised Council of Governor Working Group Terms of Reference were approved at the Council of Governors meeting held on 20 February 2020.

This included the agreement to amend the names of both the ‘Business Development Working Group’ and the ‘Community Engagement and Membership Working Group’ to the ‘Business and Development Working Group’ and the ‘People, Engagement and Membership Working Group’ respectively.

In addition, the proposed reappointment process and timeline for the chairs of the working groups was agreed.

5. NON-EXECUTIVE DIRECTOR RECRUITMENT

The recruitment process for two Non-Executive Directors has commenced with assistance from Gatenby Sanderson, with a view to appointing in the summer.

The closing date for applications is 20 April 2020. Full details can be found at: https://newcastlened-appointment.com/

6. INSIGHT PROGRAMME

Board members will recall that the Trust has participated in the first North East cohort of the Gatenby Sanderson Insight Programme which aims to increase the pool of quality Non-Executive Director (NED) candidates from underrepresented areas.

Mrs Theodora Adegbie commenced her six month placement within the Trust on 1 October 2019 and will complete this on 31 March 2020.

During the placement, Mrs Adegbie observed a number of Board of Directors and Committee meetings as well as meetings of the Council of Governors. In addition, Mrs Adegbie met with members of the Board, including both Non-Executive and Executive Directors.

The Board of Directors extends its thanks to Mrs Adegbie for her participation in the programme.

5/8 97/119

https://newcastlened-appointment.com/

Agenda item A7(iii)


The Trust was originally scheduled to host a further participant in the Programme in April however unfortunately we have taken the decision to defer the new participant start date in response to Covid-19.

7. ANNUAL REPORT PREPARATIONS

As outlined in the last report, the Trust continues to prepare for the production of the Annual Report and Accounts for 2019/20 in line with the instructions set out in the Annual Reporting Manual for Foundation Trusts.

The following details the key dates will culminate in the publication of the Annual Report on the Trust’s website on 26 June 2020 and launch at the Annual Members Meeting on 31 July 2020.

24 April 2020 – Draft annual accounts and draft Trust Accounts Consolidation (TACs) required to be submitted to NHS Improvement (NHSI).

20 May 2020 – Extraordinary Audit Committee meeting for consideration of Annual Report & Accounts.

26 May 2020 – Board of Directors Meeting to approve the Annual Report & Accounts. 29 May 2020 – Audited Accounts, TACs and Annual Report (and other submission

items) required to be submitted to NHSI. 26 June 2020 – NHS Foundation Trust deadline for submission of accounts to the

Department of Health and Social Care’s Parliamentary Office to be laid before Parliament.

24 July 2020 – Deadline for submission of the Annual Report (to include the quality report and annual accounts) to NHSI.

31 July 2020 – Annual Members Meeting.

8. MEMBERS EVENTS

The first Members Event for 2020 took place on Thursday 6 February in the Education Centre, Freeman Hospital. The event was hosted by the Trust Chairman and highlighted the work of the Institute of Transplantation. Professor Stephan Schueler, Consultant Cardiothoracic Surgeon, provided a presentation on Mechanical Heart Pumps and Professor Steven White, Hepatobiliary and Transplant Surgeon presented on Pancreas Resection.

Both presentations received excellent feedback from attendees.

Board members are reminded that the next Members Event is scheduled for Thursday 11 June which will focus on the History of the RVI.

9. NHSI QUARTERLY DECLARATIONS

Board members will recall that as a Foundation Trust, Quarterly NHS Improvement (NHSI) declarations must be completed which require Trust Board approval, being:

6/8 98/119

Agenda item A7(iii)


i) A declaration required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence.

ii) A Corporate Governance Statement declaration (‘FT4 declaration’).

Board approval of these is required and they can be found in the Appendices to this report.

10. RECOMMENDATIONS

The Board of Directors are asked to (i) receive the update and (ii) note the contents.

Report of Kelly Jupp and Fay DarvilleTrust Secretary and Deputy Trust Secretary19 March 2020

7/8 99/119


8/8 100/119

Worksheet "FT4 declaration" Financial Year to which self-certification relates Q3 19/20

Corporate Governance Statement (FTs and NHS trusts)

The Board are required to respond "Confirmed" or "Not confirmed" to the following statements, setting out any risks and mitigating actions planned for each oneCorporate Governance Statement Response Risks and Mitigating actions

1 The Board is satisfied that the Licensee applies those principles, systems and standards of good corporategovernance which reasonably would be regarded as appropriate for a supplier of health care services to theNHS.

