Annual Members’ Meeting

Welcome Bruce Laurie

Chairman

1

3rd September 2012

Annual Members’ Meeting 2012Governors’ update

Harry Dale Lead Governor

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Work of the Council of Governors• 4 formal Council of Governor meetings held and 1 joint meeting with the

Trust Board • 12 meetings of the Council of Governors working groups • Appraisals and appointment of Non-Executive Directors considered• Approval of the appointment of the Chief Executive• Governor drive for improvements to responding to complaints and listening

to our patients• Continue to be the ‘eyes and ears’ of the Trust and feed back concerns to

management which are incorporated into the Trust’s Patient Experience action plan

• Championing improved patient experience, and involvement in patient safety walkabouts

3

Changes to constituencies • Governors approved changes to the constitution in order to

make constituencies more representative of our local communities by splitting the current Wiltshire Constituency into three separate areas:

• Northern Wiltshire (2 seats) • Central Wiltshire (2 seats) • Southern Wiltshire (1 seat) • Elections in October/November to elect governors to these

new seats and to Swindon (1 seat) and Gloucestershire and BANES (1 seat)

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Changes to the Council of Governors• Clive Bassett (Appointed governor – Prospect House),

replaced Andy Cresswell (Thames Valley Chamber of Commerce)

• Dr Jon Elliman (Appointed governor, The Academy) replaced Lesley Donovan (Academy)

• Cllr Jemima Milton (Appointed governor – Wiltshire Council) replaced Carole Soden (Wiltshire Council)

End of Terms: • Kevin Parry (public governor- Swindon) replaced Katherine

Usmar

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Membership update

72222870

1473

217 156

Membership by Constituency

Staff MembersSwindon WiltshireOxfordshire and West BerkshireGloucestershire and BANES

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Developing membership• Targeting existing forums to spread the word about

membership (parish councils, health forums) • Focus on increasing youth membership, involvement

in the Trust’s “School’s day”• Plans to visiting community sites to raise awareness

of membership for patients and staff

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Upcoming dates/events

• Elections in November for seats in Swindon, Gloucestershire and BANES, Northern Wiltshire, Central Wiltshire, Southern Wiltshire and Staff constituencies

• Council of Governors 8 October 2012 at 5.00pm GWH, Academy

• Council of Governors 29 November 2012 at 4.30pm GWH Academy

• Look out for events taking place to celebrate 10 year anniversary of the Great Western Hospital

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Annual Members’ Meeting 2012The Year in Review

Nerissa Vaughan Chief Executive

The environment we’re working inA period of uncertainty and change• Health and Social Care Act 2012 made into law after considerable debate• The shift in responsibility for commissioning has begun – moving from

Primary Care Trusts (PCTs) to GPs (via Clinical Commissioning Groups – CCGs).• PCTs and Strategic Health Authority (SHAs) due to be abolished in March

2013• National Commissioning Board established• Local Involvement Networks to be abolished and replaced with Health Watch organisations• Local Health and Wellbeing Boards bringing together health, social care,

local authority, and CCGs to work in a more joined up way• A range of other bodies set up as part of the new structure of the NHS

The NHS is facing “zero growth” in NHS spending compared to an historic average of 3.2% a year

1975/76

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2014/15

-4

-2

0

2

4

6

8

10

12

% Annual change in real term NHS Expenditure and planned expenditure 1974/75 to 2014/15

A challenging but successful year

• Merger with WCHS – most significant change in past year• The first year spent aligning services, getting to know people and understand what works and what we could do better together• Work started on delivering the benefits of an integrated organisation:

Improving patient flow across the Trust – GWH and community staff, Social Services and GPs

Productive Ward being rolled out across the Trust Developing a new Ambulatory Care service Appointment of Interim Chief Nurse, Hilary Walker, to lead work on

raising profile of nursing

2011-2012

A challenging but successful year2011-2012 - continued

Very good performance across over 200 key indicators• Just two cases of MRSA across the Trust (out of 1.3m pt contacts)• 19 cases of Clostridium difficile (C.diff) – 50 fewer than the threshold• Just one case of Grade 4 pressure ulcer at GWH, 10 fewer than last year• 23 cases of Grade 3 and 4 in community – well below 40 threshold• GWH became a designated Trauma Unit in April 2012 • Improvements in PEAT scores – especially Princess Anne Wing at the

Royal United Hospital in Bath

A challenging but successful year2011-2012 - continued

• In the top three Trusts in the South West in the latest independent staff survey results (and in top 20% nationally for staff satisfaction) CQC Staff Survey

• 9/10 patients rate their care as good or excellent• From over 1.4m patient contacts last year we received 444 formal complaints – which is 0.03% of the patients we cared for• Compared with the previous year when we were responsible solely for the

GWH, we had 242 complaints representing 0.04% of patients we cared for

• Increased the number of parking spaces for patients at visitors at the GWH by 10%. After some teething problems the new pay on exit system now means the car park reaches capacity on far fewer occasions than before

Areas for improvementEndoscopy • National growth in demand in all Endoscopy units being experienced

nationally• PCT Performance notice to improve Endoscopy six week waiting times by

October• GWH now on track to deliver against the trajectory• All fast track and urgent patients treated within appropriate timescales.

