GOVERNING BODY

16th JULY 2012

Trust Headquarters 2nd Floor, Central Wing

250 Euston RoadLondon NW1 2PG

6th July 2012 Dear Governor,

GOVERNING BODY MEETING – 16th JULY 2012 Please find attached the agenda for the meeting to be held on Monday 16th July. The meeting will take place in the Education Centre, 1st Floor West Wing, 250 Euston Road, London NW1 2PG, commencing at 6.00pm. Yours sincerely, Jocelyn Laws Jocelyn Laws Trust Administrator

A G E N D A 6.00pm 1. Apologies for Absence 2. Minutes of the Meeting held on March 26th 2012 Attachment A 3. Matters Arising Report Attachment B

4. Chairman’s Report Attachment C 6.10pm 5. Chief Executive’s Report Attachment D Incorporating presentations on:

• UCLH Preparations for the 2012 Olympics Daniel Wallis, Divisional Clinical Director, Emergency Services

• A&E Performance Tara Donnelly, Managing Director, Medicine Board

7.10pm 6. To receive the Annual Report, Accounts and Quality Enclosed for Account 2011/12 and the External Audit Report on the Governors Trust’s Financial Statements Incorporating a presentation on the Annual Accounts 2011/12 Tim Jaggard, Deputy Finance Director 7.30pm 7. Report from the Nomination & Remuneration Committee Attachment E

8. Reports from Governor Representatives on Trust Committees: 8.1. Quality & Safety Committee Attachment F 8.2. Patient Experience Committee Attachment G 9. Report from the Carer Governor Attachment H 10. Revised Membership Development Strategy Attachment I

11. Foundation Trust Governors Association Report Attachment J 12. Any Other Urgent Business 13. Dates of Next Meetings: Monday 24th September 2012 – Annual Public Meeting (AGM) Thursday 22nd November 2012 Wednesday 27th March 2013 Monday 22nd July 2013. Meetings for Governors only (not public meetings): Tuesday 22nd January 2013 - Informal meeting Thursday 27th June 2013 - Joint Governing Body/Board meeting All meetings commence at 6.00pm and will be held in the Education Centre,

1st Floor West Wing, 250 Euston Road. 8.00pm End Please either confirm your attendance or send apologies, as soon as possible, to Jocelyn Laws, Trust Administrator: Jocelyn.laws@uclh.nhs.uk or by telephone: 020 3447 9608.

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Agenda Item 2

Minutes of the Meeting Held on 26th March 2012

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Minutes of the Governing Body Meeting held on 26th March 2012

Present: Richard Murley, Chairman Robert Naylor, Chief Executive Patient & Public Constituency: Joan Bell Andrea Kennedy Peter Brayshaw Fiona McKenzie Dee Carter Emma Manuel Szelepet Christine Chapman Patricia Orwell David Coulter Diana Scarrott Alison Forbes Stuart Shurlock John Green Bonnie Wallace Rosalind Jacobs Staff & Stakeholder Constituency: Denise Bavin Maureen Holas Philip Brading Tom Hughes Fion Bremner Nuruz Jaman John Carrier James Mountford Caroline Dux John Muolo Adam Harrison Marcia Persaud In attendance: Richard Alexander, Finance Director Richard Delbridge, Non-Executive Director Mike Foster, Deputy Chief Executive Simon Knight, Acting Director of Performance Diana Walford, Non-Executive Director David Wherrett, Workforce Director Tonia Ramsden, Director of Corporate Services Jocelyn Laws, Trust Administrator (minutes) Ros Waring, Membership Development Manager 1. Apologies for Absence Apologies were received from Ajay Kakkar, Bill McAlister, Sue Atkinson, Geoff Bellingan, Katherine Fenton, Gill Gaskin, Tony Mundy, Jane Ramsey and John Tooke. 2. Minutes of the Meeting held on 24th November 2011 The minutes were agreed to be a correct record. 3. Matters Arising Report Governors were advised that the seminar on the Health Bill would be arranged for June or July and the update on the patient level costing system (PLICS)

would be included in a seminar on corporate directorates (Finance, Workforce, Estates & Facilities, Capital Investment).

In addition, a seminar on transforming the patient experience had been arranged

for 24th April and a meeting with the Trust’s auditors would be arranged following the July Governing Body meeting. All details would be circulated to Governors once finalised.

Action: Director of Corporate Services

4. Chairman’s Report All items in the Chairman’s report were noted. The Chairman welcomed new

Governors Nuruz Jaman (Staff Governor) and John Muolo (Stakeholder Governor – Westminster PCT).

5. Chief Executive’s Report 5.1. Financial Position The Month 10 position was a surplus of £3.6m which £4.4m ahead of

plan. The Trust was on track to achieve a Financial Risk Rating of 3, as planned, and the governance rating for Quarter 3 was green.

5.2. Quality, Efficiency and Productivity Programme The report reminded Governors of the Trust’s target to achieve efficiency

savings of £45m in 2011/12. It was anticipated that by the year-end £42m (93% of the target) would have been achieved. Over 650 schemes within five work strands had been identified as part of the QEP programme. Many of the schemes aimed to improve quality as well as efficiency and the report referred to the implementation of a productive outpatients model which was being piloted in Cancer Services and would start to be rolled out across the Trust.

The QEP plan for 2012/13 was now being developed by clinical boards

and divisions. 5.3. Performance Report The Trust was continuing to experience an increase in activity, mostly

non-elective activity which was 4.4% above plan at the end of month 10. A&E attendances this year were projected to reach approximately 115,000, up from c.90,000 in 2007/8. The Board had recently received a presentation on A&E which had shown that the proportion of patients who required admission had remained fairly static which demonstrated that the increase in total numbers attending was not due entirely to patients who should be seen in primary care.

Meeting the A&E 4 hour waiting time target was one of our biggest

challenges and although we were confident that would meet the national target (95% of patients to be seen within 4 hours) we were unlikely to meet our own internal target of 98%.

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The Chairman said the Board was taking a keen interest in A&E performance and was aware of its importance to Governors and patients. The presentation given at the Board meeting had raised a number of issues such space and staffing levels in the department, bed capacity and flow of patients through the UCH Tower which were being addressed.

Caroline Dux said the HQPC had been advised of the proposed

reconfiguration of the A&E department some time ago and asked about progress. The Chief Executive said the latest options had been discussed with him that afternoon. Minor adaptations would provide an increase in space to resolve the problem in the short term but a longer term solution, taking account of the expected continued increase in attendances, would cost far more and take much longer to achieve. It would also impact on other departments which would have to be relocated, and the external area around the hospital (disabled car parking, rerouting traffic). Some of these issues would require planning permission. The Executive Board would be considering design options later that week and the preferred option would be presented to the Board in May.

Fion Bremner asked whether consideration had been given to providing a

separate location for minors. The Chief Executive said we had recently created an Urgent Care Centre (UCC) adjacent to the A&E Department which was staffed by GPs who could stream and treat the type of patients who should be accessing primary care.

Denise Bavin said that fewer Camden residents were attending A&E and

other hospitals in NC London were not experiencing the same level of increase in attendances as seen at UCH. The Chief Executive said there was a difference of opinion about this between commissioners and hospitals which could be due to the way in which patient numbers were counted, i.e. patients seen in the UCC may not be included in A&E attendance figures. However, it was clear that a significant number of trusts across London were struggling to meet the 4 hour access target and this situation was unprecedented.

In response to a question from Fiona McKenzie about the impact of the

London Olympics, the Chief Executive said we expected to see a huge increase in the number of people attending the Emergency Department during the period and we had put detailed plans in place, although it was difficult to predict exactly what the level of pressure would be. However, the Executive Board had already taken the decision to vacate space on the ground floor of the EGA Wing in order to expand the A&E Department.

With regard to infection rates, the Trust currently had four reported cases

of MRSA against an annual threshold of five but Simon Knight advised of a possible fifth case, although confirmation was required about whether it was hospital acquired. It was acknowledged that, even if the total increased to five, this was a fantastic achievement and a significant reduction in one year (from 13 cases in 2010/11).

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The MRSA threshold for 2012/13 would remain at 5 but the threshold for Clostridium difficile would reduce from 59 to 44 which represented a challenge. The commissioning, contract performance and patient choice updates

were noted. The Chief Executive advised that we continued to be notified by patients that they were being denied referral to UCLH. We had taken this up with the Chief Executive of NC London and in each case the decision had been overturned. The Chief Executive explained that the tariff was the same for every hospital and a market forces factor was applied to cover the additional cost of treating patients at some hospitals. The funding was allocated to commissioners and therefore there was a financial incentive to refer patients to ‘cheaper’ hospitals. This clearly was not in line with the principles of patient choice.

Denise Bavin said patients were referred through the choose and book

system and some may be influenced by shorter waiting lists. She felt the problem did not lie entirely within NC London as the market forces factor applied to all local hospitals. The Chief Executive acknowledged that many of the complaints from patients about referrals being refused originated from further afield.

Peter Brayshaw said that, in addition to the choice issue, commissioners

had now drawn up a list of conditions that they would no longer refer for treatment. He felt this could create tension between commissioners and providers.

5.4. Picker Surveys – Inpatient and Staff The Chief Executive advised that the results of the national inpatient and

staff surveys were currently embargoed and although the Trust had received early results we still needed to analyse them. However he intended to give a detailed presentation, either at the July meeting or at a seminar if Governors preferred.

Comparison with the smaller group of Trusts in the Picker survey showed

significantly improved results in the inpatient survey in which there were only two questions, of a total of more than 80, for which our results were significantly below average.

There had been a 57% response rate to the staff survey; the key results

were listed in the report. The good response rate would allow the results to be analysed by staff group and department.

5.5. Top 10 Objectives The final draft of the Top 10 Objectives for 2012/13 were attached to the

report and Governors were invited to comment. The Chief Executive said that the objectives of individuals would be aligned with the Trust objectives and used in appraisals.