Confirmed.No material risks identified.Assurances include Annual Report (declaration of compliance with Code of Governance and Annual Governance Statement, bothare subject to independent review and scrutiny by External Audit as part of the year end external audit). CQC Inspection of 'WellLed' Domain assessed as 'Outstanding'.

2 The Board has regard to such guidance on good corporate governance as may be issued by NHS Improvementfrom time to time

Confirmed.No material risks identified.Key documents are highlighted/circulated to the Board through the Chief Executive Update report, items to note and agenda items.

3 The Board is satisfied that the Licensee has established and implements:(a) Effective board and committee structures;(b) Clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to theBoard and those committees; and(c) Clear reporting lines and accountabilities throughout its organisation.

No material risks identified.The CQC reviewed the effectiveness of the Board andconfirmed Committee structure as part of the 'Well Led' review, assessed as 'Outstanding'.There are a wide range of controls in place, including: an approved Scheme ofDelegation, Standing Financial Instructions, Board approved committee structureand terms of reference in place, a Board member appraisal process is in place, agreed Executive portfolios and clear organisationalstructure/reporting lines.

4 The Board is satisfied that the Licensee has established and effectively implements systems and/or processes:

(a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively;(b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations;(c) To ensure compliance with health care standards binding on the Licensee including but not restricted tostandards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board andstatutory regulators of health care professions;(d) For effective financial decision-making, management and control (including but not restricted toappropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern);(e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board andCommittee decision-making;(f) To identify and manage (including but not restricted to manage through forward plans) material risks tocompliance with the Conditions of its Licence;(g) To generate and monitor delivery of business plans (including any changes to such plans) and to receiveinternal and where appropriate external assurance on such plans and their delivery; and(h) To ensure compliance with all applicable legal requirements.

Confirmed.No material risks identified. There are a range of systems and/or processes in place which evidence the Trust's on-goingcompliance with this requirement, including:Trust Board meetings (except in August when the Board does not meet).Routine Integrated Board Reports (covering Quality, Performance, People & Finance).Regular meetings of the Trust Executive Team, Executive Risk Group, Finance, Quality, Audit and People Committees.Board approved terms of references.Board approved Annual Plan.Regular detailed Board finance report.Board Assurance Framework and Risk Registers.External and Internal audit annual opinion and Internal Audit annual plan approved by the Audit Committee.

5 The Board is satisfied that the systems and/or processes referred to in paragraph 4 (above) should include butnot be restricted to systems and/or processes to ensure:

(a) That there is sufficient capability at Board level to provide effective organisational leadership on the qualityof care provided;(b) That the Board’s planning and decision-making processes take timely and appropriate account of quality ofcare considerations;(c) The collection of accurate, comprehensive, timely and up to date information on quality of care;(d) That the Board receives and takes into account accurate, comprehensive, timely and up to date informationon quality of care;(e) That the Licensee, including its Board, actively engages on quality of care with patients, staff and otherrelevant stakeholders and takes into account as appropriate views and information from these sources; and(f) That there is clear accountability for quality of care throughout the Licensee including but not restricted tosystems and/or processes for escalating and resolving quality issues including escalating them to the Boardwhere appropriate.

Confirmed.No material risks identified. There are a range of systems and/or processes in place which evidence the Trust's on-goingcompliance with this requirement, including:- Trust Board composition includes Chief Executive Officer, Chief Operating Officer, Medical Director, Director of Enterprise,Business and Development, Finance Director, Executive Chief Nurse and a medical Non-Executive Director- Board approved Quality Account- Patient stories to every Board meeting- Board line of sight as part of Leadership Walkabouts- Positive external stakeholder feedback (re Quality Account)- Routine Integrated Qualityand Performance Report to Trust Board (including SIRI reporting)- Quality Committee meetings to seek assurance over quality of care including scrutiny of SIRIs and Never Events- Clinical Audit Plan- Mortality Surveillance Group

Please Respond

6 The Board is satisfied that there are systems to ensure that the Licensee has in place personnel on the Board,reporting to the Board and within the rest of the organisation who are sufficient in number and appropriatelyqualified to ensure compliance with the conditions of its NHS provider licence.

There are a range of controls in place to mitigate staffing risks, including: Directorate Ward staffing reviews and a single centralisedbank for nursing and midwife posts.

Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors

Signature Signature

Name Dame Jackie Daniel Name Sir John Burn Further explanatory information should be provided below where the Board has been unable to confirm declarations under FT4.

A

1/2 101/119

Worksheet "Training of governors" Financial Year to which self-certification relates Q3 19/20

Certification on training of governors (FTs only)The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required.Training of Governors

1 The Board is satisfied that during the financial year most recently ended the Licensee has provided the necessary training to itsGovernors, as required in s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledgethey need to undertake their role.

