TEDMED Great Challenges Caregiver Crisis, Barry Jacobs: Q1 Ten Contributing Factors
Board Members Present · The TedMed Live Bristol Conference had taken place in Bristol on 18 April...
Transcript of Board Members Present · The TedMed Live Bristol Conference had taken place in Bristol on 18 April...
Minutes of a Public Meeting of the Trust Board of Directors held on 29 April 2013 at 10:30 in the Conference Room, Trust Headquarters,
Marlborough Street, Bristol, BS1 3NU
Board Members Present
John Savage – Chairman
John Moore – Non-executive Director
Lisa Gardner – Non-executive Director
Paul May – Non-executive Director
Iain Fairbairn – Senior Independent
Director
Emma Woollett – Non-executive
Director
Kelvin Blake – Non-executive Director
Guy Orpen – Non-executive Director
Robert Woolley – Chief Executive
Deborah Lee – Director of Strategic
Development and Deputy Chief Executive
Paul Mapson – Director of Finance and
Information
James Rimmer – Chief Operating Officer
Sean O’Kelly – Medical Director
Present or In Attendance
Claire Buchanan – Acting Director of
Workforce & organisational
Development
Helen Morgan – Acting Chief Nurse
Jill Foster – Interim Deputy Chief
Nurse
Prof David Wynick – Director of
Research (presenting item 08 –
Research & innovation Strategy
Progress Report)
Fiona Reid – Acting Head of
Communications
Charlie Helps – Trust Secretary
Victoria Church – Management
Assistant to Trust Secretary
Garry Williams – Patient Governor
Peter Holt – Patient Governor
Pam Yabsley – Patient Governor
Mani Chauhan – Patient Governor
John Steeds – Patient Governor – Local
Anne Skinner – Patient Governor – Local
Jacob Butterly – Patient Governor – Local
Florene Jordan – Staff Governor
Jan Dykes – Staff Governor
Sue Silvey – Public Governor
Clive Hamilton – Public Governor
Mo Schiller – Public Governor
Ann Ford – Public Governor
Sylvia Townsend – Governor, Bristol City
Council
Joan Bayliss – Governor, Community Group
Bob Skinner – Member
Item Action
1. Chairman’s Introduction and Apologies
John Savage congratulated Sue Silvey for taking over as Governor representative,
Mo Schiller for continuing in her current role, and John Steeds for completing a year
in his role as Governor representative.
There were no apologies.
2. Declarations of Interest
In accordance with Trust Standing Orders, all members present are required to
declare any conflicts of interest with items on the Board Meeting Agenda.
Guy Orpen declared a potential conflict of interest regarding Item 08 – Research &
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Innovation Strategy Progress Report. This was due to the University of Bristol and
University Hospitals Bristol NHS Foundation Trust having a close relationship
regarding research & innovation; Guy was employed by the University and was
particularly charged with developing its research strategy, although he believed that
there was a “mutual interest” regarding the research & innovation agenda.
3. Minutes and Actions from Previous Meetings
The Board considered the Minutes of the Public meeting of the Trust Board of
Directors dated Thursday 28 March 2013 and approved them as an accurate record.
There were no actions arising.
4. Chief Executive’s Report
The Board received a report by the Chief Executive, which included the activities of
the Trust Management Executive to note.
Robert Woolley highlighted the following items:
Monitor had formally contacted John Savage to advise that they had lifted the
red Governance Risk Rating over-ride and planned to take no further action in
respect of their concerns. However, they clearly remained interested in hearing the
Trust’s progress regarding plans to improve patient flow and deal with the
exceptional urgent and emergency care pressures that it, along with other hospitals
across the country, had experienced in recent weeks. Robert was pleased to report
that some of the pressure of Accident and Emergency demand had reduced in last
few days, probably due to the change in the weather.
The Bristol Acute Services Review had been subject to a change of scope and
its Terms of Reference had been altered by this Board, working collaboratively with
the Board at North Bristol NHS Trust. The project now focussed on completing the
Clinical Services Review that was already intended, but would not now work
towards an evaluation of a possible merger between the two Trusts. A new scope
and work plan had been agreed with PwC, who were the appointed external advisors
to the project, and three key pieces of work were being undertaken between now and
the end of June 2013, as follows:
1. To review the emergency care system as a whole, considering the entire
pathway of a patient requiring urgent care, both from home through
primary care, hospital, into the community and social care after discharge.
A review with health and social care partners was being undertaken in the
locality;
2. Detailed reviews were being undertaken of eleven priority services
identified between UH Bristol and North Bristol NHS Trust, as agreed
jointly by the medical directors and chief nurses. They were chosen either
because it was thought innovative steps could be taken, there was
information to suggest that quality improvements could be made, or
because it was believed there was duplication of services between the
Trusts, which it would benefit patients to address;
3. The final part of the work stream would review a series of radical options
to address the financial gap that the two Trusts were identified as facing
by PricewaterhouseCoopers (PwC) in their initial “stocktake” review.
These options would be developed by referencing other health systems
nationally and internationally and would be filtered and assessed by
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executive teams on both sites, prior to being brought back for information
to both Trusts Boards. Further action and evaluation would then be
considered at these meetings regarding any shortlisted radical options and
more detail would be provided at the end of June in this regard.
Following the review of divisional leadership arrangements, Bryony Strachan
had been appointed Clinical Chair in the Division of Women’s & Children’s
Services, with an immediate start. Andrew Hollowood was Acting Head of Division
in Surgery, Head & Neck, but had also been appointed Clinical Chair, with an
immediate start. Elisabeth Kutt had agreed to stay in the Division of Diagnostics &
Therapies as Clinical Chair, and Alan Bryan had been appointed Clinical Chair for
the Division of Specialised Services. It was confirmed that Peter Wilde would
remain in post until the end of June, prior to formal handover. Candidates for the
Clinical Chair role in the Division of Medicine would be interviewed this week,
along with applicants for Divisional Director posts.