Improvements also taking place to provide capacity for this growth and improve the estate to provide more single sex accommodation

Areas for improvementClinical correspondence – clinic letters to be typed and sent to GPs within two working days• A challenging target which the Trust has continued to focus on improving the

speed with which letters are sent to GPs • Over the course of the year there has been gradual improvementsDelayed Transfers of Care • Over the course of the year there’s been a rise in the number of patients

who are medically fit to be discharged but who remain in hospital• Big challenge for health and social care as it relies on both social care and

the NHS playing its part• Working together with Local Authorities to tackle this problem to free up

beds

Extra scrutiny• Nine unannounced inspections from the Care Quality Commission in 12 months across the Trust – five at GWH and four in the community.• Concerns raised:

Hydration document on wards Consistency of safety checks in theatres Use of Extra Bed Spaces (EBS) on the wards

• Following sustained focus, as the Trust we’ve now been given the all clear and are compliant with every area the CQC measure.

Hydration documentation is much improved (and acting as an example to other Trusts) Consistent implementation of the World Health Organisation (WHO) Safer

Surgical Checklist and Team Briefing in theatres has improved processes By the end of September the final few Extra Bed Spaces will be removed

which is good news for patients and good news for staff We expect many more inspections over the next 12 months

The year ahead (1)A new strategy• An ageing population, rising costs, increasing competition, reductions in funding,

new technology and drugs and rising expectations mean we can’t stand still.• Work has begun on developing a new five year strategy for the Trust –

designed to put us in the best position to meet future challenges• Six workstreams are looking at where we need to get to, to provide patients with

the best services not just now but in the future: Maternity Patient Flow New Technology Long Term Conditions Community Hospitals & Neighbourhood Teams Marketing

• We want to be the Trust that delivers the best for our patients and commissioners.

The year ahead (2)Pay and Reward• Regional Pay, Terms and Conditions Consortium established to look at

options around how we can meet the financial and operational challenges in the future

• 20 Trusts involved• 70% of our income is spent on pay – this year pay pressure has added an

extra £1.7m on our pay bill and this pressure grows each year• We’ve already looked at a whole range of other areas where we can reduce cost and we need to seriously look at what we do with pay and reward• The aim is to avoid some of the more difficult decisions we may have to

make in the future if we don’t deliver savings i.e. redundancies• No decisions on what this means in practice for staff have been made –

work at this stage is simply looking at the options• Final decision rests with the Trust Board here

Financial overview

Maria MooreDirector of Finance and Performance

Financial headlines for 2011/12• Income £290.5m• Surplus £536k• Financial risk rating 3• Payment of suppliers 88% within 30 days

• KPMG External Auditors opinion– Unqualified Opinion on the Trust’s Financial Statements – Limited assurance opinion on Trust’s Quality Accounts (the best you can have)

Income £290.5m

NHS Swin-don£112.6m

NHS Wiltshire£117.2m

Other PCT & Trusts £30.3m

Education & Research £7.5m

Other income£22.9m

Patients TreatedElective 35,082 patients£39.9m £1,179 per patient

Outpatients 309,343 patients£38.6m £119 per patient

Elective 35,082 patients£39.9m £1,179 per patient

Outpatients 309,343 patients£38.6m £119 per patient

Elective 35,082 patients£39.9m £1,179 per patient

Outpatients 309,343 patients£38.6m £119 per patient

Elective 34,043 patients£39.9m £1,173 per patient

Outpatients 400,570 patients£38.6m £96 per patient

Community Services£65.6m803,545 community patients

46,507 minor injury patients7,445 inpatients£76 per patient

Other Clinical Ser-vices£38.2m

A&E Attendances£7.8m 70,731 patients

£110 per patient

Emergency£73.4m

35,804 patients£2,049 per patient

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Pay £172.1m

Building & Estates £20.3m

Drugs £17.8m

Other services inc Facilities Management £18m

Supplies/services for clinical & general requirements £25m

Clinical insurance£5.7m

Services from other Trusts and NHS bodies£16.3m

All other expenses£14.7m

Approximately £794,000 spent each day to provide Trust services

How we spent the money

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What a typical treatment costs the NHS