Confirmed

Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors

Signature Signature

Name Dame Jackie Daniel Name Professor Sir John Burn Capacity Chief Executive Officer Capacity Chairman

Date DateFurther explanatory information should be provided below where the Board has been unable to confirm declarations under s151(5) of the Health and Social Care Act

A

2/2 102/119

Worksheet "G6 & CoS7" Financial Year to which self-certification relates Q3 - 19/20

Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licenceThe board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming anotheroption). Explanatory information should be provided where required.

1 & 2 General condition 6 - Systems for compliance with licence conditions (FTs and NHS trusts)

1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licenseeare satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as werenecessary in order to comply with the conditions of the licence, any requirements imposed on it under theNHS Acts and have had regard to the NHS Constitution.

Confirmed

OK

3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only)EITHER:

3a After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee willhave the Required Resources available to it after taking account distributions which might reasonably beexpected to be declared or paid for the period of 12 months referred to in this certificate.

Confirmed

OR3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is

explained below, that the Licensee will have the Required Resources available to it after taking into accountin particular (but without limitation) any distribution which might reasonably be expected to be declared orpaid for the period of 12 months referred to in this certificate. However, they would like to draw attention tothe following factors (as described in the text box below) which may cast doubt on the ability of the Licenseeto provide Commissioner Requested Services.

OR3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available

to it for the period of 12 months referred to in this certificate.

Statement of main factors taken into account in making the above declarationIn making the above declaration, the main factors which have been taken into account by the Board ofDirectors are as follows:The Trust has taken all necessary precautions as were necessary to comply with the conditions.The Trust has continually achieved its Control Total.Transformation,performance and finance management arrangements are in place to support the delivery of the TrustCost Improvement plans, overseeen by the Trust Finance Committee.The Transformation, Performance and Finance Teams continue to work on the Trust's long-term sustainability andimprovement programme.The annual going concern assessment was presented to the Trust Board in April 2019 and an update presented inMarch 2020 as part of the Finance Director report.

Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors

Signature Signature

Name Dame Jackie Daniel Name Professor Sir John Burn Capacity Chief Executive Officer Capacity Chairman

Date Q3 Date Q3Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6.

1/1 103/119

Agenda item A8

1

BOARD OF DIRECTORS


Title People Update

Report of Dee Fawcett, Director of HR

Prepared by Dee Fawcett, Director of HR




Summary The purpose of the report is to update and provide Board assurance regarding the Trust People agenda.

Recommendation The Board is asked to read the report and note content.


People: Supported by Flourish, we will ensure that each member of staff is able to liberate their potential. We aim to be the recognised employer and educator of choice in the North East.



(please mark as appropriate) ☒ ☒ ☒ ☒ ☒ ☒ ☒

Impact detail Impacts on all areas from a People perspective.

Reports previously considered by Routine Board update.

1/7 104/119

Agenda item A8

____________________________________________________________________________________________________People UpdateTrust Board – 26 March 2020

PEOPLE UPDATE

1. BACKGROUND

As previously advised, the publication of the national ‘NHS People Plan’ is expected and should be a significant step in producing a coherent workforce strategy to generate change. It was expected that this would be published before Easter 2020 however this has been deferred to later this year.

2. CORONAVIRUS (COVID 19)

In line with advice developed by ACAS and a joint statement issued by the NHS Staff Council to ensure appropriate precautions are taken to maintain the safety of patients and staff, the Trust has issued a range of communications to help and assure staff in response to particular concerns, and to be vigilant to prevent the wider spread of the virus.

3. KEY PERFORMANCE AREAS

Flourish At Newcastle Update 2019 NHS Staff Survey Overview provided to the Board at its Development Day in

February 2020. Directorate data resource packs produced and circulated across

the organisation to enable all teams to identify and develop local improvement plans.

Enhancing the ‘staff offer’

As part of ongoing work to improve the ‘staff offer’ a number of initiatives are in development including a new ‘Home Electronics’ salary sacrifice scheme which will be available from April 2020.

Free Spirits Nursery: Ofsted inspection in January 2020 has confirmed the second consecutive ‘Outstanding’ rating.

Health and Wellbeing Wellbeing policy review on-going. Given the national focus on improving leadership behaviours, the

‘NHS Leadership Promise’ is anticipated to include the publication of a leadership behaviours framework against which leaders will be held to account. Locally, a refresh of the Trust ‘behaviours’ framework is due with the objective of aligning with core values.

The regional ‘Great Place to Work’ programme continues with a focus on the NHS health and wellbeing framework, menopause and aging workforce. Health and wellbeing is a key area about which staff provided feedback in the NHS staff survey earlier this year.