The changes in divisional leadership were accompanied by a complete review of
ways of working and further steps included investing in new Clinical Director roles,
to replace Lead Doctors inside the divisions, and fulfil the Trust Management
Executives’ commitment in establishing an effective clinical and management
partnership in the running of the divisions.
Jonathan Benger was congratulated as he had been appointed a national
Clinical Director for Urgent and Emergency Care. Due to Jackie Cornish’s recent
appointment as National Clinical Director for Children & Young People, the Trust
now had two national Clinical Directors working with the NHS Commissioning
Board, working directly to Professor Sir Bruce Keogh. As such, the Trust could feel
justly proud that it had nurtured them in their ambitions to operate at a national
level.
The TedMed Live Bristol Conference had taken place in Bristol on 18 April
2013; this was put together to formally launch Bristol Health Partners. Robert
reported that this was a superlative occasion with fantastic speakers and good
attendance, and he thanked all at the Trust, and its partners, who were involved in
putting it together. In particular, David Relph, Head of Planning and Strategy, was
thanked, as it had been his idea to approach TedMed in the first instance.
The new Duty of Candour had been enshrined into Trust policies following
publication of the inquiry into the failings of Mid Staffordshire NHS Foundation
Trust (the “Francis Report”).
The new Interim Deputy Chief Nurse, Jill Foster, was welcomed to the
meeting. Jill joined the Trust while formal recruitment was underway for the
substantive Chief Nurse position.
Claire Buchanan had appointed Richard Lewis as Interim Head of HR, while
Alex Nestor picked up the Organisational Development and Teaching & Learning
agenda.
Comments:
Referring to the Trust Management Executive summary, Iain Fairbairn asked
for clarity regarding risks to the potential delay of implementing the Safe &
Sustainable Review of Paediatric Cardiac Services. Robert Woolley responded that
these uncertainties continued, particularly while the decision of the Joint
Commissioning Board remained under judicial challenge. A possible risk was that
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Marlborough Street, Bristol, BS1 3NU
the change to patient flows intended as part of the rationalisation of Children’s Heart
Surgical Centres would take longer to come into effect. Nonetheless, the Trust was
investing in developing the service in the way it required and had now established
two children’s cardiac high dependency beds, as promised to the Care Quality
Commission. These were located on the Paediatric Intensive Care Unit at present,
but as recruitment proceeded five beds would be opened on ward 32 to support this.
The Trust was starting to see some welcome organic change in patient flow, which
included referral patterns from the south west, which aligned to the
recommendations of Safe & Sustainable and also supported Trust development.
This would provide UH Bristol with time to “pause” its expansion to the level it
intended on the back of the activity and income that the review had intended.
Iain Fairbairn asked if this decision would be made in time to ‘flex’ the Trust’s
premises changes, to which Robert Woolley that there was no timescale. Deborah
Lee added that it was important to note that current configuration plans were
significantly flexible and that, overall UH Bristol were not expecting significant
growth which would lead to a step-change in theatre capacity, for example.
Therefore, Deborah was confident delays would not impact on planning for Bristol
Royal Hospital for Children.
Robert added that the Trust had completed the update of Medway Phase 1b this
weekend, which was successful.
Responding to a question regarding divisional changes from Paul May, John
Savage explained that Divisional Chairs were not members of the Trust Board of
Directors. Robert Woolley added that there was no requirement or expectation that
Clinical Chairs and Divisional Directors should do so, but they would be welcome
to attend meetings of the Trust Board of Directors if they so wished, and this would
be encouraged.
Delivering Best Care1
5. Quality and Performance Report
The Board received and reviewed this report by members of the Executive. It was
noted that the Quality and Outcomes Committee continued to consider the quality
and performance report in detail prior meetings of the Trust Board.
a. Patient Experience
The Acting Chief Nurse, Helen Morgan, presented the Patient Experience report
which was submitted by the Division of Specialised Services. The report highlighted
the fundamental importance of good communication between staff and patients.
Comments:
John Moore felt that it was refreshing to have a patient experience which
highlighted the work of administration and clerical staff. He asked if the Trust had
phone tracking software to identify where calls were being missed. James Rimmer
replied that this system was in use in some areas of the Trust, such as the centralised
booking team, although was not widespread. The booking team used call centre
technology and plans were being considered to ensure this was more widespread.
The Trust was unable to log the telephone numbers of those who called, but
percentages of those patients whose calls were answered within a certain time
period were available. Staff were moved accordingly, depending on caller demand
1 Headings reflect the Transforming Care Programme
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and staff were also increased in centralised booking at peak times. James also
confirmed that patients were called back when they left messages on answer phones.
Robert Woolley added that a large transformation project was underway for
outpatients under the Transforming Care Programme and this formed part of the
reason why booking was partially centralised. The Trust continued to consider total
centralisation and was reviewing wider administration support needs. Although
technological solutions seemed attractive, this was about setting standards of
behaviour and expectations and the values of staff.
Iain Fairbairn asked for an estimated figure of the general proportion of calls
processed through the centralised booking service, as opposed to the Trust as a
whole. Paul Mapson said that the figure was approximately half for out-patients.
Kelvin Blake reiterated Robert Woolley’s comment about the importance of Trust
Values in responding to phone calls, whether technological solutions were available
or not.
Regarding Quality in general, Helen Morgan said that she was pleased to report
a monthly improvement in the reduction of Hospital Acquired Pressure Ulcers.