£203 First outpatient appointment

£4,559 Emergency hernia

£109 Follow-up outpatient appointment

£7,097 Major hip operation

£1,236 Birth by normal delivery

£5,138

Capital Expenditure £4.1m

Plant, Equip-ment & Ma-chinery£733k

Car Parking at GWH£410k

IT & Clinical Sys-tems£1469k

Buildings£209k

Medical Equipment Replacement£784k

Cath Lab£407k

Birthing Centre£94k

Speech and Language Therapy Service in Wiltshire

Jennifer LewinHead of Speech and Language Therapy

What is communication ?Universal

Why are Pictures Powerful?Specialist

Speech and Language Therapy Services in Wiltshire

Provided to:-

Children

Adults

ALD population

in Wiltshire with the exclusion of adults in the south (SFT.) and in Swindon.

School nurses

Range of cases• Complex feeding issues in babies• ASD diagnostic team• Acquired communication impairment • Specific language Impairment• Phonological disorders• AAC from high tech-low tech• Progressive neurological conditions• Voice disorders• Fluency• CVA• Oral cancer

• Focussed on community model• The best care close to home• Engaging with families who find it hard to

access traditional models of healthcare• Working with others• Focus on early intervention• Flexible workforce to meet needs

Service Aims

AdultsProvided in :• Local community hospitals • Residential and nursing homes• Client’s homesProvision :• Specialist assessment, diagnosis and advice• Group intervention • 7.2 wte SLT/SLTAs supporting the Adult Service

Referrals are received from :• 52 Nursing and Residential Care Homes • GP surgeries• 11 Neighbourhood Teams• 3 community hospitals• 1 stroke unit• 1 hospice• Consultants from surrounding Acute Hospitals

Children The children’s speech and language therapy service in Wiltshire went out to tender in 2009

New service commenced May 2010, 3 yr contract with option of extending to 5yrs

Jointly commissioned by Wiltshire Council and NHS Wiltshire

Children

• 340 Early Years settings• 240 schools• 14 clinics• 4 District Specialist Centres.• 3600 current caseload• 150-200 referrals a month• 23 wte SLT/As supporting the

children’s service• 150 requests for statutory

assessment per annum

Newly commissioned model of service delivery ensures:• Early identification of need by all professionals• Single point of entry.• All referrals are be triaged.• Signposting to other services, the SLT website and

advice line. • Choice of location and time.• Children will be assessed by a specialist Speech and

Language Therapist within 13 weeks.• Programmes of care delivered by the TAC to develop

communication rich environments. • The service is flexible to meet the needs of the

population of Wiltshire.

Choice Making

Visual Timetables• Transition times• To let children know

what is expected

TEACCH• Structured teaching• Change activities to

maintain interest• Reward at the end• Focus on adult agenda

and timescale

Sentences

• “Thank you for helping me with my talking. I’m a lot happier now and have lots of fun playing with friends and talking to everyone. Mummy and Daddy keep smiling at all the new words I say.”

• Parents writing for their child

• “Jack… came for a course of speech therapy, although he was reluctant to get involved at the time we have continued to do the worksheets. His speech is now 100% improved.”

• School

• “I just wanted to say that the information you gave us last night was really helpful – so good to be given it rather than have to find it out! I hope there will be more training opportunities like this for SENCOs and other school staff too.”

• SENCO

• “Meeting other people makes me feel less isolated. I didn’t want to attend, but thank you for including me”

Natter Matters: Parkinsons group

Collaborative PracticeKey to successful outcomes • Parents/families• Paediatricians/specialist health services• Teachers/SENCos• Early Years settings• HVs/School nurses• Specialist SEN services• Team around the Child TAC• Clients/carers• Multidisciplinary team around the adult – Physio, OT, District

Nurse, Dietitian

PartnershipQuality Community

The New Ambulatory Care Service at GWH

Ijaz AhmedCharlotte CannonAmanda Pegden

Sharif Ullah

Introduction• Why we needed a new way of working• What is ‘Ambulatory Care’?• Directory of Ambulatory Emergency Care• Implementing the service

Why we needed Ambulatory care?

• Problems with the traditional way of working• Increasing demand for emergency admissions• Investment in the NHS slowing• Delays and inefficiencies caused by high bed

occupancy• Patients looked after by incorrect specialties also

contributing to delayed discharges

Definition of Ambulatory Care

• Clinical care including diagnosis, observation,treatment and rehabilitation,

“not provided within the traditional hospital bed base or within the traditional outpatient service, and that can be provided across the primary/secondary care interface”

Ambulatory Care Sensitive Conditions (ACSCs)• Care of a condition perceived as urgent• Requires prompt clinical assessment, undertaken by a

competent clinical decision maker. • Require prompt access to diagnostic support

What did we want to achieve with the 6-month pilot?