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Christine Chapman asked whether measuring medication errors and patient mortality (outside of hospitals) could be included under ‘Improving Patient Safety’. The Chief Executive said we already monitored mortality rates in hospital and within 30 days of discharge.

Stuart Shurlock proposed the inclusion of patient transport services under

objective 3 (Deliver High Quality Patient Experience). This was agreed. Action: Chief Executive

5.6. Cancer Centre The report advised that the building phase was completed at the end of

January and the Centre was on track to open to patients on 2nd April. 5.7. Transport Contract/Service It was noted that two non-emergency transport contracts within the Trust

had been consolidated for an interim period while a procurement market testing exercise was being managed by the Royal Free Hospital on behalf of themselves, UCLH, the Whittington and Moorfields Hospitals. This would be evaluated with a view to exploring the potential for a managed transport service across UCLP sites. A number of meetings at UCLH, focusing on transport, had been with Governors representing the views of service users.

Dee Carter said that on a recent PEAT visit she had spoken to patients

about transport services. Some had commented that drivers would benefit from training in the different needs of patients and she would like assurance that this would be taken into consideration. The Chief Executive said we would expect services to improve under the new contract and he was confident that these issues would be taken on board in the contract discussions. However, he was willing to arrange for Governors to meet with Trevor Payne, the Director of Estates and Facilities, and other key staff if they wished.

Peter Brayshaw commented that the transport service was an important

element of patient care. He had been involved in the initial discussions but had not heard anything further about the contract specifications. Mike Foster said the contribution of Governors had been very helpful and he provided examples of the issues that had been included in the specification:

• Estimated journey times should be made known to patients • Patients to be given an estimated time of transport arrival • Provision of comfort breaks during journeys • Identification of training needs for drivers related to patient

requirements. Rosalind Jacobs felt that improvements were required for patients and carers arriving in their own transport, for example more car parking permits for people with disabilities. The Chief Executive said we could review this but our central London location meant that parking space was

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extremely limited. Patricia Orwell commented that the Trust should be more open about this on the website and in its patient information. 5.8. Local Education and Training Board This issue was noted. 5.9. Trust’s Response to the Challenge of the Olympic Games 2012 The report provided details of the role that UCLH would take as one of the

three designated Olympic hospitals in London. It also advised of the planning to mitigate the impact on activity at University College Hospital and of the Olympic Route Network on other Trust hospital sites.

5.10. Institute of Sports and Exercise Health (ISEH) The Trust had been awarded a grant of £10.5m by the Department of

Health to establish an Institute of Sports and Exercise Health, in collaboration with UCL, the British Olympic Authority and the Hospital Corporation of America (HCA). The primary focus of the ISEH would be on research.

5.11. NHS Confederation Report into Dignity in Care for Elderly Patients The report advised that the Trust had been asked to take part in the launch of the above report which had resulted in extremely positive media coverage, particularly by the BBC, about how this issue was

tackled at UCLH. 5.12. Update on UCL Partners This issue was noted. 5.13 Prime Minister’s Visit to the National Hospital for Neurology &

Neurosurgery The Chief Executive advised Governors that the Prime Minister had

visited the NHNN that morning where he had been shown a new dementia research facility, prior to a Government announcement about doubling research funding for dementia by 2015.

6. Reports from Governor Representatives on Trust Committees 6.1. Quality and Safety Committee Fiona McKenzie presented the report and spoke about the revised

format of the Committee which meant that membership would reduce to between 14 and 20 people. The Chairman explained that arrangements had been implemented to ensure Divisions undertook more quality and safety monitoring and the Quality & Safety Committee would now take a more strategic view.

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It was noted that Diana Scarrott had been appointed as the reserve Governor on the Committee.

Fiona McKenzie drew attention to the proposal to create a Governors’

quality measurement working group as some Governors had expressed interest in learning more about what data was measured and why. The proposal was endorsed.

6.2. Older Persons Steering Group (OPSG) Dee Carter presented the report and acknowledged that the Trust was

working hard to promote excellent care for all patients, but stressed the need to maintain high quality care for vulnerable patients. She was concerned about medical staffing levels, as two geriatricians were due to commence maternity leave and there was a further Registrar vacancy. The Chairman said an appointment panel would be held shortly but it was difficult to find good people to cover for maternity leave. This was being addressed by Dr. Matt Hayman, Consultant Physician in Care of the Elderly and chair of the OPSG.

Dee Carter also highlighted the request for a Non-Executive Director to

attend OPSG meetings. Diana Walford offered to become involved in the work of the group and this was welcomed.

7. High Quality Patient Care Group The report was noted. The Chairman commented that this was an extremely

useful group whose members were very engaged, and he paid tribute to the contribution made by Governors. It was noted that a discussion on the 2012/13 work programme had generated 28 suggestions for projects to enhance patient care. A definitive list would be drawn up at the HQPC’s April meeting.

8. Annual Report on the Work of the Audit Committee Richard Delbridge, Chair of the Audit Committee, presented the report and

referred to the change in membership which had resulted in an increase in Non-Executive Director committee members. The Chairman said he believed there was a very good balance of Non-Executives on the Audit Committee.

The remainder of the report was noted. 9. Foundation Trust Governors Association Report The report from Tom Hughes was noted. The Chairman felt the training and

development programme for Governors and Foundation Trusts was very important, given the changes that were likely to come about as a result of the NHS reforms.

10. Presentation: Financial Aspects of the Draft Annual Plan 2012/13` Richard Alexander gave a presentation which included:-

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• An income waterfall illustrating the impact of activity growth, tariff changes, £10m at risk from commissioner intentions, £3m income contingency and the impact of major service changes arising from the RNTNEH and the Cancer Centre; • An expenditure waterfall illustrating the impact of inflation; cost of growth

at about 60% which included issues such as replacement or maintenance of equipment and staff costs; £5m Board contingency; R&D funding changes; and the costs associated with opening the Cancer Centre and the transfer of the RNTNEH. The Board contingency was set aside to cover unpredictable expenditure; • Highlights within the draft plan; • Summary of 2012/13 cost pressures; • Draft I&E plan, showing a planned surplus of £2m; • Reasons for a savings target of £38m including issues such as expected

tariff deflation, NHS inflation, the risk associated with new commissioning intentions and the need to recreate Board and income contingencies.

Highlights from the draft plan included an assumption of £20m ‘Project Diamond’ funding to offset the cost of the specialist expertise offered by the Trust which was not covered by the tariff. £3m had been budgeted for strategic projects to cover development costs associated with major investments such as Proton Beam Therapy. Richard Alexander advised that a planned surplus of £2m would result in a

financial risk rating (FRR) of 3 which was felt to be adequate. We had planned for an FRR 3 in 2011/12 but it was possible that we may achieve an FRR 4.

The QEP requirement had been identified as approximately £38m; although this was lower than the QEP in 2011/12, Richard Alexander said the challenge should not be underestimated. The imperative to make savings would be with us for the foreseeable future and the figure that had been mooted of £20bn savings across the NHS over the next few years may be insufficient. The Trust had managed to realise almost all of its QEP savings in 2011/12 while at the same time maintaining quality, which was a great achievement. Questions were invited. Peter Brayshaw said that £3m for strategic capital projects seemed low.

Richard Alexander explained that this was a revenue budget for associated costs, for example architects’ fees. The capital programme covered smaller capital schemes and the maintenance or replacement of equipment but major projects such as the Cancer Centre were funded from loans such as the Foundation Trust Financing Facility and Public Dividend Capital.

The Chairman said the approach to determining the financial plan was to

decide what level of surplus we wished to achieve and what level of contingency was required, and then work out what savings had to be made to achieve a balanced budget. The Chief Executive said it was becoming more difficult to make the savings, although we were able to make up some of the deficit by growing activity. We anticipated further growth next year of around 2%. The greater the growth, the easier it was to achieve the QEP and therefore it was essential that we continued to improve our services so that patients

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exercised their right of choice to be referred to UCLH. The Chief Executive believed that a QEP of £38m, although challenging, was achievable and a number of schemes had already identified that would meet more than half of the total. This was a better position than at the same point last year.

Christine Chapman asked whether the Trust had a robust marketing strategy to

encourage more patients to request referrals here. The Chief Executive said there was a plan and although we did not anticipate much more growth in general acute services for local residents, we did expect growth in the specialist services we provided nationally.

John Carrier asked about SIFT (service increment for teaching) funding.

Richard Alexander said that the Government was becoming much more specific about the determinants for payment of SIFT as they had with R&D funding. It has also been confirmed that block SIFT funding would be phased out but it was not clear how it would be replaced.

In response to a question from John Muolo about what was covered by ‘other

income’, Richard Alexander advised that R&D and Education funding were the biggest contributors but there were also other issues such as payment for services provided to other trusts.

John Green congratulated the Trust on its financial management but asked

what would happen in the event of a significant deficit, caused by events such as the Olympics. He also asked whether the Trust had any bad debts. Richard Alexander said the Trust had a healthy cash balance and expected to end the current financial year with sufficient cash to cover the payment of salaries and bills for some time. The Chairman said that in the case of a serious deficit Monitor would intervene and put the Trust into turnaround mode. Monitor had the authority to replace the Chairman and had done so in some foundation trusts.

Richard Alexander said that 25-40% of bad debt was related to overseas

patient costs. He would provide the figure to John Green. Action: Finance Director

Stuart Shurlock stated that the achievement of almost £45m QEP in 2011/12

was due to the efforts of the staff who must be encouraged to continue to improve efficiency. Richard Alexander said the key priority for staff was to provide care for patients to the best of their ability and, traditionally, they were not driven by financial targets. However it was acknowledged that there was a change in culture and staff were now beginning to understand the importance of greater efficiency while maintaining or improving quality. The 650 schemes that made up the QEP programme had been put forward by staff.