Regarding Access in general, James Rimmer said that pressures on Accident &
Emergency 4-Hour targets remained unabated, both locally and nationally, although
April performance remained the same as March. Of additional note, the South West
Ambulance Service had incorporated Great Western Ambulance Service (GWAS),
so there might be potential for pinch points. However, the Trust was working in
partnership with them to mitigate issues and these had been highlighted to the NHS
England Local Area Team. Nevertheless, pressure remained on the acute trusts and
ambulance services.
b. Overview
The Director of Strategic Development, Deborah Lee, introduced the item, reporting
that overall, there had been a “significant improvement in the health of the
Organisation”. This was due to a reduction in Red-rated quality indicators by four,
and the movement of five further indicators to Green.
The Hospital Standardised Mortality Ratio (HSMR) continued to be positive at
the Trust, which demonstrated that despite a complicated case mix, patients were
being served well in terms of their outcomes under our care.
Whilst recognising that this was a ‘snapshot’ in time, the level of patients
readmitted quickly to hospital following discharge had declined in the month, which
was positive news.
Robert Woolley alluded to the challenging times that the Trust had been
through recently, which the Compliance Framework report had acknowledged. It
had not achieved 62- Day Cancer Standards or the Accident & Emergency 4-hour
standard, and the Methicillin-Resistant Staphylococcus Aureus (MRSA) standard
had exceeded its target in the year, so also did not achieve. However, Monitor were
currently satisfied with the quality of Board governance during these recent
challenges.
c. Quality and Outcomes Committee Chair’s Report
The Chair of the Quality and Outcomes Committee, Paul May, presented his report,
noting that the Committee had achieved a quorum this month, but apologies were
received from Iain Fairbairn.
Paul presented the following points to the Board:
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1. Matters arising – Accident & Emergency – A paper was presented regarding
progress of the flow project, outlining the nine specific projects based on three main
themes: 1) Avoidance of admissions; 2) Reduction of length of stay; and, 3)
Improving morning discharge. The Committee agreed to monitor progress at each
meeting and asked for outcome projections, benefits and measures, to ensure 97%
achievement by September 2013. As a joint private/Trust project, excellent working
and backfill support had been provided if required.
A specific incident reported at the last meeting would be reviewed to ensure that
system improvements reduced/eliminated the risk of human error.
‘Black’ Escalation – A formal report presented 18 items recorded. Each division had
fed back specific responses to the corporate review. There had been an excellent
staff response, and staff had been thanked for demonstrating good practice. A key
issue was to review the policy regarding escalation and step-down after the event.
2. Draft Quality Report – Work was in progress to examine the latest draft
before external consultation. The format was similar to last year, but would be more
concise. Additional points raised would be picked up within the Chief Executive’s
introduction, such as the “Francis Report” and governance. The Hospital
Standardised Mortality Ratio target would be service-specific and amended to
reflect the subtlety of the task. Following a full discussion the detailed overview by
the committee was noted.
3. Quality & Performance Report
Quality – The Committee was delighted to note significant progress in many items,
but it would not lessen its scrutiny. After several ‘black’ escalation incidents, Trust
staff could feel proud of their dedication. Of key note, the Hospital Standardised
Mortality Ratio figure was excellent and Theatre Productivity was an issue. A
briefing about South Bristol Community Hospital would be provided by the Medical
Director.
Outlier figures for 30-Day Readmissions had been reviewed by the Quality
Intelligence Group and the Committee was reassured by the outcomes of this
review. Quality issues were examined, including Antibiotic Prescribing. A Falls trial
was being rolled out to a further ten wards across the Trust. A new unit for
Fractured Neck of Femur patients was seeing positive results. Transient Ischaemic
Attack - managed to keep 80% on ward despite ‘Black’ escalation.
Workforce – A Workforce deep dive would commence in May.
A Review of Bank & Agency was expected to be provided to the Board soon and
changes already made were showing improvements, including changing local
recruitment of nursing assistants. There was a visit to Dublin where a recruitment
drive was held for nurses. Sickness improvement was still under constant scrutiny,
and a detailed review of training definitions was being undertaken.
Access – Theatre capacity and patient choice. Intensive Care Unit capacity and Last
Minute Cancelled Operations.
4. Clinical Audit – This presentation covered the role of Clinical Audit, how the
process was supported, and answered Non-executive Director queries. There was
assurance about the process and discussion about how outcomes could be more
challenging in the future and how benchmarking could be more visible to Non-
executive Directors.
5. Clinical Effectiveness Strategy – It was agreed that this would be one of
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three Quality Strategies and was welcomed by the Committee. The Strategy would
be submitted to the Board for formal approval, following the agreement of
amendments. This would move the agenda forward regarding responding to
“Francis”.
6. Clinical Annual Report and Plan – The Committee was pleased to note the
progress reports from the audits, but would welcome more structure regarding
priorities, planning and delivery in the future.
7. Clinical Quality Group notes. Some detailed issues arose from figures
provided, such as the clinical audit of medical records.
8. Due to the length of the meeting the Committee were unable to examine the
Corporate Risk Register and the Quarter 4 Compliance Framework, but these were
included on the main Board agenda.
d. Board Review
Referring to Hospital Acquired Pressure Ulcers, Iain Fairbairn noticed that one
of the Root Cause Analysis investigations had mentioned a shortcoming in “poor
nutrition and sepsis” as a cause, and asked if this had related to nutrition provided at
the Trust or externally. Helen Morgan said that this referred to patients admitted to
hospital with poor nutrition, and the importance of ensuring that if a person was at
high risk of poor nutrition that they were automatically highlighted as at risk of
developing a pressure ulcer. Kelvin Blake added that it was important to maintain
progress regarding pressure ulcers, including the requirement for provision of
appropriate mattresses.
Referring to Inpatient Falls per 1,000 Bed Day statistics, John Moore said that
the Trust should review patients with cognitive impairments, and he requested an
additional graph to show these figures separately. Helen Morgan confirmed that
Xanthe Whittaker planned to include this graph at the next meeting of the Board.