• Reduction in length of stay• Reduction in hospital admissions• Reduction in number of ward moves• Reduce medical outliers• Single sex accommodation for all• Faster time to senior medical review• Improvement in the ED service• Provide rapid diagnostics to patients on the Acute Medical Unit and

Ambulatory Care unit• Improve the patient experience

Impact on patient flow

Peak admissions late in the afternoon

Which type of patients make up this bulge?

Segmentation of patients by Length Of Stay0-1 day LOSShort stay 48-72 hours General Internal

medicine > 2days20-25% of patients with zero

LOS also took up beds (same % of 1 day LOS)

Institute for Innovation and Improvement

Institute for Innovation and Improvement

• Identified extent of pre-existing ambulatory care services

• 49 emergency conditions (including surgical) with the potential for ambulatory care– Aimed as a guide for Trusts to enable service

development– Learning from each other

Financial implications

• Total cost of Inpatient care to NHS England 2009/10 …~ £20.5 billion

• Emergency admissions (60%) 12.2 billion• ACSCs (11.6%) cost ~ £1.42 billion• This is equivalent to £1739 /ACSCs admission• An Average cost of £170,590 for ACSCs per

General practice.

Suitable Conditions Condition Target % Condition Target % Acute Admissions From Care Home 30 Gastroenteritis 60

Acute headache 30 Lower resp tract inf 30

Anaemia 60 Oesophageal stenosis 60

Asthma 10 Painless jaundice 30 Cellulitis 60 PE 60

Chest pain 30 Pleural effusions 60 Community acquired pneumonia 10 Pneumothorax 10

Congestive cardiac failure 30 Seizure in known 60 COPD 10 Stroke 10

Diabetes 60 Supraventricular tachycardias 30

DVT >90 TIA 60

Falls 60 Upper gastro haem 10 First seizure 60 UTI 30

And others too..

Why offer ambulatory care?• Safe• Better experience for the patient• Reduce admission rates• Take pressure off the inpatient bed status• Reduce risk of health care-acquired infections• Reduce overall length of stay• Maintain high level of clinical activity• More ‘efficient’ service

How did we do it?

Old AAU Service• 26-bedded AAU• Ambulatory Care provided from the seating area with 3

Consulting Rooms– Not formal– Dependent on availability of CRs for assessment– Overflow into CR impacted on service

• 59% of 0-2 day LOS patients were transferred– Increasing their LOS, often out-lied so delayed PTWR even

further– Increased number of ward transfers

Redesigned Service – 6/12 pilot• AAU moved to 33 bedded Linnet AMU• AAU became a combined ACU and Observation Ward,

based adjacent to ED• Opening Hours 10am-7pm Monday-Friday

– Aim to discharge all patients by 7pm– Last referral must arrive by 6pm

• Consultant led service• Improved diagnostics• Early discharge decisions

Redesigned Service• Designated clinical area

– Waiting area – chairs– 11 bed spaces (2 monitored)– 3 Consulting Rooms– Cardiac Physiology bay with Echo and ETT – ward TNI– Doctor’s office

Redesigned service• Staff

• 4 FTE Acute Physicians – cover Mon-Fri from 10am to 7.45pm with no other clinical commitments

• 1 Band 6 nurse (10am – 6pm)• 1 Band 3 auxiliary• F2 and Physicians Assistant • SHO level doctor/Clinical Fellow• Secretarial staff • Ward Clerk• Cardiac Physiology – until 18:00• SPA (formerly EDAT) support• Excellent radiology support for diagnostics

Making it work• Rapid access to investigations

– X Rays/Ultrasound/Echocardiography/ETT CT brain/CTPA

• Use of existing clinical pathways• Modified clerking proforma

Making it Work• New electronic take list accessible in all clinical

areas• AMU Band 6 takes GP calls and decides if

patient is suitable for Ambulatory Care• Development of an ED “pull” system – 12pm

board round/notes review

Making it workCultural change

Embedding a new pattern of behaviourKeeping momentum going (much harder getting

people home than admitting)Proactive not reactiveChanging the mindset among clinicians to avoid

unnecessary overnight stay, asking “what do I need to do to get/keep this patient home?”