Fiona McKenzie asked about the financial position of partner organisations and

how it was intended to move towards greater integration and collaboration. Richard Alexander said our strategy was to consider what areas we were particularly good at and what services we should or should not continue to provide. This required honest discussion with other organisations about patient pathways which was beginning to happen more now.

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With regard to the financial health of organisations, the Chief Executive said the Commissioners had been removing money from parts of the service and giving it others that were doing less well. However, with the advent of clinical commissioning groups this was less likely to happen in future, although it was difficult to know where the real power to make decisions would lie.

11. Any Other Business There was none. 12. Dates of Next Meetings: Monday 16th July Monday 24th September – Annual Public Meeting Thursday 22nd November Wednesday 27th March 2013 All meetings would commence at 6.00pm.

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Agenda Item 3

Matters Arising Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

GOVERNING BODY

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 26th MARCH 2012

Minute no.

Issue Outcome

3. Matters Arising report: Meeting with Trust auditors to be arranged

A meeting between Governors and the Trust’s auditors has been arranged for 20th July at 12.30pm. Action completed.

5.5. Chief Executive’s report: Top 10 Objectives – Include patient transport services under the objective to deliver high quality patient experience

The sub-objective: “Improve the appointment and transport booking services we offer to patients” has been added to the Trust objectives for this year. Action completed.

10. Financial Aspects of the Draft Annual Plan 2012/13: Bad debt

This issue is being taken up separately with John Green.

MATTERS ARISING FROM PREVIOUS MEETINGS

Date of Meeting

Minute no

Issue Outcome

30th March 2011

6.8 Chief Executive’s report: Partnerships with GPs – seminar for Governors

A seminar on partnerships and integrated care will be arranged later in the year, led by Dr Mike Roberts who has been appointed to lead on these initiatives. At the request of Governors a seminar will also be arranged in the Autumn on medication errors. Governors will be notified of the date.

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Agenda Item 4

Chairman’s Report

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UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHAIRMAN’S REPORT TO THE GOVERNING BODY

16 JULY 2012

1. GOVERNING BODY ELECTIONS

Elections are being held for seven governors: one public; three London based patients; one non-London based patient; and two staff. We have contested elections in every seat with 39 candidates standing in total. The ballot opened on 29th June and will close on 20th July. The results will be announced on the Trust's website on Thursday 26th July. We say farewell to Maureen Holas and Bonnie Wallace. Joan Bell, Dee Carter, Alison Forbes and Marcia Persaud are coming to the end of their terms but are seeking re-election. I would like to thank all of them for the contribution they have made during their time with us and to wish good luck to all those standing for election or re-election.

2. NON-EXECUTIVE DIRECTORS

Governors may have seen that we have now advertised for the replacement for Jane Ramsey in the local press and in the Sunday Times. We have already had approaches from some interesting candidates. Applications close on 20th July and we will shortlist on 2nd August and the interview panel will take place in September.

Governors should also note that Sue Atkinson has been offered a visiting fellowship in New York in public health from the end of August until Christmas. She will remain a Director and will continue to receive papers but will obviously be unable to participate physically in meetings. I have suggested to the Nomination & Remuneration Committee that it would be appropriate to extend Sue's term of office from end March 2013 to end of June 2013. This will also allow a more satisfactory gap between the appointments to replace Jane and Sue.

3. UNIVERSITY COLLEGE HOSPITAL/MACMILLAN CANCER CENTRE

As Governors will know, the Cancer Centre opened on 1st April. Feedback from patients and staff has been excellent, reflecting this fantastic new facility. It is very good to be working with our partners at Macmillan whose influence is already being very clearly felt around the building. There have been a number of teething problems which I hope will be ironed out and there is still more work to do in important areas such as getting outpatient appointments to start on time. However, it is excellent that we have been able to complete this large, important and complex project on time and within budget.

4. VISIT TO LAMBETH PCT FRAIL/ELDERLY PILOT PROJECT

On 5th April, Jane Ramsey and I visited the Frail/Elderly Project at Lambeth Community Centre. We learnt in some detail about the integrated approach being taken by the healthcare system for the care of frail/elderly patients in the area. This meeting followed on from a similar meeting we had had at Imperial Healthcare in March. It has been very useful to understand the approach being taken by other Trusts as we seek to develop our strategy for integrated care in conjunction with primary and social care in our area.

5. ROYAL NATIONAL THROAT, NOSE & EAR HOSPITAL (RNTNEH)

I should also record here a welcome to our new colleagues at the RNTNEH who have joined us from the Royal Free Hospital. We had an enjoyable ceremony to mark the transfer early in

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April and the Chief Executive and I visited the hospital on 3rd July. We received very positive feedback on the staff’s early experience of working at UCLH.

6. UCLH CHARITABLE FOUNDATION GALA BALL

On 25th April, the Chief Executive and I were at the UCLH Charitable Foundation Gala Ball as guests of the Chairman, Christopher Moran. This was a very enjoyable and successful evening with some 400 guests enjoying an excellent dinner at the Dorchester Hotel. A significant sum was raised for the charity and it provided a good opportunity to thank all of those who had helped to create the UCH Macmillan Cancer Centre. I should record here our thanks to Lord David Evans who chaired the organising committee for the dinner. More broadly, I should also record the debt of gratitude that we owe to Christopher Moran and to John Gray, the Charitable Foundation’s Chief Executive, for their enormous efforts and success in leading the charitable effort for the Cancer Centre

7. OCCUPATIONAL HEALTH

On 4th May, I met with Professor Ewan McDonald from Glasgow University who had been asked jointly by UCLH, the Royal Free London and Whittington Health to conduct a review of the arrangements which the three Trusts currently have in place for occupational health. This is a critically important area for the wellbeing of our staff. I look forward very much to receiving his report.

8. INTEGRATED CARE

Governors might like to know that the Trust has appointed Professor Mike Roberts, Dean for Students at Barts and Queen Mary School of Medicine and Dentistry, to a temporary position for six months to lead our efforts in providing ever more integrated care. His work will obviously reinforce that of Dr Jonathan Fielden, who joins this month as Medical Director, Medicine Board, for whom integrated care will also be a very high priority.

9. SISTER DOROTHY LOUISE THOMAS

On 18th May, we held a very successful ceremony at John Astor House to mark the unveiling of a City of Westminster Green Plaque to commemorate the courage shown by Sister Dorothy Louise Thomas, Theatre Sister at the Middlesex. On 26th January 1934, Sister Thomas was working in one of the operating theatres when an explosion occurred in a large oxygen cylinder. Despite considerable risk to her safety, Sister Thomas remained at her post to make sure that all members of staff had been safely evacuated. Sister Thomas' courage was recognised at the time by the award of what subsequently became the George Cross. There is a splendid Pathe News clip of the brief award ceremony which can be seen at http://www.britishpathe.com/video/brave-nurse-honoured.

10. MULTI-FAITH CEREMONY IN THE CANCER CENTRE

On 18th May I also attended a multi-faith ceremony to inaugurate the Cancer Centre, This was held in the roof garden (unfortunately a light drizzle!) but was felt by all who attended (patients, staff and representatives of the different faiths) to have been a very moving and important occasion.

11. CARERS EVENT

On 11th June, I visited the Carers Event in the Atrium at UCH. I have agreed with Ros Jacobs, Carer Governor, that she and I will work together to see how the Trust can communicate better with carers and take more account of their needs.

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12. JOINT BOARD & GOVERNING BODY MEETING

A number of Governors were able to attend the Joint Board & Governing Body meeting on 12th June. I thought we had a very interesting session where we covered the Staff Survey, the Inpatient Survey and the Outpatient Survey, all critical areas for the efficient running of the Trust. I am very grateful to those who prepared what was an excellent meeting.

13. SURGICAL RECEPTION

Governors will be pleased to know that, after a long struggle, the new surgical reception facility has been inaugurated in the Podium at UCH. This now offers more space and appropriate single sex arrangements for patients awaiting surgery and should greatly improve what was previously a very poor facility for patient experience. I visited the facility a couple of weeks ago and was struck by the transformation.

14. SERVICE OF REMEMBERANCE - RLHIM

On 18th June, I attended a Service of Remembrance to mark the 40th anniversary of the Staines air crash in which 16 homeopathic clinicians who were on their way to a conference in Brussels, were killed. This was a very moving ceremony which was attended by a number of relatives of those who died, including Professor Lord Winston whose mother-in-law was killed in the crash.

15. JUNIOR DOCTORS

On 3rd July, I spoke at a forum to promote leadership skills in junior doctors. We had an interesting session discussing the position of the Trust and the role of junior doctors. As some Governors will know, improving the training and mentoring of junior doctors and encouraging them to subscribe to the values of the Trust is a personal high priority for me this year.

RICHARD MURLEY CHAIRMAN

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Agenda Item 5

Chief Executive’s Report

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UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

CHIEF EXECUTIVE’S REPORT TO THE GOVERNING BODY

16 JULY 2012

1. FINANCIAL POSITION

Finance Director’s Report

Month 12 position - 2011/12

I am pleased to be able to report that our financial results for last year showed a surplus (before exceptional items and accounting rule change) of £8.2m was significantly ahead of plan. The

Trust achieved over 95% of its challenging £45m QEP saving requirement in 2011/12. Month 2 - 2012/13

Under the new Department of Health (DH) accounting rules (which include charitable donations as income in the month they are received) the Trust reported a year-to-date net surplus of £2.6m at month 2 (£1.5m ahead of plan). This position includes £2m of Macmillan cancer centre support funding, received in May, which was originally planned for June. When reported under the old accounting regime (which the Trust will continue to use internally as the best measure of underlying financial performance as it is unaffected by the timing of charitable donations) the year-to-date income and expenditure position is £0.5m behind plan.