Guy Orpen referred to the Accident & Emergency 4-Hour standard, saying that
the transfer of Great Western Ambulance Service to the Trust covering the whole of
the south west might unbalance the relationships previously formed and require
them to be re-built. James Rimmer confirmed that a pilot of protocols was being
worked through at present in this regard.
Robert Woolley asked the Board to note that while it had been a positive
month for Infection Control in March, the Trust had breached the MRSA target for
the year and the targets for the current financial year would be considerably more
challenging regarding Clostridium Difficile, and a “zero tolerance” approach would
be taken towards MRSA. A review into whether more significant reporting was
required at Board would be considered in this regard.
There being no further questions or discussions, the Chair concluded this review of
the Quality and Performance Report.
Chief
Executive
6. Quarterly Transforming Care Report
The Board received this report by the Chief Executive to note.
Robert Woolley said that there was both a need to refresh the programme and was a
sterling opportunity to do so, with changes now being implemented in divisional
leadership. A new Programme Director, Simon Chamberlain, had been appointed
for the Transforming Care agenda, commencing work in the first week of June. He
would advise James Rimmer and Robert Woolley on how the programme could be
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Marlborough Street, Bristol, BS1 3NU
re-launched as a whole, and refresh work streams such as the Enhanced Recovery
from Surgery Programme, which was showing a significant impact and improving
Length of Stay.
Robert wanted the Board to have greater visibility of these improvements, and for
there to be a significant push regarding staff engagement, towards continued
delivery of high quality and compassionate care for the individual needs of patients.
James Rimmer referred to NHS Change Day, which was held on 13 March 2013.
The aim, nationally, was to involve at least 5% of the NHS. Locally, people planned
to pledge over 400 changes. Stations were placed across the Trust throughout the
day and over thirty patients also gave their opinions regarding change, particularly
in respect of outpatient services, which reemphasised the Patient Experience.
Comments:
Emma Woollett welcomed the re-launch of the Transforming Care agenda
within the Trust. She said that given how busy staff were, it is always difficult to
find the time to stop and think about how to do things differently; however, this re-
launch provided a valuable opportunity for innovative thinking.
John Moore asked if the Trust was setting itself ambitious targets in aiming to
find £3m of Non-Pay savings and if these might be too ambitious for the new
leaders of the Divisions in terms of their responsibility to save costs and achieve
targets without losing staff. Robert Woolley responded that he had been
communicating this challenge to colleagues and a detailed review regarding Non-
Pay and Procurement had been taken to one of the Board sub-committees. A number
of divisions had taken significant steps and positive engagement in the Non-Pay
savings work stream. Although the targets were ambitious, Robert felt that they
were realistic and proportionate.
Kelvin Blake requested the report continued to take this format and also
highlighted the key blockages stopping the Trust from “going the extra mile”.
Robert Woolley confirmed that the next time the item would be brought to Trust
Board, a new Programme Director would be in place and reviewing how reporting
could be adjusted.
Guy Orpen stated that one of the benefits of working in a research and teaching
organisation was the opportunity for capacity to be an ‘innovative organisation’.
The mind set for developing practice allowed it to be more readily implemented
than other organisations, and Guy was interested to explore how Research &
Innovation could be synergised with the Transforming Care Programme. Robert
Woolley acknowledged Guy’s observation and added that more thinking was
required to build the research agenda, whilst demonstrating outcome improvements
through this programme.
There being no further questions or discussions, the Board resolved to note the
Quarterly Transforming Care Report.
7. Timetable for Responding to the Mid Staffordshire NHS Foundation Trust Public Inquiry Report (the “Francis Report”)
The Board received and considered this report by the Medical Director for
approval.
Sean O’Kelly said that the paper set out the plan regarding how the Trust planned to
respond to the “Francis Report” in two ways:
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1) It would review the report and its recommendations and conclusions in detail
and derive an action plan from these; and,
2) It would review the report more generally and conduct a number of
opportunities where staff could reflect on it and explain any themes and ideas
arising from the report.
The requirement was for the Trust to produce a detailed action plan by the end of
the year, but completion was expected before this time.
Work would be led by Sean O’Kelly, Helen Morgan and the Trust’s Clinical Chairs.
A Core group would oversee this initial phase of work and groups were due to meet
on Wednesday 01 May to initiate process.
Comments:
Emma Woollett said that useful sessions had been held to review how the
Board could take responsibility, not just in light of the “Francis Report”, but also
due to changes in constitution and structure. Robert Woolley confirmed that the
Trust Secretary was currently engaging with other acute providers across the south
west to share governance lessons and any pertinent information regarding this would
be taken into account by the Francis Report Core Group.
Guy Orpen asked how the “patient voice” would be brought in to the response
to the report. Sean O’Kelly said that this would have to be considered carefully as
there were many pre-existing mechanisms for patient experience. Another
recommendation was specifically regarding the ‘patient voice’, so this work stream,
in particular would inform thinking in this regard. Deborah Lee added that in
preparing the annual report, the Trust examined how it approached patient
experience and gathering patient insight from the previous year. Of note, as well as
building on more routine survey approaches, UH Bristol almost doubled the number
of specific focus group type experiences. Deborah considered this one of the most
powerful ways in which the Trust could investigate what it was like to be patient at
this Trust.
Lisa Gardner asked if listening to staff would be part of designing our response
to the “Francis Report”. Helen Morgan confirmed that all nurses had access to the
report and Sean O’Kelly added that there had been considerable editorial comment
regarding the report in medical literature, so it was in the general discourse for
medical staff. Robert Woolley said that more staff ‘listening events’ were intended
and he was interested in whether the Board challenged itself further and commenced
reporting of staff satisfaction at Trust Board, in addition to the Workforce report.
Robert was interested to research and follow a practice in Europe where the spread
of patient safety culture was monitored within hospitals.