Equality, Diversity and Inclusion

Gender Pay Gap Report – shared with People Committee and Trust Board will be published by 31/3/2020.

2/7 105/119

Agenda item A8


Flourish At Newcastle Update Stonewall Top 100 Employer – the Trust jumped 109 places to 40th

in the UK in the Workplace Equality Index. The ‘Surash/Pearce’ Report on ethnic pay was recently shared

with Board and Executive Team. The recommendations have begun to be implemented.

Steering Group established to coordinate organisation for the Trust to host first national NHS LGBT+ Staff Conference on 17 July 2020. It will include national LGBT+ and NHS Heroes Awards.

Reverse Mentoring initially to help staff in senior roles understand the challenges those from diverse backgrounds can face in the workplace will be introduced in April 2020.

Cultural Ambassador, trained to identify and challenge cultural bias, will be introduced from April 2020.

Pensions Following the budget statement this month, the Chancellor has sought to address the pension’s tax challenges and reformed the AA taper increasing it by £90k and also increased the Lifetime Allowance.

It was also confirmed that the government will no longer pursue the pension flexibilities options for clinical staff following the consultation last year. Nationally the NHS continues to seek wider flexibilities – to encourage all staff to participate in a pension scheme.

Junior Doctor in Training contract

Junior Doctor Contract Review Group continues to meet to monitor progress.

135 department rotas reviewed for compliance. February deadline for compliance met. Focus on maximising training time and minimising disruption whilst maintaining patient safety.

Excellence in Education and Learning, including leadership development.Associate Director, Education and Workforce Development.

Ms Gill Long joins the Trust on 23rd March 2020.

Education and Training Review

Communications and engagement regarding the Joint action plan has been rolled out.

Statutory and Mandatory Training Compliance

Compliance rate 89.71% v target of 95% at 29/2/20.

Appraisal Compliance 79.11% at end February 2020 versus 90% target. This month has seen the launch of new appraisal e-form Trust wide, using Robotic Process Automation technology. This is expected to positively impact on improving this compliance as more efficient data recording of appraisals becomes embedded.

3/7 106/119

Agenda item A8


Flourish At Newcastle UpdateStudy Leave Development of the e-study leave application process is on track

to be launched from beginning of April 2020. Nearly 500 colleagues participated in the recent survey – the data

is being collated and analysed.

Funding Scoping of the potential ‘Newcastle Clinical Skills Training Academy’ has commenced, with a view to using the NAMAHP CPD/CWD funding, due via the LDA in April 2020.

Detailed audit and scrutiny of medical education allowances is concluding this month. Intended to clarify governance arrangements and provide transparency regarding the value of medical educators.

Postgraduate Education The first cohort of learners undertaking the newly developed PG Certificate in Education (Health Professionals) commences at Sunderland University this month. It provides an opportunity to reach a wider audience of learners.

Medical Education The annual Medical Education event is planned for 25 June 2020.

Leadership Development ‘Newcastle 150’ – the Trust hosted an ‘immersive event’ for participants in this programme developing our city-wide leaders of the future. This group of 18-25 year olds were set the challenge ‘how do we ensure that by 2032 Newcastle is a city where all of its young people can reach their potential’?

Joint system leadership programme continues with excellent feedback.

Apprenticeships The first cohort of 15 people for the Prince’s Trust ‘Get Into Health’ programme partnership will commence in April. This scheme is intended to support improved employment opportunities for disadvantaged people in our local communities.

The inaugural ‘Health and Care Support Worker’ apprenticeship programme is likely to be launched in June 2020.

HEE have advised that dental apprenticeships funding will change to enable the Trust to use more of the levy. This is welcome.

Becca Carlson, an OT Assistant in the Trust won the national ‘Apprentice of the Year Award’.

Careers Events Another very successful ‘Careers Day’ was hosted in the RVI on 7th March 2020. Over 600 people attended from 52 schools and colleges across the region. The next event is planned for 7 November 2020.

4/7 107/119

Agenda item A8


Flourish At Newcastle UpdateWorkforce Design, planning and transformationRecruitment and retention Trust ‘Recruitment and Retention Strategy’ being refreshed to

ensure explicit goal of widening participation from local population.

All volunteer recruitment processed via TRAC from May 2020. A regional BAME and disabled people recruitment event is being

collaboratively arranged across the region for later in 2020.

Workforce Planning ‘Deep dive’ workforce design and planning has begun in three directorates (Cancer Services, Medicine and MSK) to achieve better appreciation of potential gaps, demand and potential solutions. Trust has also sought support from HENE to incorporate relevant regional/ICS-wide data.