Month 2 financial performance

Budget Actuals Variance Budget Actuals Variance

£m £m £m £m £m £m

Trust

Medicine (2.3) (2.2) 0.1 (0.9) (0.5) 0.4

Specialist Hospitals 4.3 3.4 (0.9) 3.0 3.4 0.4

Surgery & Cancer (2.4) (2.2) 0.1 (0.6) (0.5) 0.1

Research & Development - - - - 0.0 0.0

Education (0.5) (0.5) (0.0) (0.3) (0.3) (0.0)

Corporate budgets 9.5 9.8 0.4 4.8 4.7 (0.1)

EBITDA 8.6 8.3 (0.3) 6.0 6.8 0.8

ITDA (old accounting regime) (9.6) (9.8) (0.2) (4.8) (5.0) (0.2)

Net surplus/(deficit) - old accounting regime (1.1) (1.5) (0.5) 1.2 1.8 0.6

ITDA (new accounting regime adjs.) 2.2 4.2 2.0 1.2 3.2 2.0

Net surplus/(deficit) - new accounting regime 1.1 2.6 1.5 2.4 5.0 2.6

Year-to-date In-month

Table 1 – M2 financial position (figures shown with rounding)

There has been no release of contingencies and the Trust achieved a financial risk rating of 3, in line with plan. The overall picture shows income over-performance, under-achievement of QEP and an adverse variance on non-pay expenditure. The Royal National Throat Nose and Ear Hospital is now part of UCLH and is reported as a separate division within the Specialist Hospitals Board. Clinical Board Performance

Both the Medicine Board and Surgery and Cancer Board were ahead of plan at month 2. Specialist Hospitals Board reported a year-to-date adverse positions against plan, driven largely by clinical income behind plan. However, further validation has identified some under recording of activity, which when incorporated into the position next month should bring the division’s net position back into balance.

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2. QUALITY & EFFICIENCY PROGRAMME

Review of 2011/12

The Trust achieved 95% savings against the planned target. Governors will recall that our quality indicators have improved, particularly in hospital acquired infections, patient experience and mortality rates. It is a significant achievement to reduce cost and improve quality at the same time and I have thanked staff and teams across the Trust for the role they have played in this. QEP – 2012/13

We are in the early stages of the 2012/13 QEP programme and continue to focus across five QEP themes; workforce, productive clinical services, procurement, asset utilisation and clinical and corporate support services. I am grateful for the Governors engagement in a number of these projects. Productive service programmes

The productive outpatients programme aims to engage front line staff to redesign and improve outpatient services. The objective was to design a toolkit to support the redesign of outpatient services to ensure they meet future demands. General Managers have implemented action plans to address under utilised clinics and these principles will be applied to other elements of planned care including diagnostics and ambulatory care which have similar issues. Our productive outpatient approaches show increasing evidence of the benefits. Staff presented at the 2012 International Forum on Quality and Safety in Healthcare in June, and at the National Clinical Leaders Network. Enhanced Recovery

One of the key pillars of efficiency is improving elective pathways. The Trust has delivered a substantial improvement in length of stay (LOS) as part of an organisation wide programme on enhanced recovery. Led by Geoff Bellingan, Medical Director Surgery and Cancer, our teams worked with patients to re-design care at each stage of the pathway to improve the both patient care and the patient experience. Benefits included:

Patients that have experienced elective pathways before and after the introduction of enhanced recovery have been very positive about the improvements

Re-admission levels have not increased despite reductions in LOS

Bed days have been released creating additional capacity for other patients. Results were shared across London and an article about this work appeared in the Health Service Journal in May 2012.

Reducing agency spend

Our approach to reducing agency usage has set us apart from organisations. We have avoided implementing rules demanding compliance with an ‘agency ban’ and moved instead to a culture of individual commitment to improving patient care. We engaged clinical staff as the drivers of change and motivated our staff, particularly ward sisters and charge nurses, by talking about patient experience and safety first, and the financial benefits second. Our success in reducing agency staff has been delivered by doing the following:

Increasing our staff bank for all staff groups with 1000 additional staff recruited;

Using technology to drive change using electronic booking; and

Use of real-time management information to support ward-level monitoring.

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In 2009/10, UCLH’s annual agency expenditure topped £24m. In 2010/11, the Trust reduced this by £11.5m. In the last eighteen months, the Trust has virtually eliminated expenditure on agency nurses and midwives. It now aims to do the same for all other staff groups. The agency work initiative has been shortlisted for the 2012 HSJ efficiency awards.

3. PERFORMANCE REPORT

Activity and referrals

The performance to the end of March remained above plan, as set out in the table below and at Appendix 1.

Activity Type 2011/12 activity to end of month 12

% Variance vs. 2011/12 plan to end of month 12

Outpatient (new + follow up) 789,828 3.0%

Elective (day-case + inpatient) 87,783 0.3%

Non-Elective 49,949 6.0%

Table 2 – 2011/12 performance to end of Month 12

Performance against national targets Q4 Monitor governance rating

We reported an Amber-Green governance rating for Q4. We performed well within the Monitor compliance framework across the year, with a green rating in quarters two and three and an amber-green rating in quarters 1 and 4. This was a notable achievement in an environment of funding pressures and ever-demanding targets. The breach of the A&E standard in quarter 4 was the only significant breach of a standard across the year. Infection – MRSA and Clostridium difficile

By the end of March, we had reached 5 cases of MRSA against our annual threshold of 5 cases. Our threshold for the coming year remains at 5 cases. At the end of March, we recorded 54 cases of Clostridium difficile against a threshold of 59. The

Trust’s maximum threshold set by the DH for 2012/13 is a 20% reduction on last year’s levels namely 44 cases. The Executive Board has approved a detailed action plan to address Clostridium difficile infections, and this will be monitored through the Infection Zero Tolerance

Committee.

18 week referral to treat targets

For the full year 2011/12 we achieved the targets for the waiting times metrics: non-admitted pathways 97.2% (target 95%); admitted pathways 93.6% (target 90%). For 2012/13 there will be a new target for diagnostic waits, with 99% needing to be seen within 6 weeks. In 2011/12 99.4% of our diagnostic waits were seen within 6 weeks. In April we maintained compliance with 18 week completed admitted pathways (93.5%), completed non-admitted pathways (97.1%) and also with the new standard that 92% of incomplete pathways have been waiting less than 18 weeks (92.1%). Also in 2012/13 the Department of Health has introduced income penalties for specialties failing monthly closed 18 week pathway targets. We are likely to miss some specialty-level indicators in the opening months of 2012/13, incurring financial penalties under our contract with commissioners.

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A&E – 4 hour wait target and CQI indicators

A&E performance against the four-hour target was challenging during Q4, and we only attained 94% against the Monitor target of 95%. There has been an increase in A&E attendances and emergency admissions over the past three to four years, with a significant increase in the proportion of days with very high attendances and emergency admissions. The increase in activity last year equated to 20 beds. This was exacerbated by norovirus outbreaks at UCLH and neighbouring trusts in December and January. A&E performance was better than the 95% threshold for April although we are still experiencing a high number of breaches on individual days due to high levels of attendances and a constrained bed base. Cancer waiting times

For Q4, we achieved the target waiting times for all cancer metrics. To ensure we maintain the performance our clinical teams continue to review individual breach reports for any pathway not delivered within the timescales of waiting time standards. We are carrying out a series of audits into how we can further improve the time that patients wait for their first appointment after a referral for cancer, looking in particular at whether we provide patients with enough choices of appointment. For April we were above threshold for all cancer waiting times at a trust level, except the 14 day referral to first outpatient target. This was largely due to patient choice and management of outpatient capacity issue for lower gastrointestinal services

4. CONTRACTING UPDATE

We are reaching the end of the negotiation process for 2012/13 with a draft financial position and contractual terms agreed with our lead commissioner NHS NCL. Many of the financial values with other commissioners both inside and outside of London have also been agreed, with those outstanding being followed up, although there are no significant problems anticipated. Negotiations with NCL have been constructive and collaborative in nature and we feel that the relationship is stronger than may have been the case a couple of years ago. Not withstanding the constructive nature of negotiations there have been some very difficult discussions on key areas of risk for the Trust, most notably in the application of financial penalties for underperformance. However, we think we have now reached an acceptable conclusion and it is possible that the arrangement agreed between UCLH and NCL could be used to inform the national arrangement in 2013/14. Another key issue for UCLH is the national policy on Emergency Readmissions whereby the Trust does not receive payment for readmissions within 30 days (caveats do apply such as cancer patients and children under 4 years old). The Trust has agreed a cap on the level of financial exposure and has agreed that that there will be a joint process to determine the use of readmission monies. Importantly, there has been a significant change to the national guidance that provides greater certainty of payment for activity over and above indicative activity plan levels. This is a direct result of the Cooperation and Competition Panel report published in 2011 in which UCLH played a significant part. A key element of negotiation with NCL has been the application of efficiency metrics, particularly in outpatients. We have agreed to reduce follow up outpatient activity and each Clinical Board is currently setting internal targets to achieve this. This potential reduction in activity will release clinical capacity to possibly utilize to reduce waiting list pressures, meet 18 week targets or support new activity and income streams.

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5. OLYMPIC PREPAREDNESS

As Governors will be aware, there has been considerable planning undertaken in preparation for London’s hosting of the 2012 Olympic and Paralympic Games and the effect of an increase in the capital of an estimated 500,000 people over the period. We are also one of the three hospitals providing care for members of the Olympic Family. Following scenario planning and agreement on assumptions regarding likely increased activity, significant work has been done to address issues of capacity, staffing, major incident preparedness, infrastructure and procurement. The Trust’s focus is on ‘business as usual’ as far as possible for the local population and aiming to minimise the impact on patients. There are of course aspects beyond the control of the Trust such as transport issues. Through our three Clinical Boards, we have assessed capacity and capability to sustain a 20% increase in emergency demand over the 16 day period of the Olympic Games (27th July to August 12th inclusive). Our planning for an additional 20% means being ready for the possible volumes of patients in the emergency department in terms of both space and staff, and across the trust in terms of levels of bed availability. Dr Daniel Wallis, Divisional Clinical Director Emergency Division, will outline our plans in a presentation at the meeting.