There being no further questions or discussions, the Board resolved to approve the
Timetable for Responding to the Mid Staffordshire NHS Foundation Trust Public
Inquiry Report (the “Francis Report”).
8. Research & Innovation Strategy Progress Report
The Board received this report by the Medical Director to note.
The Director of Research at North Bristol NHS Trust and University Hospitals
Bristol NHS Foundation Trust, David Wynick, joined the meeting and introduced
his presentation to the Board.
David had been Joint Director for North Bristol NHS Trust and UH Bristol for three
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years, and he reported that the “quantum” had changed the whole research landscape
and the buy in and involvement of research active trusts like ours.
Highlights of David’s presentation:
It was important to note that patients treated in a research active environment
responded considerably better than those who had not, and there was evidence to
prove this, even when resources were under great pressure.
Research Funding from the Department of Health (DoH) to the National
Institute for Health Research (NIHR) had stayed constant in recent years despite
cuts in other Government departments; as such, changes were being seen in care and
outcomes from research.
A considerable amount had been achieved regarding Research & Innovation at
UH Bristol in the time since the Trust Board signed off the Research & Innovation
Strategy in December 2010. Within a month of this a major review had commenced
and by the summer of 2011 the whole department had been restructured. By
September 2011 detailed operational delivery plans had been completed.
The vision of Research & Innovation at the Trust was to improve patient health
through excellence, with a focus on three key areas:
1. To recruit patients into clinical trials;
2. To increase income through commercial and non-commercial research
and develop grant income; and,
3. To develop a “research-savvy” workforce to underpin this work.
The function had been mirrored with the structure and the department reorganised to
align with the three major work streams.
Funding was now better balanced than before; the Trust received stable
funding from the Comprehensive Local Research Network, NIHR grants were rising
rapidly and commercial research had risen. As a consequence of these grants
research capability funding had also increased. In total the Trust’s current grants
matched any of the other large research-active trusts outside the “golden triangle”
(Oxford, Cambridge and London). David felt that it would be possible for UH
Bristol to be one of the top research trusts outside of these in two to five years.
Looking at performance, metrics had been re-cast, largely to deal with the three
areas judged upon from a national point of view. ‘Performance Initiating Research’
was the time it took someone to submit a valid application to start a study, to the
time the first patient was recruited. Of note, the national benchmark set by the
Department of Health for this was seventy days. Following data collection at UH
Bristol, the number of studies that met this benchmark were 9% a year ago, but first
quarter data showed an increase in the figure to 29%. This was positive, but 71%
were still not meeting the benchmark. If areas were removed where delays were due
to outside forces or a rare cancer study, for example, more than half the studies
reached the benchmark and the figure was rising. The Trust was aiming for the
figure of exclusions to be 70% within a year.
The process for recruiting patients to clinical trials would be reviewed, as 2011
had been a poor year and a major driver to reorganising the department. As a
consequence of the changes, recruitment to trials jumped by almost 30% and 2012
had seen the best year of recruitment.
At present, the total grant income of all active grants was over £25m and a
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further increase was expected. If the Collaboration for Leadership in Applied Health
Research and Care (CLAHRC) application was awarded another £9m of funding
would exist.
Of positive note, Professor John Sparrow at the Bristol Eye Hospital had just
been awarded a prestigious NIHR programme grant over five years to look at
various research aspects of cataracts.
David highlighted some areas of importance regarding change and challenge within
Research & Innovation over the next year:
1. The Western Comprehensive Local Research Network was one of over a
hundred comprehensive and topic-specific networks. The Department of
Health had decided to focus down all networks into just fifteen, which
mapped into the Academic Health Science Network geography. In the
west, UH Bristol were bidding to host the local Comprehensive Clinical
Research Network and it would be known whether this was successful by
the end of summer.
2. The Trust was in a strong position to bid for £9m through the new NIHR
CLAHRC scheme on 13 May. There was confidence in the application
and interviews were being held in July for an expected outcome by the
end of summer, for commencement in January 2014. This would have
major synergies with Bristol Health Partners and the £9m of new funding
would mean could do more with Bristol Health Partners.
Two particular areas of importance were highlighted within the Trust:
1. With the advent of closure of the Old Building, there were plans to merge
the two Clinical Trial units in both Medicine and Surgery, which would
mean greater efficiencies.
2. Space in the BRI was due to be converted into a Research unit, for
completion by autumn 2013. This would provide greater capacity, and
further studies and grants could be undertaken.
The larger picture for Bristol was Bristol Health Partners and the West of England
Academic Health Science Network. Bristol Health Partners had gone from strength
to strength since its launch in May 2012 and the recent TedMed Conference was “a
huge success”. There were now twelve health integration teams and 3 more had
recently been accredited. Of these, five were hosted by UH Bristol and at least
another six were in development and were noted to map effectively into the
CLAHRC.
Comments:
Responding to a question from Paul May regarding whether Research &
Innovation looked at the entire process of the continuum of work contracts for
consultants through to the delivery of research, David Wynick confirmed that a
consultant was offered a mentor from the moment they were appointed to a research
position. Anyone with an area of interest in research would be assisted in setting up
a research profile and if necessary, would be provided with ‘pump priming funds’ to
buy their time for research activity. Once they were busy recruiting into clinical
studies, they would be assigned a research PA of activity to allow them to continue
this work. As Bristol’s reputation had risen over recent years, the quality of
applicants was rising and there was now a university or academic partner on each
consultant appointment panel to ensure research was a priority.
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Kelvin Blake asked what work was being undertaken to engage the nursing
contingent to ensure they submitted research projects. David said that this was one
of the major drivers for UH Bristol. With University of West of England (UWE)
funding the Professor of Nursing Research, Margaret Fletcher, planned to focus on
this bigger agenda and conduct research.