Number of admissions to Ambulatory Care

Acute Med Obs Grand Total

% of all patients admitted to subsequent ward

Nov-11 200 157 357 14.0%Dec-11 233 233 466 8.4%Jan-12 261 234 495 9.3%Feb-12 243 203 446 8.3%Mar-12 262 241 503 9.1%

Number of patients with an ambulatory care HRG and diagnosis by month and group

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

General Medicine 577 716 698 681 698

General Surgery 73 71 69 72 75

Obs and Gynae 22 29 27 23 24

T&O 19 21 17 19 30

Urology 22 27 18 30 26

Grand Total 713 863 829 825 853

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11Jul-1

1

Aug-11

Sep-11Oct-

11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12Jul-1

20

100

200

300

400

500

600

700

800

General Medicine Ambulatory Care Admissions by month

Num

ber A

dmiss

ions

8.9 % reduction in the number of Emergency admissions

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 710

50

100

150

200

250

300

350

400

Overall emergency admissions with a medical specailty 01/11/2010 - 11/03/2012

AAU -Amb Care Opening Admissions

Week

Num

ber o

f adm

issio

ns

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Average LoS in days for General Medicine Amb Care Conditions

2010-11

2011-12

2012-13

Month

LoS

in d

ays

Number of Medical ambulatory care conditions admitted and number going to AAU - ambulatory care under an Acute Med ConsNov-11 to July-12 only (Mon-Fri 10-6)

Condition Target %Adms by condition

Of these, number going to AAU - amb care

% going to amb care

Number admitted outside of amb care opening

% going to AAU-Amb Care when admitted in opening hours

Acute Admissions from Care Homes 30 3 1 33.3% 2 100.0%

Acute headache 30 179 51 28.5% 95 60.7%

Anaemia 60 53 25 47.2% 23 83.3%

Asthma 10 110 24 21.8% 66 54.5%

Chest pain 30 1279 312 24.4% 738 57.7%

Community acquired pneumonia 10 619 46 7.4% 405 21.5%

COPD 10 392 35 8.9% 232 21.9%

Lower resp tract inf 30 240 32 13.3% 142 32.7%

Oesophageal stenosis 60 20 4 20.0% 16 100.0%

PE 60 80 20 25.0% 49 64.5%

Pleural effusions 60 49 13 26.5% 21 46.4%

Pneumothorax 10 23 3 13.0% 16 42.9%

Seizure in known 60 6 1 16.7% 5 100.0%

Stroke 10 270 10 3.7% 169 9.9%

Supraventricular tachycardias 30 416 77 18.5% 236 42.8%

Upper gastro haem 10 78 4 5.1% 49 13.8%

Diabetes 60 11 2 18.2% 5 33.3%

DSH 60 634 48 7.6% 518 41.4%

DVT >90 32 14 43.8% 15 82.4%

Falls 60 394 31 7.9% 260 22.8%

First seizure 60 243 28 11.5% 161 34.1%

Gastroenteritis 60 54 4 7.4% 38 25.0%

Hypoglycaemia 60 49 1 2.0% 34 6.7%

Lower gastro haem 60 9 1 11.1% 6 33.3%

PEG associated problems 90 1 0 0 0

Cellulitis 60 134 38 28.4% 67 56.7%

Congestive cardiac failure 30 230 19 8.3% 127 18.4%

Painless obstructive jaundice 30 48 0 0.0% 39 0.0%

TIA 60 123 19 15.4% 85 50.0%

UTI 30 272 16 5.9% 186 18.6%

Number of Medical ambulatory care conditions admitted and number going to AAU - ambulatory care under an Acute Med Cons

Nov-11 to July-12 onlyTarget Total

admitted

ACU %ACU OOH % ACU in hours

Other benefits we have seen so far…KPI Nov 2010 - Feb 2011 Nov 2011 - Feb 2012 performance

ED Attendances 21366 22585 ↑5.7%

Attendances with a ambulatory care condition 2483 2667 ↑7.4%

Ambulance handover within 20 minutes 92.60% 94.10% ↑1.5%

4 hour breaches within ED associated with medical bed

availability36.20% 31% ↓5.2%

Medically expedited patients being seen within the ED average of 31 per week average of 27 per week ↓14.8%

Mixed sex accommodation 98 4 ↓95.9%

3 or more moves between different wards as an inpatient average of 40 average of 8.5 ↓78.8%

Discharged from a non medical ward (Outlier) average of 44.7 per week average of 44.7 per week Equal

Number of days with bays or wards closed due to infection reasons 17 55 ↑323%

Escalation ward open 45 27 ↓40%

Future plans• Full cover for Fridays (limited at present)• Extending to weekend ACU cover• Follow up clinic in Ambulatory care area

Your questions

Bruce LaurieChairman