Our plans have recently been ‘peer reviewed’ by a review panel led by the University of Birmingham Hospital Foundation Trust’s Executive Nurse. The review team was impressed with our plans and the level of detail that had been thought through.

6. DEMAND FOR EMERGENCY CARE

Since the University College Hospital opened in 2005, we have continued to experience rising demand for emergency care. Space is a real limitation as our emergency department designed for 65,000 annual attendances is now seeing over 110,000 per annum. Despite this, the department managed to achieve a very high rating from patients for the care that they provide in the National NHS Patient Survey, achieving the best result for any emergency department in the capital on questions relating to privacy and dignity. During the Winter 2011/12, performance against the four-hour access target was not as strong as it had been as outlined in the performance report. Although this has generally improved in the first quarter of this financial year, there have been particular days when it has been very difficult to achieve a match between the volume of patients on the one hand, and staff resources and space within the department on the other. We continue to be very busy, and on one day in June we saw 390 patients which is the highest number yet. In the light of these increasing demands maintaining timely availability of beds for those emergency patients requiring an admission is a real challenge, and a project on improving this ‘flow’ has commenced. We have also recently agreed a scheme to increase the size of the emergency department in the short-term while a longer-term solution is being developed. I have asked Tara Donnelly to give a presentation on the action being taken to deal with A&E capacity pressures.

7. LONDON CARDIOVASCULAR & SPECIALIST CANCER SERVICES

Barts Health NHS Trust and UCLH have been in discussions for the past year about working together on cardiac and cancer services. This reflects the emerging strategy of UCL Partners (UCLP) to achieve global competitiveness in a number of service areas. One of the options being considered is the establishment of a unified governance arrangement with each trust taking a lead in one or the other specialty. There are many other options including leaving services as they are, particularly those at the Heart Hospital. These services are currently highly regarded by staff and patients alike.

6

Cardiovascular The Cardiovascular vision is to create a fully integrated cardiovascular service for the 3.3 million people served across North Central and North East London, the boundaries of UCL P. One of the options being considered is the relocation of the Heart Hospital, cardiac services at Barts Hospital and The London Chest Hospital, combine in the new development currently under construction on the Barts site. It would create one of the largest single cardiovascular services in Europe, although reconfigurations in other sectors of London are under discussion that could achieve similar scale. It would combine the academic strengths of Queen Mary University of London (QMUL) and University College London (UCL), positioning itself as the premier clinical and scientific academic cardiovascular centre in Europe. UCLP Strategy

The UCLP emerging strategy seeks global competitiveness in six service areas, including cancer and cardiovascular. It is possible that in return for the transfer of UCLH’s cardiovascular services Barts Health will transfer governance responsibility for its specialist cancer services on the Barts site to UCLH. This transfer of Barts Health cancer services would create the potential for UCLH to develop a cancer service offering on a scale that could support the UCLP vision of global competitiveness. Strategic Context

Despite improvements introduced via the National Service Framework (NSF) for coronary heart disease (published in March 2000), UK death rates from cardiovascular disease are relatively high and, compared with elsewhere in Europe, the UK has the worst mortality outcomes following some types of vascular surgery. A review of the world class performers for cardiovascular services highlighted a number of common features including scale, distinctive service portfolios, and clinical research.

NHS London undertook a Cardiovascular Review published in 2012 which identified an opportunity to improve outcomes, quality and equity of access to cardiovascular services in London, as well as to enhance patient experience. The review also produced the Model of Care, which made specific

recommendations to help commissioners develop a world-class service for cardiovascular patients. Commissioners are taking this forward and it could result in a rationalisation of services.

Similarly, NHS London undertook a review of cancer services and published a Case for Change which identified the need to transform London’s cancer care in order to achieve world-class services. Central to this is the need to adopt a pan-London approach to cancer services in order to tackle the current inequalities in patient care. These matters are currently under discussion in both trusts and will be subject to detailed options appraisal and business case analysis by both trust Boards. This is likely to come to a conclusion this autumn when a decision about the ongoing development at Barts will need to be made.

8. NEW DEVELOPMENTS SINCE THE LAST GOVERNING BODY MEETING

University College Hospital/Macmillan Cancer Centre I am delighted to say that the new UCH/Macmillan Cancer Centre opened on time and on budget in April. It is the realisation of a strategy to provide excellent facilities for our developing cancer services to replace those in very unsatisfactory accommodation in the Rosenheim wing. The new development is a vehicle for the expansion of ‘ambulatory cancer care’, which we began more than 5 years ago by converting inpatients into day cases, using hotel accommodation for overnight stay when inpatient admission was unnecessary. This has proved to be highly successful and was featured in a recent article in a leading cancer journal which suggested that we have treated many more patients than would otherwise have been the case, at higher levels of patient satisfaction and with successful clinical outcomes.

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The new Cancer Centre will shortly have access to a new patient hotel provided by UCLH Charity. This facility will be accommodated in 170 Tottenham Court Road, a building purchased by UCLH Charity partially for this purpose. The new patient hotel will provide 60 hotel rooms designed specifically for overnight stay for those patients who are unable to return home, but do not require overnight stay in an inpatient hospital bed. Governors have had several opportunities to visit the new Cancer Centre, but if there are significant numbers that have been unable to do so then they can make arrangements through Ros Waring. Institute of Sport & Exercise Health Governors will be aware that UCLH was awarded a £10m grant from the Department of Health to create a new Institute of Sport & Exercise Health, as part of the Government’s Olympic commitment to provide a health legacy. The Institute will be formed jointly between the Trust, UCL, the British Olympic Authority and HCA (a private health provider). In turn, the Institute is part of a collaboration with Loughborough University and Sheffield Hospitals Foundation Trust to form the National Centre for Sports & Exercise Medicine. Taken together, this collaboration will form the basis of the Government’s strategy to extend the boundaries of biomedical research into sports and exercise health, with benefits for those involved in elite sports activities, the ‘weekend warrior’ and the health of the population as a whole. Royal National Throat, Nose & Ear Hospital Since the last Governing Body meeting, the Trust has completed the transfer of the RNTNEH from the Royal Free Hospital. This plan was previously reported to the Governing Body and was implemented on 1st April with no inconvenience to patients. We have already invested considerable capital into improving the infrastructure of the hospital which has been left in a poor state of repair. The longer-term plan is to replace the RNTNEH in a purpose-built facility (together with the Eastman Dental Hospital) on the phase 4 site above the proposed Proton Beam Therapy unit. This major capital scheme is currently in detailed planning and subject to approval of the business case it should be completed by 2016/17. The Proton Beam Therapy component of Phase 4 will be largely funded by a capital allocation from the Department of Health. As Governors will be aware, this is part of the Government’s strategy to create two national centres for Proton Beam Therapy, with the other at the Christie Hospital in Manchester.

9. LOCAL EDUCATION & TRAINING BOARDS (LETBs)

In January 2012, the Department of Health launched the policy framework, ‘Liberating the NHS: Developing the Healthcare Workforce’, which outlined a new approach to workforce planning and the education and training of the healthcare workforce. The proposals aim to increase the role of employers in the education commissioning process and give them the national support to identify and anticipate the key workforce challenges, and to be flexible and responsive in planning and developing their workforce. There are two central planks to the new system – Health Education England (HEE) and the Local Education and Training Boards (LETBs). HEE will provide national leadership and oversight on strategic planning and development of the health and public health workforce, and allocate education and training resources. The LETBs will be the vehicle for providers and professionals to work with HEE to improve the quality of education and training outcomes so that they meet the needs of service providers, patients and the public. In due course the commissioning role for pre registration and other education is expected to pass to the LETBs and UCLH’s full engagement in the leadership of the LETB and in the current and future methods to establish our future supply of staff to meet our expected demand is important.

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At the same time as the development of the new education commissioning arrangements, the NHS will see a reduction in the funding made available centrally for education. The combination of significant instability and budget reductions means that UCLH has to play close attention to this agenda over the coming months. There are three LETBs planned for London. We will be part of the North Central and East London (NCEL LETB). I am a member of a core transition board overseeing the move to the new education arrangements in NCEL. David Wherrett, Workforce Director is the relevant Director for this. In the coming year the Trust will review its education and training strategies and work plans. David Wherrett will lead this work, liaising with professional leads for various staff groups e.g. Katherine Fenton for Nursing, and with Medical Directors. As an indication of the scale of funding received through the current arrangements the Trust receives approximately £20m pa of Medical and Dental Education Levy (MADEL), £22m pa of Service Increment for Teaching (SIFT) and non-medical education training monies of circa £5m pa. We have an opportunity to influence the new arrangements and ensure we can continue to invest in undergraduate, postgraduate and continuing professional development to deliver the current and future workforce needs of the organisation.

10. TOP TEN OBJECTIVES

I attach as Appendix 2 the final version of the Top 10 objectives for this year. These form the foundation of the Annual Plan 2012/13, which has been circulated separately to Governors and is available on the Trust’s website. Governors were provided with an opportunity to consider an earlier draft of the Annual Plan and Top 10 objectives which are used as a framework to set objectives for all Staff on a cascade basis across the Trust. The Top 10 objectives link the Trust’s values with its Vision to deliver ‘Top Quality Care, Excellent Education and World Class Research’.