Guy Orpen requested more information regarding what form grant outputs
would take. David said that the NIHR would find it more difficult than the
university would find in its research assessment exercise, but if the Trust thought
about what its impacts were such as alterations in clinical care, pathway, and
redesign, and ensuring postcode lotteries in terms of peoples’ variability in care,
these stories and outcomes were less tangible and it would be more difficult to say
how well the Trust had done by its patients. This was an on-going issue but David
felt sure that looking at what BHP and CLARHC had achieved in three to five years,
it was likely that the Trust would have provided better care and outcomes and
reduced morbidity than it would have otherwise. This would be easier to do once the
Health Integration Team was up and running. Guy added that he thought some
evidence might engage people in thinking that research was valuable in patient
outcomes. David agreed with this, saying that the Trust’s Hospital Standardised
Mortality Ratios were good, but it was difficult to link this directly to research.
Garry Williams, a Patient Governor who was present, asked if Research &
Innovation would work with external providers of the NHS. David confirmed that
this would definitely be the case as BHP would bring together all health research
and partners across Bristol. He provided an example of this, saying that this week a
full application for the Health Integration Team had shortlisted cataract surgery.
50% of this surgery was completed by independent sector providers and
traditionally, they had not input into research due to their commercial models, but
David was delighted to see that a chief executive of an independent provider was
keen to do just that, and as such he could see a scenario that if solid evidence was
generated over the next five years to show a pathway or treatment regime worked, it
would attract interaction with non-NHS agencies. Guy Orpen added that a key
partner in BHP was Bristol City Council, which was a central player in healthcare
delivery.
Referring to the “postcode lotteries” David mentioned, Anne Skinner, a Patient
Governor who was present, requested clarity regarding assistance for local people
outside of Bristol, in places such as Weston and North Somerset. David responded
that BHP was starting in Bristol, and if CLARHC was achieved, it would expand to
Bath. Overarching BHP and CLARHC was the AHSN, which had a major remit in
bringing together all of these activities and minimising postcode lotteries across the
whole geographical boundary. Each area had its own AHSN, and they would work
together over time to share best practice and even out variation.
Robert Woolley asked if the Board had any expectation to see a report
regarding Research & Innovation regularly. Guy Orpen said that he was interested
in how Research & Innovation delivered transformation and outcomes and also
suggested that it was likely to couple in to the Trust’s ability to compete effectively
in the provision of Specialised Services. Finally, it would relate to delivering
education.
The Board agreed it would like to see an update report on a quarterly basis.
There being no further questions or discussions, the Board resolved to note the
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Research & innovation Strategy Progress Report.
Delivering Best Value
9. Finance Report
The Board received and considered this report on the activity of the Finance
Committee for review. The most recent meeting was held on Friday 26 April 2013.
a. Overview – Director of Finance and Information
Paul Mapson highlighted the following main headlines from the report:
The end of year position was still subject to audit, but of a headline surplus of
£6.6m, of which £865k was called a ‘reversal of an impairment’, which was a
technical item. Therefore, the real management reported surplus position was £68k
higher than the original plan of £5.7m. Paul anticipated this remaining the same
following audit.
CRES equated to 82% of the plan and impact of this and performance had
played in to next year’s position.
It was decided at year end to change the way in which income was billed. In
the past there were always estimates for March activity and these were adjusted in
the new financial year. A view was taken that given the scale of change in the
system, expecting new bodies to pick up estimated variances and pay bills in the
new year was risky, so the estimate was fixed at a slightly higher level.
A couple of adverse variances were seen in the divisions in March. Of most
concern was the Division of Medicine, where the variance shown was £268k, which
was after a significant amount of winter funding was applied. The scale of actual
deterioration was well in excess of £0.5m, which was entirely due to the cost of
coping with emergency pressures. The major concern was the impossibility to
sustain this if it continued. The Division of Surgery, Head & Neck had deteriorated
by £0.5m but it was thought this was due to the valuation of supplies, with some
improvement anticipated.
The risk rating was 3.1, potentially.
Capital had slipped further than planned and as a consequence a report had
been taken to the Finance Committee suggesting a slightly different approach was
taken to capital planning.
The cash balance at end of year was £35m, which was satisfactory. Debtors
rose slightly but these were mainly short-term debtors. Payment performance was
seen to have improved towards the end of the year.
Surplus had been achieved for the tenth year. The long-term plan culminated in
the next two or three years, with major capital redevelopments. It was essential that
the Trust did not go into financial deficit when buildings were opened.
Service Level Agreements (SLAs) had been agreed with commissioners, which
covered specialist, local and regional commissioners in one contract. Significant
benefit had been gained from the contract, including tariff changes and renegotiating
terms regarding payment of readmissions marginal tariffs, so it was likely that 1.5%
had been taken back from a 4% reduction in the tariff, as set nationally. This
equated to about £7m, which would be provided to divisions to reduce their
underlying deficits. Assuming the negotiation held true, it would provide the Trust
with a good starting position in the next financial year.
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John Savage said that the Board should acknowledge that ten years of consistent
financial control was a considerable achievement.
b. Finance Committee Chair’s Report
The Chair of the Committee, Lisa Gardner, presented a verbal report on the meeting
of the Finance Committee of 26 April 2013.
Lisa stated that it was important to note that the divisions did well, if the
Division of Surgery, Head & Neck was removed from the equation. £17m of £21m
of CRES funds had already been identified and risk assessed, which was good
progress.
More information been received from Plymouth Hospitals NHS Trust, which
was being analysed to see where differences were, always ensuring quality was
maintained.
Changes to Accounting Policies were also reviewed in the Committee and an
extraordinary Audit Committee meeting was also held to approve these, due to the
timing of the release of the Monitor financial reporting document. There were no
major changes.
A paper and presentation was received regarding Monitor’s approved costing
guidance and the Trust’s approach, which required further work before bringing it to
the Board Development Seminar on 17 May.