Job Planning 83% compliance of senior medical staff with signed off e-job plans. A single job planning Trust policy will be developed and

implemented by the end of April.

Workforce Information Systems

Very productive and positive visit from NHSi to review progress against ‘Developing Workforce Safeguards Guidance’ to ensure safe sustainable staffing measures.

NHSE/i ‘Meaningful Use Standards’ – system scoping to identify a suitable e-job planning platform for all clinical staff continues to ensure compliance against national Levels of Attainment are met by April 2021.

Harnessing use of technology

The launch of Robotic Process Automation (RPA) has commenced with excellent feedback.

An e-form to simplify appraisal outcomes data input is now available from the newly launched HR Portal. This will be completed using an HR ‘bot’ and is expected to release significant management admin time (anticipated to be in excess of 4,000 hours annually) and facilitate focus on value adding activity.

Support received from national WRES team to use RPA to enhance disclosure of protected characteristics across the organisation.

Use of voice recognition/digital recording implementation in HR function is continuing.

Volunteer Workforce 193 new volunteers have joined the Trust in the last 12 months. Currently, active programme with schools and colleges to recruit

16 – 18 year olds to place into companionship and activity roles with the elderly care wards, and support roles in urology and paediatric outpatients.

5/7 108/119

Agenda item A8


3.1 Immigration

The Home Office issued a policy statement at the end of February setting out the future immigration system which will apply to EU and non EU citizens from 1/1/2021. Its intention is to allow NHS Employers to continue to attract and recruit people from overseas and proposes the creation of a points-based and salary threshold system. Nationally, NHS Employers as part of the Cavendish Coalition will work with government on this development.

3.2 Good Work Plan (GWP)

The GWP was published by the government in December 2018 in response to the Taylor Review of Modern Working Practices in the UK. It introduces a number of reforms designed to ensure fair and decent work for all. As a result a number of changes to employment legislation were introduced for implementation from 6th April 2020. Included in the changes is the new right to receive a written statement of employment particulars (i.e. an employment contract) from day one.

A review of the current template employment contracts and arrangements has been completed to ensure that the Trust is compliant.

4. RECOMMENDATIONS

The Board is asked to read the report and note content.

Report of Dee FawcettDirector of HR13 March 2020

6/7 109/119


7/7 110/119

Agenda item A9

BOARD OF DIRECTORS


Title NIHR CRN NENC Annual Business Plan 2020-21

Report of Andrew Welch, Medical Director

Prepared by Morag Burton, NIHR CRN NENC Chief Operating OfficerCaroline Wroe, NIHR CRN NENC Clinical Director



Purpose of Report☒ ☐ ☐

Summary

The National Institute of Health Research, Clinical Research Network North East and North Cumbria (CRN NENC) is a service hosted by The Newcastle Upon Tyne Hospitals NHS FT. The CRN provides regional infrastructure research services for study support, staff development and research leadership. It works across >500 GP practices and all Hospitals in the region. The CRN NENC is required to submit an annual business plan, financial plan and report on progress using a national format, to a national timeframe for submission to the national Coordinating Centre team, and final national approval from the Department of Health and Social Care (DHSC). These require approval by both the CRN NENC Partnership Group (the senior board comprising representatives of each of the regional Partner Organisations) and also the Host Trust Board. The report clearly identifies what activities will be carried out within the North East and North Cumbria region in accordance with the Performance and Operating Framework CRN NENC Contract with DHSC. There are key performance indicators required (called Higher Level Objectives (HLOs)) for each region. These were renamed in 2020-21, so previous names have been included for clarity. For 2019-20 and going forward into 2020-21 these are:1. Participant Recruitment 4.3 (A) and 4.4 (B) - previously HLO 1. Number of participants

recruited into portfolio studies & participants recruited into commercial portfolio studies.2. Time and Target 4.1 (A) and 4.2 (B) - previously HLO 2A and B. Proportion of commercial and

non-commercial studies recruiting to time and target.3. Priority Specialties 4.15 - previously Specialty Group Objectives. Increase in research activity

in 10 locally agreed areas.4. Targeting Health Needs - metric derived for 9 Specialty areas wherein disease incidence is

particularly problematic nationally. Metric measures the proportion of distribution of disease incidence relative to the proportion of research activity. This is notably an issue within our region.

RecommendationThe Annual Business Plan is required to be approved by the Host Trust Board prior to sign off by the Department of Health and Social Care. The date of submission to DHSC is 26 March 2020.