11. STAFF CHANGES

I am delighted to welcome Dr Jonathan Fielden as one of the Trust’s new Medical Directors to replace Paul Glynne. Jonathan started here on 9th July and was previously Medical Director at the Royal Berkshire Hospital in Reading. I hope the Governors will have an early opportunity to meet Jonathan. He will have responsibility for a number of the Trust’s critical services, including Accident & Emergency. I am disappointed to report that two of the Trust’s senior staff, well known to Governors, will be leaving shortly. Trevor Payne, Director of Facilities, who has been with the Trust for a number of years, has been offered a new appointment at Barts Health. Trevor has built an excellent reputation for the astute management of support services associated with our PFI partners and a national reputation for sustainability in NHS buildings and services. Kara Gelb, who has held a number of senior appointments in the Trust over recent years, has decided to return to the US. Kara is well known to Governors in her work in maternity services and more recently in masterminding the Trust’s new Values. I am sure that the Governors will wish to join me in thanking both Trevor and Kara for their fantastic support and commitment to the Trust in recent years and wish them well for the future.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

CHIEF EXECUTIVE’S REPORT TO THE GOVERNING BODY: 16 JULY 2012 Q4 March 2012

Appendix 1 Figure 1

Day case & Elective Inpatients

0

5,000

10,000

15,000

20,000

25,000

08/09Q4

09/10Q1

09/10Q2

09/10Q3

09/10Q4

10/11Q1

10/11Q2

10/11Q3

10/11Q4

11/12Q1

11/12Q2

11/12Q3

11/12Q4

Num

ber o

f FC

Es

Activity Plan

Figure 2

Non-Elective Inpatients

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

08/09Q4

09/10Q1

09/10Q2

09/10Q3

09/10Q4

10/11Q1

10/11Q2

10/11Q3

10/11Q4

11/12Q1

11/12Q2

11/12Q3

11/12Q4

Num

ber o

f FC

Es

Activity Plan

Figure 3

Outpatients

0

50,000

100,000

150,000

200,000

250,000

08/09Q4

09/10Q1

09/10Q2

09/10Q3

09/10Q4

10/11Q1

10/11Q2

10/11Q3

10/11Q4

11/12Q1

11/12Q2

11/12Q3

11/12Q4

Num

ber o

f atte

ndan

ces

Activity Plan

Figure 4 Referrals – All Services

Number of referrals to UCLH by working day

0

100

200

300

400

500

600

700

800

900

2010/11Q1

2010/11Q2

2010/11Q3

2010/11Q4

2011/12Q1

2011/12Q2

2011/12Q3

2011/12Q4

GP referrals Non GP referrals Total referrals

1

Appendix 2

Table 1: Monitor Indicators – Compliance Framework

Thresholds Weighting Mar-12Q1

PerformanceQ2

PerformanceQ3

PerformanceQ4

Performance

Refer to comments 1.0 1 2 4 4 5

Refer to comments 1.0 6 15 30 42 54

23.0 1.0 21.0 18.0 19.0 20.0 21.0

18.3 1.0 16.0 16.0 15.5 14.0 16.0

85% 86.2% 91.6% 85.1% 87.1% 90.5%

90% 50.0% 88.9% 70.0% 83.3% 86.7%

94% 95.0% 100.0% 98.7% 100.0% 98.5%

98% 100.0% 100.0% 100.0% 100.0% 100.0%

94% 98.7% 99.5% 99.0% 100.0% 99.4%

96% 0.5 97.0% 98.5% 100.0% 98.9% 98.1%

93% 93.7% 93.0% 94.4% 94.5% 93.8%

93% 95.9% 93.1% 97.9% 95.9% 96.2%

95% 1.0 95.8% 97.5% 97.0% 95.9% 94.0%

TBC 0.5 0.0% 0.0%

Amber -Green Green Green Amber-Green

Green: <1.0, Amber-green: >=1.0, <2.0, Amber-red: >=2.0, <4.0, Red: >4.0

62 day wait for first treatment from urgent GP referral

Two week wait from referral to date first seen: all cancers

31 day wait for second or subsequent treatment: Surgery

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

31-day wait from diagnosis to first treatment (all cancers)

62 day wait for first treatment from consultant screening service referral

31 day wait for second or subsequent treatment: Radiotherapy

Incidence of Clostridium difficile

Indicators

Referral to treatment waiting times – admitted(95th percentile)

Referral to treatment waiting times – non-admitted(95th percentile)

Incidence of MRSA

Overall governance rating

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

Stroke indicator

1.0

1.0

0.5

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

2

3

Appendix 3 Cancer 62 day quarterly performance

62 day from GP referral target (including reallocations)

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

100%

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2009/10 2010/11 2011/12

Actual Threshold

62 day screening target

3.5

65

78.5

12

9 9

56

7

4

0

2

4

6

8

10

12

14

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2009/10 2010/11 2011/12

0%

20%

40%

60%

80%

100%

Performance Threshold Number of cases

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST CHIEF EXECUTIVE’S RPEORT TO THE GOVERNING BODY: 16 JULY 2012 – APPENDIX 2

TOP 10 OBJECTIVES 2012/2013

1. Deliver Excellent Clinical Outcomes

• Improve performance on hospital mortality • Reduce avoidable emergency admissions • Achieve 100% participation in clinical audits

2. Improve Patient Safety

• Reduce hospital acquired infections • Reduce hospital acquired pressure ulcers and patient falls • Reduce the number of blood clots and medication errors

3. Deliver High Quality Patient Experience

• Improve the appointment and transport booking services we offer to patients • Implement the ‘Making a Difference Together’ campaign • Specifically improve patient experience in cancer services

4. Integrate Care with Partners to Improve Patient Care

• Work with GPs to improve patient pathways in long-term conditions • Improve timeliness and quality of all communications with GPs and community carers • Evaluate urgent care centre and implement if agreed with GPs

5. Achieve Sustainable Financial Health

• Achieve income, expenditure and cash targets • Develop service line management and patient level costing • Replace the financial management system

6. Deliver the Quality, Efficiency and Productivity Programme

• Deliver QEP savings target in 2012/13 • Develop 3-year efficiency and productivity plans • Improve support service efficiency (inc radiology and pathology)

7. Develop R&D and Education

• Develop the Biomedical Research Centre (BRC) with a focus on experimental medicine • Participate in the devolution of commissioning for education • Contribute to new UCLP patient pathways

8. Enable Staff to Maximise their Potential

• Improve the experience of staff working at UCLH • Ensure all staff benefit from appraisal and mandatory training • Create a new leadership development programme to deliver the Trust’s aims and objectives

9. Deliver Wait Time in line with Contract

• Deliver mandated in-patient and out-patient waiting times • Deliver A&E waiting times and targets • Meet the cancer waiting time targets

10. Implement Service Developments

• Open the new Cancer Centre • Progress plans for Proton Beam Therapy and Phase 4 • Transfer the Royal National Throat Nose Ear Hospital (RNTNEH) services to the Trust

Top 10 objectives – Annual Plan 2012/13

E

Agenda Item 7

Nomination & Remuneration Committee Report

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

REPORT TO THE GOVERNING BODY REPORT OF THE NOMINATION & REMUNERATION COMMITTEE

16 JULY 2012 1. Introduction Since the Governing Body last received a report in November 2011, the Nomination and Remuneration Committee (N&RC) has met on four occasions, on 15 November 2011, 27 February, 26 April and 27 June 2012. This report summarises the work of the N&RC at those meetings. The Chairman attended the June meeting to discuss annual performance 2011/12 and objective setting for 2012/13. 2. N&RC Chair At the November meeting I was elected Chair of the N&RC. 3. Terms of reference At the November meeting, we reviewed the terms of reference approved by the Governing Body in 2009. We proposed one amendment relating to the right to call a meeting (4.2) and suggested that if the N&RC Chair was asked to call a meeting by four members he should do that. The revised terms of reference are attached as Appendix A to this report. 4. Annual Appraisal of Non-executive directors (NEDs) At the June meeting, the N&RC received a report from the Chairman on the NEDs performance. He confirmed that he was very satisfied with their overall performance and contribution. His report included a commentary on the effectiveness of the Board committees. We were assured that the NEDs chairing of the committees and their contributions on the Board provided independent challenge which gave the Trust a strong and effective Board. 5. Annual Appraisal of the Chairman At the February and April meetings, the N&RC reviewed feedback from NEDs, governors and board members on the Chairman’s performance during 2011/12. This was extremely positive, it confirmed that he had met his objectives in 2011/12 to a substantial degree and had fully demonstrated his commitment to his role. Board members observed that he had been particularly good at ensuring the Board maintained its focus on the quality of care and governors were very pleased that his personal interest in infection control had made a real difference. In June, Jane Ramsey and I met the Chairman to undertake his annual appraisal. At the June meeting, the N&RC reviewed a comprehensive report from the Chairman which provided further evidence of his achievement of his objectives for 2011/12. He was particularly pleased that the Trust had met its MRSA threshold and he had written and thanked the staff that had played a role in that success. He thought he had been useful in ensuring there was the right amount of focus on the issue and although he would continue to do so, he felt he should broaden his focus beyond infection to other issues of patient safety. 6. Chairman’s Objectives 2012/13 At the June meeting, we discussed the Chairman’s draft objectives for 2012/13. These had been developed following consultation with the Chairman, governors and board members. We agreed with the Chairman’s proposal that he should oversee and provide assurance to the Board and Governing Body regarding the delivery of the Trust’s Top 10 objectives by the executive team. In addition, we identified specific objectives for the Chairman himself to deliver

N&RC REPORT JULY 2012 1

on, including effective leadership of the Board and Governing Body, and developing relationships with key stakeholders. A copy of the agreed objectives is attached for information as Appendix B to this report. 7. Remuneration 2012/13 At the February meeting, we received and discussed a report from the Director of Corporate Services which included reference to the level of remuneration set by other Foundation Trusts, based on a framework provided by the Foundation Trust Network. Following our review we agreed to recommend that the remuneration for NEDs’ should not be increased in 2012/13. 8. Non-executive director appointments At the February meeting, we were advised that the terms of office of two non-executive directors, Jane Ramsey and Sue Atkinson, were due to come to an end in 2012/13. Subsequently Jane Ramsey was appointed as Chair of Cambridge University Hospitals. We triggered the process for the appointment of her post, and a non-executive appointment panel has been established to recruit to the position. At the June meeting, the Chairman advised us that Sue Atkinson (due to stand down in March 2013), would be taking a sabbatical for four months between August and November 2012. In order to create a gap in the turnover of non-executives on the Board he proposed that we extend her post by three months from end of March to the end of June 2013. We supported this proposal and agreed to recommend it to the Governing Body. This will allow the Governing Body to recruit to the two positions separately. 9. Membership Maureen Holas will stand down from the N&RC at the end of August. Other members are standing for re-election to the Governing Body. The following procedure will be used to fill the vacancies as required.