A Monitor assessment and regulatory system financial performance Quarter 4
was included in papers and the Finance Committee had to commit and recommend
to the Board that it would still maintain a Finance Risk Register of 3, which it
anticipated and agreed.
The main focus at present was regarding the new financial year and how to
work differently and ensure divisional targets were more realistic and achievable.
c. Board Review
Kelvin Blake gave his opinion that despite hearing of pressure areas and
overspend, the Trust had actually achieved results at year end. Robert Woolley said
that UH Bristol demonstrated that it was able to consistently achieve a level of
savings without the risk of harming patients. The position Paul described in terms of
getting savings target to a realistic level for the year gave confidence of achievement
and continued to drive the message regarding Transforming Care. Ultimately, the
Trust had a declining resource pool and it either provided services to standards
insisted on as a minimum or cease to provide them. Paul Mapson added that a
contract had been negotiated at high level which gave UH Bristol the ability to earn
a significant amount of money in delivery of services. If it delivered activity in
specialist areas particularly, it would then go a long way to making the plan
deliverable.
Emma Woollett highlighted the importance of conveying a message that the
Trust must not use activity to mask an inability to control costs.
John Moore asked if Earnings Before Interest, Taxes, Depreciation, and
Amortization (EBITDA - operating surplus before financing items) increased or
decreased this year? Paul Mapson confirmed that it was lower and the surplus being
below EBITDA this year was one of the mechanisms used to mitigate overspend in
certain divisions.
There being no further questions or discussions, the Chair concluded this review of
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the Finance Report.
Renewing Our Hospitals
10. Quarterly Capital Projects Status Report
The Board received this report by the Director of Strategic Development to note.
Deborah Lee said that four major capital schemes were being progressed across the
Trust’s campus.
Referring to the Bristol Haematology & Oncology Centre (BHOC), Deborah stated
that the Trust had not communicated as well as it could previously with patients
when making changes, and Governors had been particularly instrumental in helping
Deborah’s team to understand how it could have undertaken these challenges
differently. This time, patients were notified about the disruption and given advice
regarding parking, and some focus groups were undertaken with patients to gauge
their opinions, which assisted in this.
The paper outlined the following two risks:
1. The transfer of Specialist Children’s Services from Frenchay. The policy
direction regarding Specialised Services had changed with the introduction of the
National Commissioning Board, and two of the assumptions made regarding aspects
of care had changed, which were:
a. Specialist Spinal Surgery on Children, where the assumption at the time
was that the care would only be delivered in specialist centres. The Trust
therefore assumed that work undertaken elsewhere in the region would come
to the Bristol Royal Hospital for Children. This policy had not emerged, so it
was prudent to assume that there was an element of risk regarding the
assumption. UH Bristol would continue to work with other providers in the
region to understand what best care looked like for the most complex children;
b. When the original plan was cast for the provision of Paediatric
Neurosurgical Services, it was thought that Wales would be unlikely to sustain
specialist elements of the service and that around 200 operations would be
transfer from South Wales to Bristol. Since that time Wales had changed their
policy direction with the aim of maintaining local neurosurgical and the
Trust’s plans were now being revised to reflect this. The clinical view was that
in the next two years the risks regarding clinically sustainable services in
Wales for specialist neurosurgery would re-emerge, but at present a
contingency plan was required as from next April the envisaged flow would
not materialise. There were opportunities to mitigate the cost base, which the
Trust would take.
2. Deborah Lee advised that the recently completed capacity refresh had
indicated that the proposed future bed base for the BRI may be insufficient to meet
the predicted demand in light of both local and national changes to activity and
length of stay. Deborah Lee advised that the Trust Management Executive was now
recommending a higher bed base than currently assumed, though this was still a
reduction over the current number of beds. Options for providing additional beds
were being worked up and would be presented to the Board at its May meeting.
Comments:
Responding to a question from John Savage regarding the Old Building,
Deborah Lee confirmed that the plans were still consistent with the
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decommissioning of the building. Deborah and Paul Mapson were working closely
to manage long term financial planning in this respect.
There being no further questions or discussions, the Board resolved to note the
Quarterly Capital Projects Status Report.
Corporate Governance
11. Corporate Risk Register
The Board received and reviewed the report by the Chief Executive.
Robert Woolley said that the Corporate Risk Register had been reviewed following
appointment of the Trust Risk Manager, Lee Mercer, who had changed the format of
the document and improved its legibility.
Work continued on the way that corporate risks were managed, logged, reported and
then extracted for the Board.
Of note, Risk 759 had been escalated to the Corporate Risk Register since its last
presentation to the Board in January 2013. The cover paper also outlined the risks
which had been deescalated, which provided evidence of the Trust’s continued
attention to risk management and pursuing the high rated risks, particularly those
with a patient safety implication.
Three risks had a high residual rating:
1. Hospital Acquired Infections;
2. Emergency patients, particularly patients queuing in corridors;
3. Obsolete radiotherapy hard and software.
Deborah Lee reported positive performance in the following two areas:
1. Lack of trauma theatre capacity; following transfer of Surgery, Head & Neck
in March, performance for patients accessing theatre within 36 hours was at about
30% – 50%. As at the first few weeks of April, performance had now achieved 80%.
2. A focussed action plan was being led by the divisions regarding Endoscopy,
however positively the backlog of 900 patients had now reduced to 200.
Comments:
Emma Woollett emphasised the continued concerns regarding maternity
staffing and endoscopy service capacity, which had been included on the register for
some time. Robert Woolley said that both risks had been carefully reviewed in light
of significant assessment and recruitment.
Referring to healthcare infections, Emma then highlighted her concern
regarding the description of controls, some of which did not have a number of
actions to justify the assessment of low risk. Robert Woolley responded that this
was a reporting position to date and the Trust know that the action regarding MRSA
had not been sufficient enough this year to keep UH Bristol near the contractual
target or within the Monitor threshold. The Trust’s controls regarding MRSA in
particular, had been of low effect. The rigour of the plan would be assessed in the
current year, but the issue now was that the targets were substantially lower and
actually ‘zero’ for MRSA and the risks were still high.