Links to the following strategic objectives:- Ensuring that we are at the Forefront of Health Innovation and Research- Flourish - Ensuring that each member of staff is able to liberate their potential- Effective Partnerships

1/9 111/119

Agenda item A9



(please mark as appropriate) X X X X X

Impact detail

Quality - delivery of the business plan includes a significant number of quality improvement initiatives to more effectively support research in the NENC region. Finance - the annual budget allotted to CRN NENC is just over £18,000,000 and as such is impactful in terms of staff and infrastructure investment.Human Resources - almost 800 staff are employed using the budget of CRN NENC annually.Reputation - successful delivery of the CRN NENC business plan is an opportunity to increase the reputation of the Host organisation as an advocate and deliverer of research, in addition to its opportunity to partnership work with the other organisations in the region across all sectors.Sustainability - investing in research infrastructure using CRN NENC budget has resulted in significant income generation in grant, Small to Medium Enterprise (SME) and Life Sciences Industry research monies.

Reports previously considered by New report - annual requirement for Trust Board approval.

2/9 112/119

Agenda item A9

____________________________________________________________________________________________________NIHR CRN NENC Annual Business Plan 2020-21Trust Board – 26 March 2020

NATIONAL INSTITUTE OF HEALTH RESEARCH CLINICAL RESEARCH NETWORK NORTH EAST AND NORTH CUMBRIA (NIHR CRN NENC) ANNUAL BUSINESS PLAN

2020-21

1. BACKGROUND

The National Institute for Health Research Clinical Research Network (NIHR CRN) is the clinical research delivery arm of the NHS in England and has been hosted by The Newcastle upon Tyne Hospitals since 2014. Its purpose is to ensure patients and healthcare professionals from all parts of the country are able to participate in and benefit from clinical research; integrate health research and patient care; improve the quality, speed and coordination of clinical research; increase collaboration with industry partners and ensure that the NHS can meet the health research needs of industry.

The NIHR CRN has been funded for the past 5 years by the Department of Health and Social Care (DHSC) to support the following aims:

a) Promote equality of access, ensuring that wherever possible, patients, the public, and users of social care services have parity of opportunity to participate in research.

b) Improve the quality, speed and coordination of clinical research by removing the barriers to research in the NHS and wider health care settings.

c) Streamline and performance manage NHS Support for eligible studies, to ensure the NHS Service Support Costs of these studies (or equivalent support in wider health and social care settings) are met in a timely and efficient manner.

d) Work in partnership to unify and streamline administrative procedures associated with regulation, governance, reporting, and approvals.

e) Meet the research delivery needs of the life sciences industry including: pharmaceutical; biotechnology; diagnostic; medical technology; and contract research organisations (CROs).

f) Further integrate health research and patient care.g) Engage the providers of NHS services in research in line with the NHS Constitution to

promote research participation and a research culture.h) Engage the providers of Public Health and social care services to promote research

participation and a research culture.

Before April 2014, there were over 100 clinical research networks in England hosted by NHS Trusts in adjacent localities. From April 2014, there has been one research "branch” of the NIHR CRN in each NHS region; these are termed Local Clinical Research Networks (LCRNs). The Newcastle upon Tyne Hospitals NHS Foundation Trust (the Trust) successfully applied to host this network on behalf of the NIHR and partner organisations in the North East and North Cumbria region (County Durham, Teesside, North Cumbria, Tyne & Wear and Northumberland). The CRN is divided into 30 Clinical Specialty areas for operational management, each with a regional clinical lead in post.

The CRN is intended to fund research infrastructure throughout the region - predominantly research delivery staff e.g. research nurses in all of the Partner Organisations and service support department staff e.g. pharmacy technicians. In the North East and North Cumbria, this

3/9 113/119

Agenda item A9


currently funds approximately 798 people comprising 271 Nurses, Midwives and Allied Health Professionals (NMAHPs), 234 Medical Staff, 188 Research Delivery Support Staff and 104 Operational Management and Study Support Staff.

In January 2018, the remit of the CRN was widened by the new National Director to incorporate both Public Health and Social Care Research and in October 2018 it also took over the national payments administration of Excess Treatment Costs on behalf of NHS England. The staff funded have traditionally been NHS staff but increasingly this is branching into the Local Authorities and non-NHS sector. The network engages actively with local HEIs, Life Sciences Industry, including Small to Medium Enterprises (SME) and other local research infrastructure e.g. NIHR Applied Research Collaborative (ARC), Academic Health Sciences Network, NIHR Med Tech and Invitro Diagnostics Collaborative (MIC).

The Host holds contracts with providers in the NENC region of varying financial levels: 11 Category A Partners (>£50,000 annual funding). 7 Category B Partners (£10,000 - £50,000 annual funding). 239 Category C Partners (<£10,000 annual funding).