Process Date Publicise work of Committee to all Governors ( including NEW governors) August / September

Invite Governors to stand for a position on the Committee (if relevant) By end September

Elect Members to the Committee Mid October

Committee meeting Early November

Recruitment training for Committee members and other interested governors By end February

10. Recommendation The Governing Body is asked to:

i. Note this report and the work of the N&RC. ii. Approve the revised terms of reference. iii. Agree the recommendation that the remuneration for NEDs (as a class) should not be

increased during 2012/13. iv. Support the recommendation to extend Sue Atkinson’s term by three months to end

June 2013. v. Note the arrangements to elect members to vacant positions on the N&RC.

David Coulter Chair Governing Body Nomination and Remuneration Committee 29 June 2012

N&RC REPORT JULY 2012 2

Appendix A

UNIVERSITY COLLEGE LONDON HOSPITAL NHS FOUNDATION TRUST

TERMS OF REFERENCE FOR THE NOMINATION AND REMUNERATION COMMITTEE OF THE GOVERNING BODY

1. Purpose

The Nomination and Remuneration Committee (the Committee), a Committee of the Governing Body, will oversee the arrangements for appraisal, remuneration and re-appointment of non-executive directors (including the Trust Chairman) and make recommendations to the Governing Body.

2. Roles and functions 2.1 The Committee will establish procedures to:

• Conduct and manage the annual appraisal of the Trust Chairman;

• Consider and review each year the Trust Chairman’s annual appraisal of the non-executive directors;

• Review annually the remuneration of non-executive directors (including the Trust Chairman) and make recommendations to the Governing Body;

• Periodically review the overall remuneration package of non-executive directors (including the Trust Chairman) taking into account evidence from comparable organisations as appropriate;

• Where appropriate, consider any allowances and other terms and conditions of office of the non-executive directors (including the Trust Chairman);

• Conduct a review to determine whether it is appropriate to recommend to the Governing Body the reappointment of non-executive directors (including the Trust Chairman); and

• Consider the appointment and removal of non-executive directors (including the Trust Chairman).

3. Membership 3.1 The Committee will comprise:

• Five public or patient Governors • One staff Governor • Three stakeholder Governors

3.2 A period of service on the Committee will be three years. Members shall be elected by the Governing Body for the remainder of their tenure as a Governor; this period will be extended to the full term of three years if they are re-elected/re-appointed as a Governor.

3.3. Members shall be eligible to be re-elected to the Committee for a second period of three years. The maximum a member can serve on the Committee shall be six years.

3.4. A reserve list of Governors who sought election to the Committee but were unsuccessful will be maintained. If a Governor who is a member of the Committee is not re-elected/re-appointed at the end of their tenure, the vacant seat on the Committee will be offered to the Governor from the appropriate constituency who received the next highest number of votes.

N&RC REPORT JULY 2012 3

3.5. A Governor elected by the Committee will chair the Committee. If the Committee Chair* is absent from the meeting the attending Committee members shall choose one from amongst their number to chair the meeting.

3.6. Four members of which at least two must be public/patient Governors shall form a quorum.

3.7. The Trust Chairman will be entitled to attend a meeting of the Committee where the issue relates to the re-appointment, appointment or removal of a non-executive director other than the Trust Chairman.

3.6. The Committee will be authorised to invite other Governors or Board Directors to a meeting as appropriate.

3.8. The Committee will seek advice from external advisors or other bodies as required.

4. Meetings 4.1 The Committee will meet a minimum of twice a year and meetings will be held in

private. 4.2 Meetings will normally be called by the Committee Chair. If the Chair receives a

request to call a meeting by four members he should do that. If the Chair does not do that within 14 working days of the request the four members may call the meeting.

4.3 Papers for each meeting including the agenda and supporting papers will be distributed to members of the Committee at least seven working days before the date of the meeting.

4.4 Confidential minutes of all meetings will be produced and distributed to members of the Committee only.

4.5 The office of the Director of Corporate Services will support the Committee. Minutes will normally be produced within ten working days of the meeting.

4.6 The Committee will submit a report to the Governing Body at least twice a year and more often where there are material issues to report. The Committee Chair will determine, in discussion with the Trust Chairman, whether any report should be made to a part II session of a Governing Body meeting.

4.7 Individual members will not have the right to call a meeting. Should a member consider there is a need for a meeting this must be discussed with the Chair who will call the meeting if it is considered necessary.

5. Process 5.1 Appraisal of non-executive directors

5.1.1 To comment on the method and process of appraising the non- executive directors proposed by the Trust Chairman; and

5.1.2 To report to the Governing Body annually on the appraisal of non-executive directors, having first reviewed and considered a report on non-executive directors’ performance from the Trust Chairman and Chair of the Committee.

5.2 Appraisal of the Chairman 5.2.1 To agree with the Trust Chairman objectives for the coming year; 5.2.2 To consider and review annually the performance of the Trust Chairman

against the objectives set in the previous year; 5.2.3 To review the process of appraising the Trust Chairman; and 5.2.4 To report on the above annually to the Governing Body.

N&RC REPORT JULY 2012 4

5.3 Remuneration

5.3.1 To review and make recommendations to the Governing Body on appropriate remuneration, effective from 1st July each year, for: a) The Trust Chairman; b) The Chair of the Audit Committee; and c) All other non-executive directors.

5.4 Re-appointment of non- executive directors

5.4.1 To invite the Trust Chairman and Chief Executive to conduct a review of the job description and person specification for any non-executive director’s position;

5.4.2 To conduct a review (or to receive the results of such a review) of the qualifications, skills and experience required for any non-executive position against the overall requirements of the Board (taking into account the views of the Board of Directors);

5.4.3 To consider whether any recommendation from the Trust Chairman for re-appointment of a non-executive director meets the requirements for the position; and

5.4.4 To make a recommendation to the Governing Body.

5.5 Re-appointment of Chairman 5.5.1 To conduct a review of the qualifications, skills and experience required for

the Trust Chairman’s post against the overall requirements of the Board, (taking into account the views of the Board of Directors);

5.5.2 To review the job description and person specification and submit them to the Governing Body;

5.5.3 To consider the performance of the Trust Chairman seeking confidential opinion from various parties as determined by the Committee; and

5.5.4 To make recommendations to the Governing Body. 6. Terms of reference

6.1 The terms of reference will be approved by the Governing Body. 6.2 The terms of reference will be reviewed in accordance with Standing Orders.

7. Definitions *

7.1 Chair means the Chair of the Nomination and Remuneration Committee (unless clearly stated otherwise)

N&RC REPORT JULY 2012 5

Appendix B Chairman’s Draft Objectives for 2012-13

Objectives

Implementation Examples of

evidence/measurement

To ensure effective leadership of the Board

Recruit and induct one or two new NEDs (one may carry over into 13/14). Commission external Board review in Autumn 2012.

Successful recruitment of new NEDs. Report from external Board review in Autumn 2012.

To ensure effective leadership of the Governing Body

Integrate new governors. Keep governors informed of financial constraints and extent to which Trust is meeting them, while maintaining quality. Keep governors informed of strategic issues and major changes operational facing the Trust. Work with Fiona McKenzie to provide Governor’s summary page on quality/performance information and to alert Governors to any major issues arising between meetings.

Completion of new governor induction and one to one meetings with new governors. Reports to Governing Body, attendance at some informal Governors meetings, seminars (as required).

Develop relationships with key stakeholders

Improve ways in which the Trust develops partnerships with other organisations. Support the work of Jonathan Fielden and (if implemented) GP relationship managers to enhance GP’s perceptions of the Trust. Support Sarah Johnson’s work on marketing. Tighten senior level communications and strategy development between UCLH and UCL. Utilise lobbying and information sharing potential of the Shelford Group.

Reports to Board/Governing Body.

Communicate and Support Achievement of the Trust’s Top 10 Objectives 2012/13

Deliver Excellent Clinical Outcomes • Improve performance

on hospital mortality • Reduce avoidable

emergency admissions • Achieve 100%

participation in clinical audits

Assure self, Board and Governors as to processes, information flow and identification of issues and ensure follow up. Support strategic management interventions where necessary.

Reports to Board/Governing Body. Reports to Monitor.

Improve Patient Safety • Reduce hospital

acquired infections

Assure self, Board and Governors as to processes, information flow and identification of issues and ensure

Reports to Board/Governing Body. Reports to Monitor.

N&RC REPORT JULY 2012 6

• Reduce hospital acquired pressure ulcers and patient falls

• Reduce the number of blood clots and medication errors

follow up. Maintain focus on driving down the incidence of MRSA, C Difficile and other infections. Support strategic management interventions where necessary. Continue to meet regularly with Annette Jeanes and follow her reports to QSC.

Deliver on High Quality Patient Experience • Improve the

appointment and transport booking services we offer to patients

• Implement the ‘Making a Difference Together’ campaign

• Specifically improve patient experience in cancer services

Support Katherine Fenton and David Wherrett specifically on the Making a Difference Project. Encourage follow up of significant complaints, participating in meetings with complainants, when appropriate.

Reports to Board/Governing Body. Patient and Staff Surveys.

Integrate Care with Partners to Improve Patient Care • Work with GPs to

improve patient pathways in long-term conditions

• Improve timeliness and quality of all communications with GPs and community carers

• Evaluate urgent care centre and implement if agreed with GPs

Support the work of Jonathan Fielden and (if implemented), GP relationship managers and enhance GP’s perceptions of the Trust. Support Sarah Johnson’s work on marketing.

Reports to Board/Governing Body.