John Moore highlighted the risks regarding the information management
system, as it was not said to be watertight. John asked if the Trust Management
Executive had discussed risks in detail regarding this and record keeping. Robert
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Woolley confirmed that this was monitored against related outcomes for the Care
Quality Commission and the Information Governance Toolkit. Risks were not
considered as ‘high’, but were fully on the Trust’s agenda and encompassed a
number of areas of work.
There being no further questions or discussions, the Chair concluded this review of
the Corporate Risk Register.
12. Board Assurance Framework Report (including Strategic, Corporate & Compliance Objectives Status Reports)
The Board received and reviewed the report by the Chief Executive.
Robert Woolley introduced the report and said that it concluded a review of the
Trust’s performance against the 2012/13 milestones in its 3-year action plan.
UH Bristol had achieved 80% of its own objectives, for conclusion in the year. A
small number were amber rated and were therefore automatically carried over into
the new financial year; three objectives had a red residual risk rating. There were
issues with the Monitor green rating, which was not surprising, given that the Trust
was recently red rated.
Non-delivery of Cash Releasing Efficiency Savings had been fully evident to Board.
The Trust awaited results of the Care Quality Commission’s follow-up review of
performance in the Paediatric Cardiac Surgery Service and in maternity staffing,
following a visit on Friday 26 April. Informal results were positive, but a formal
response was required before the risk was cleared.
Comments:
Referring to page 148 of the meeting pack and the pause in improvements to
Fire Safety in the Trust, Paul May asked if there was any risk to patients. Robert
Woolley reported that “huge strides” had been made in fire safety compliance, so he
doubted there was any significant risk. James Rimmer reassured Paul that Fire
Safety did not pose a risk and had actually been deescalated from the Corporate
Risk Register.
There being no further questions or discussions, the Chair concluded this review of
the Board Assurance Framework Report.
13. Quarter 4 Compliance Framework Monitoring & Declaration Report (including Quarterly Financials)
The Board received and considered this report by the Chief Executive for approval.
Robert Woolley explained that the Board had to declare to Monitor its retrospective
appraisal of compliance for Quarter 4, when the Trust was amber red for
Governance. It also took into account the prospective performance for Quarter 1.
The Trust Board was asked to note potential risks in Quarter 1, particularly
regarding the Accident & Emergency 4 Hour target, Referral to Treatment Times
(largely as a result of transfer of Head & Neck and Ear & Throat services from
North Bristol NHS Trust), and Infection control and risks regarding screening.
The Board was asked to make a declaration of amber red compliance for
retrospective Quarter 4 and prospective Quarter 1, based on the Trust’s performance
for the quarter so far.
The Finance Risk Rating (FRR) was at 3 for the quarter.
Comments:
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In response to a query by Emma Woollett regarding Quarter 2, James Rimmer
stated that the Trust was expecting improvements to targets, due to the
establishment of action plans. He continued, saying that improvements in Referral to
Treatment Time would were more likely be seen at the end of Quarter 2.
There being no further questions or discussions, the Board resolved to approve the
Quarter 4 Compliance Framework Monitoring & Declaration Report (including
Quarterly Financials).
14. Risk Management Strategy
The Board received and considered this report by the Chief Executive for approval.
Robert Woolley explained that the Strategy had been referred to the Trust Risk
Manager for review, and the Board were asked to approve this revised statement.
The Board were asked to approve the strategy based on the following aspects:
1. The Statement of Objectives, which was included at page 188 of the pack;
2. The Board Statement of Risk Appetite.
Comments:
Referring to table 8.2a on page 189 of the pack, John Moore asked if all
foundation trusts were adopting this methodology and how they might rate
themselves by utilising this approach. Robert Woolley was not aware that all trusts
were moving to this approach, which was based on ‘best practice’. For clarity,
Deborah Lee added that, the score chart overleaf regarding the assessment of risk
materialising, was entirely independent of this table and there was no read across.
Each de-escalated risk was considered by the Trust Management Executive each
month. Robert Woolley explained that the Risk Management Group received and
reviewed divisional risk registers on a rolling basis and any risks were interrogated
at the meeting and also at departmental level.
Responding to a query from Paul May regarding the first bullet point of Item 7
– Risk Management Objectives, and the acceptance of levels of risk, Robert
Woolley said that the indicator was consistent in the approach the Board had taken.
If the South West Pay Terms and Conditions Consortium was reviewed, for
example, the Board was prepared to take steps which staff could regard as
provocative or creating uncertainty or discomfort; by the same token, the Board was
not prepared to compromise on safety or quality of service so in the current climate,
this made sense.
Referring to finance, Guy Orpen said he was aware that the Trust had taken out
loans and made investments in business, which was indicative of an appetite for
taking certain types of risks regarding confidence in future performance. Guy asked
if it was worth considering having two different sorts of financial appetite, such as
investment versus appetite for performance. Robert Woolley said that there was a
read across between business and finance and in line with what Guy described and
the Trust had prepared to invest in taking a degree of risk, but the risk regarding
investment was tempered by UH Bristol’s concern that it was conducted affordably.
If approved, the Risk Management Policy and Procedures would be revised, and
there would be a plan for implementation, which would include training of relevant
staff at each level of organisation, to deliver the strategy as the Board intended.
There being no further questions or discussions, the Board resolved to approve the
revised Risk Management Strategy.
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Information and Other
15. Any Other Business
There was no other business.
16. Date of Next Meeting
Public Meeting of the Trust Board of Directors, Friday 31 May 2013 from 10:30
– 12:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol,
BS1 3NU.