CRN NENC is governed by the Performance and Operating Framework (POF) contract which the Host has agreed to. This clearly outlines the areas of responsibility each year and the rules in relation to finance and operations. There are several sub-sections within this: Governance and Management; Financial Management; CRN Specialties; Research Delivery; Information and Knowledge; Communications; Patient and Public Involvement and Engagement (PPIE); NHS Engagement; Workforce Learning and Organisational Development; and Business Development and Marketing.

The Annual Business and Finance Plans outline all proposed activities to deliver the POF each year.

2. ANNUAL BUSINESS PLAN 2020-21

The Business Plan is structured using a national template with standardised sections and requirements. The full plan is included in the Board Reference Pack. The notable sections for approval are listed below.

2.1 Section 3: Part C POF Requirements

Local Funding Distribution Model (3.2.3) - this has been updated annually and is publicly available. It has allowed for funds to be made available to our new non-NHS settings and also strategic investment in areas of local priority health needs.

4/9 114/119

Agenda item A9


Multimorbidity Research (3.3.6) - this is a new priority need area and a relevant local priority to our partner organisations AHSN and CRN ARC. A programme of complementary or joint investment is being explored in support of this across these agencies.

Year of Birth (3.3.7) - recording of year of birth for all participants in research studies is being implemented in 2020-21 across all studies, with some rare disease exceptions. This will provide invaluable data on the demographics of research participants in the region. Discussions are underway with North East Quality Observatory Service (NEQOS) around providing research indicators to the “Well Led” data set provided to all Partner Organisations in the region.

Specialty Focussed Alliances (3.4.2) - there are several cross-organisational initiatives to work with a workforce across the disease specialty, in varying stages of development. These have demonstrated a proven flexibility and willingness to support research where the need is successfully giving better value for money.

Urgent Public Health Research (3.4.6) - each Partner Organisation has an urgent public health plan for research to both ensure that any specific “sleeping” urgent public health studies are delivered but also research is safely continued during a pandemic scenario (as with COVID-19 currently)

ENRICH (3.4.8) - working in partnership with Newcastle University’s School for Social Care Research an expanding portfolio of research is being developed and delivered in local care homes, originally primarily in support of Dementia research but now widening.

Patients and the Public (3.6.1 & 3.7.1) - there is a regional plan in place to work in partnership with local organisations to hear the patient voice within research, supporting national campaigns and regional patient panels.

Communications (3.6.2) - there is a regional communications plan to work in partnership with other organisations regionally placed from the NIHR e.g. RDS, CTU, BRC, MIC and ensure that both CRN communications presence is clearly felt but also our local NHS organisations, non NHS organisations and stakeholder partners are cross-promoted. This is an area of considerable opportunity for cross-working drive by our Host organisation and Newcastle University and Councils under the strategy.

NHS Engagement (3.8.1) - the widened remit of CQC Well Inspections to include research provides an excellent opportunity to offer support to our local organisations in terms of detailed evidence and quantitative data from the Local Portfolio Management System (LPMS). This work is in early stages of development and is a great opportunity for the CRN NENC to provide a service on behalf of our regional stakeholders and in support of our Host and ICS strategy.

Staff Wellbeing (3.9.3) - there is a regional staff wellbeing strategy, dovetailed into the Flourish at Newcastle work and implemented throughout CRN NENC. This work has been recognised as a national exemplar and was rewarded by the Host organisation in 2019 by winning the Making a Difference Flourish Award. The bi-monthly blog, community and other activities continue all year.

5/9 115/119

Agenda item A9


National Strategy Leadership (3.9.4) - there are several instances of CRN NENC staff members leading the development of national programmes of work on behalf of CRN - ranging from Continuous Improvement projects for delivery of the Study Support Service to Business Development Leadership for the Participant Research Centres (PRC) of which Newcastle Hospitals hopes to secure one of five regional centres.

Business Development & Marketing (3.10.1) - a regional business development profile has been developed, utilising a national template, to share information with both Life Sciences Industry and non-commercial funders and potential partners.

2.2 Section 4: HLOs

Time and Target (4.1 & 4.2) - this has been an area of previous high performance reflecting delivery of the agreed contracted number of participants in a research study. It is highly prized as an indicator of performance by the Life Sciences Industry. The target to be met is 80% of research closing within the time and to the target agreed by each study or site.

Participant Recruitment (4.3 & 4.4) - across the country there has been a drop in recruitment in research during 2019-20 which has disproportionately affected this region, owing in part to the lack of new studies available and also potentially external factors e.g. BREXIT. It is also likely that the current COVID-19 outbreak will impact significantly on commercial and non-commercial recruitment to trials in 2020-21. To allow clearer visibility of anticipated activity a new Forecasting Application is being rolled out across the region to display at a team, NHS organisation or network level the potential and actual recruitment numbers for the year. This is a significant development and will help with workload capacity planning across all teams and organisations in the region.

Provider Participation (4.9 & 4.10) - the network aims to develop increasing working relationships and research activity throughout the ICS geography with new providers - these include increased primary care and community settings but also non-NHS environments e.g. Local Authorities, Schools, Hospices and Charities. NENC is an exemplar for working with both Public Health and Social Care.

Participant Experience (4.12) - a fully digital Patient Research Experience Survey has been designed within CRN NENC and successfully implemented locally in 2019-20. This will be further developed and has been chosen as the national solution to a digital survey resulting in potential further investment in NENC.

Priority Specialties (4.15) - working with other local agencies (AHSN and NIHR ARC) CRN NENC has prioritised and invested in actively trying to increase research activity in areas of greatest need. These are agreed areas of local disease prevalence but more limited research activity. Strategic investment of 2% of the budget has been directed to providing development and delivery infrastructure to underpin this change.

2.3 Section 5: Local Initiatives

New Strategy Launch 2020-23 (NENC 5.2) - the regional research strategy devised by CRN NENC in 2017 comes to a close in 2020 and the date for the launch of the new strategy is 14th October 2020. Scoping work has already been carried out with both internal and external

6/9 116/119

Agenda item A9


stakeholder groups already. This will affect the membership of the LCRN Executive group and Terms of Reference for all management groups in 2020.

RDA Review (PANN5.1) - a review of the current investment into time for research delivery for Principal Investigators (previously PA allocations) is underway in conjunction with other regions in the country. There is continued pressure from the national team to disinvest in this as CRN NENC disproportionately funds this area of activity. Consultation is underway with internal and external stakeholder groups.

Primary Care Cost Recovery (NENC5.5) - a model of reimbursing CRN NENC for its primary care delivery workforce to cover primary care activity is in its early test phase. This would allow some commercial growth within CRN NENC and reinvestment into research infrastructure.

Research Alliances (NENC5.12) - working in the sub ICS, 4 ICP geographies, 4 regional alliances are at different stages of development. Each ICP alliance has a steering group taking forward initiatives to work cross organisationally to set up research, deliver research and strategically invest and support research in the new areas of non-NHS settings and primary care. Steering groups include local heads of public health, primary care and CCG representatives, university and NHS provider organisation members.

Cross-NIHR Platform Patient Equity of Access (NENC5.16) - focussing on mental health, a project is underway in collaboration with the NIHR ARC and local mental health trusts to provide access to research for patients who have a secondary mental health condition alongside other primary illness under test.

Mentor Directory (PANN5.4) - launch has begun for a regional matching online directory of mentors and mentees to be paired to develop research experience and skills. There is significant interest in other regions and nationally in the development of this elsewhere and the potential to generate income in support of the roll out of this scheme.

Digital Wellbeing (PANN5.5) - working across other LCRN partners, CRN NENC is leading on a plan to ensure staff practice digital wellbeing - this will include tools and information to be implemented and shared across the region and beyond.

2.4 Section 6: Financial Management

This section details the split of finances between all sectors and relative to previous year’s spend. It is clearly detailed in the Annual Finance Plan section 3.

3. ANNUAL FINANCE PLAN 2020-21

CRN NENC has an annual budget awarded by the Department of Health and Social Care which is shared between its constituent Partner Organisations, which are predominantly but, not solely, NHS Trusts.

The principles of financial planning are agreed through the CRN Partnership Group, which comprises representatives from all Category A Partners, on behalf of Primary Care, NHS England and Public Health, including Lay Representation. These principles are applied to the given

7/9 117/119

Agenda item A9


annual allocation for the region - this is based on a national funding model of 80% fixed budget and 20% variable. The variable component is linked to 5 Performance Indicators for 2020-21:

1. Recruitment of Participants in Research2. Recruitment to Time and Target for Non-Commercial Research3. Recruitment to Time and Target for Commercial Research4. Delivery of National Clinical Specialty Objectives5. Delivery of Research in Targeted Areas of Need

The Finance Plan includes financially sensitive information relating to the recipient organisations and is therefore approved in the Private section of the Board Meeting.

4. RECOMMENDATIONS

The Board is asked to approve both the Annual Business and Financial Plans for CRN NENC for 2020-21.

Report prepared by Morag Burton and Prof Caroline Wroe, on behalf of Dr Andrew Welch, Medical Director/Deputy Chief Executive15 March 2020

8/9 118/119


9/9 119/119

wµ o] } }( ] } p v of director… · a7(iii) corporate governance update ts attached 11.26 –...

Documents