Achieve Sustainable Financial Health • Achieve income,

expenditure and cash targets

• Develop service line management and patient level costing

• Replace the financial management system

Assure self, Board and Governors as to processes, information flows and identification of issues and ensure follow up. Support strategic management interventions where necessary. Re-engineer fund-raising capability at Trust level.

Reports to Board/Governing Body. Reports to Monitor.

Deliver the Quality, Efficiency and Productivity Programme • Deliver QEP savings

target in 2012/13 • Develop 3-year

efficiency and productivity plans

• Improve support service efficiency (inc

Assure self, Board and Governors as to processes, information flows and identification of issues and ensure follow up. Support strategic management intervention where necessary.

Reports to Board/Governing Body.

N&RC REPORT JULY 2012 7

radiology and pathology)

Develop R&D and Education • Develop the

Biomedical Research Centre (BRC) with a focus on experimental medicine

• Participate in the devolution of commissioning for education

• Contribute to new UCLP patient pathways

Support the executive team to improve the way in which the Trust trains, develops and mentors junior doctors. Tighten senior level communications and strategy development between UCLH and UCL.

Reports to Board/Governing Body.

Enable Staff to Maximise their Potential • Improve the experience

of staff working at UCLH

• Ensure all staff benefit from appraisal and mandatory training

• Create a new leadership development programme to deliver the Trust’s aims and objectives

Support the executive teams to improve the way in which the Trust trains, develops and mentors junior doctors. Support David Wherrett in driving forward staff experience initiatives. Support the Chief Executive in his work on a programme of leadership development and organisational development.

Reports to Board/Governing Body. Staff Surveys.

Deliver Wait Time in line with contract • Deliver mandated in-

patient and out-patient waiting times

• Deliver A&E waiting times and targets

• Meet the cancer waiting time targets

Assure self, Board and Governors as to processes, information flows, identification of issues and ensure follow up. Support strategic management interventions, where necessary.

Reports to Board/Governing Body, Reports to Monitor.

Implement Service Developments • Open the new Cancer

Centre • Progress plans for

Proton Beam Therapy and Phase 4

• Transfer the Royal National Throat Nose Ear Hospital (RNTNEH) services to the Trust

Participate in the Trust’s consideration and implementation of these Projects. Assure self, Board and Governors as to information flow, risk assessment and identification of issues and ensure follow up.

Reports to Board/Governing Body.

N&RC REPORT JULY 2012 8

F

Agenda Item 8.1

Quality & Safety Update

Quality & Safety Update

May 2012

Metrics

Issues of Concern:

• Pressure ulcer rates remain high but the numbers of Grade 3 and 4 ulcers seem to be dropping over time.

To note: • Mechanisms have been reviewed for ensuring that lessons learnt from audit are effectively

followed up. The scope for using IT to support audit activity will be revisited once requirements and options have been fully examined.

Progress on Previous Issues of Concern:

• No breach of MRSA limit for 11/12. C. diff. limit will be a particular challenge this (12/13) year. • Patients’ worries and fears results from a frequent feedback question will start to be tracked

again with the launch of the new system (demonstrated to the HQPC in June). This new system gives more flexibility to adjust the questions asked and provides direct access to findings. We also hope to see improvement following launch of new Trust values and on-going work by the Making a Difference Together campaign.

• Lack of quiet rooms for breaking bad news – QSC continuing to monitor work in this area. • Patients’ charts and records – QSC continuing to monitor progress.

To note:

• The shift to a smaller, more dynamic meeting for the QSC is working well so far and we will report further at the 6-month mark.

• Fiona will be moving off the monthly Clinical Quality Review Group, where UCLH meets with the NCL Commissioners, and Diana will become the governor involved in this work while Fiona focuses on the QSC. We intend to sub for each other as required.

• The Quality Measurement Group of governors met for the first time in April and will be meeting again on 31 July. There are currently around 10 members and any other governors interested in joining this group are urged to contact me for further details.

Fiona McKenzie and Diana Scarrott Governors on Quality and Safety Committee & Clinical Quality Review Group

G

Agenda Item 8.2

Patient Experience Committee

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Report to the Governing Body

16th July 2012

Patient Experience Committee

The Patient Experience Committee (PEC), chaired by the Chief Nurse, Katherine Fenton, changed its name from Patient Issues Committee (PIC) in September 2011. It meets every two months and two Patient/Public governors – Alison Forbes and Patricia Orwell - were selected for membership of the PEC. Around 15-20 managers attend at any one time. Since meeting every two months, and being more targeted in its membership, the committee has achieved greater efficiency, with action points being followed up to a deadline, and members being clear about what their responsibilities are. The PEC has made considerable inroads into matters such as complaints, in and outpatient administration and the physical layout of the hospitals and its impact on patients. Both governors have played an active part in the committee. Their role has been to question assumptions and practice, as well as bring observations and views directly from patients, thus providing a patient perspective. We feel that the PEC’s commitment to humane, friendly nursing, and its taking genuine notice of patient feedback, via the governors, has led to considerable and noticeable improvements in patient care. However, there is little room for complacency and we welcome feedback data, to be collected from different sources to enable us further to improve the patient experience. In order to support the aims of the PEC, Alison has been attending breast feeding breakfasts and listening to new mothers’ views about maternity services, and has assisted with a review of responses to complaint letters in cancer services. Patricia has continued to promote the need for better access to the main hospital for people with disabilities; improved signage, for example in A&E, and to push for improved patient information. Alison Forbes Patricia Orwell July 2012

H

Agenda Item 9

Report from Carer Governor

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

Carer Governor’s Report to the Governing Body, 16th July 2012

I have now been an elected Carer Governor for just under one year and a carer who has had to access the NHS for my daughter for 21 years. It has been a great opportunity to see how things run on the other side of the fence. I have slowly taken on a few additional commitments, one being Learning Disability Governor Champion. I also participate in the Ground Floor Service Improvement Group which looks at issues concerning the Atrium in UCH. I have been surprised at my passion to want to make a difference for other carers, as some in my position are unaware of how to access services for their partner, sister or child, or the support that they should be having. Carers, over many years, tire and many put their lives on hold for the person they support, normally self sacrificing. In the long term their health can suffer and even if they are exhausted they will struggle on for the love of a person who may become a patient at UCLH. This is why it is so important for UCLH to support this situation, to make the carer’s life a little easier. When I decided to stand for election to the Governing Body I was asked why I wanted to be a Governor. This question took me some time to answer. My answer was “to be a voice for other carers who could not ask for support themselves and to make their lives easier by accessing information and finding on the other side of the fence that support and ongoing learning was there for easy access. Primarily, I have been fascinated by the knowledge I have gained since becoming a new Governor. How certain areas of the hospital work, how the Trust is committed to making a difference, not just medically, but the ethos of their staff and the willingness to listen about where it can make improvements in areas where it may be weak or has previously failed. This is very important - being able to realise that nothing is perfect and always being willing to learn. I have had the opportunity of meeting carers who deal with mental health issues everyday of their lives which I feel is more difficult to deal with than some other health issues. I have taken part in my first Carer Week where I was proud to stand and support others and take back with me any concerns and worries they may have had. It’s an important week as it recognises the good work that carers do. I have also had the opportunity to have been asked my opinion on the collation of the new Carers Policy and to learn how people in the Trust have strived to find a balance to treat patients with learning issues or individual needs, with respect, involving them in their care but not undermining the fountain of knowledge that the carer brings with them.

I now understand that UCLH is willing to listen to carers and learn, but still has areas where progress is slow. But I have become aware that outpatient services have greatly improved. The way the clinics are run is more efficient and waiting time has reduced. This is so important for the patient and carer, who really just want to go home. The overall improvement in the way staff of all levels deal with carers is phenomenal and as a carer myself, I know is greatly appreciated. This includes answering questions which helps to reduce anxieties. I also understand that having policies is important but this is not so relevant to a carer who has no interest, energy or inclination to want to know that they exist. What is important to carers is that the Trust understands the complexity of their lives and the pressure that they live with, and provides support wherever it can. I appreciate that this is very important to the Trust – but please don’t take carers for granted. When my daughter was an inpatient a couple of years ago I felt I could not leave her side, as I was not confident that her high level of need would be met. In addition I was not looked after myself, to the point where on Christmas day I was not offered any form of meal. Hopefully this has also changed. So, what is important to the Carer? Easy access to the hospital Information and advice is offered to them and they are not expected to have to find it

for themselves If the patient is left alone by the carer, the high standard of care that the carer gives

is still delivered so that the carer has the confidence to walk away without feeling further stress.

Rosalind Jacobs, Carer Governor June 2012

I

Agenda Item 10

Membership Development Strategy

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST REPORT TO THE GOVERNING BODY - 16 July 2012

MEMBERSHIP DEVELOPMENT STRATEGY: 2012 -2015

Making a difference together

1. Introduction A group of Governors (Patient Governors: Bill McAlister, Dee Carter, Christine Chapman John Green, and Fiona McKenzie; and Staff Governor, Tom Hughes) met on four occasions to review the Membership Development Strategy – Become a Member make a difference, which was approved by the Governing Body in November 2009. Between March 2010 and March 2012, the Governing Body received four progress reports from the Membership Development Manager providing updates on how the strategy was being delivered. Governors also discussed membership as part of the annual planning process. The group concluded that the objectives set in 2009 had been delivered and a report summarising how those objectives were achieved is attached as appendix 1 to the New Membership Development Strategy 2012 – 2015 – Making a difference together (attachment 2 to this report)

2. Membership Strategy Review The group reviewed the Trust’s overall membership strategy. It agreed it supported the requirement to develop and maintain a representative membership but remained flexible. It enabled the Membership Development Manager with Governors to identify different strategies to engage and involve each membership community as appropriate. Although the strategy remained fit for purpose, the group suggested the following changes which it felt would enhance the strategy.

• Members should be encouraged to make a difference together - this aligned the strategy with the Trust’s ‘making a difference together’ campaign and more closely with its PPI strategy.

• Although the strategy was aimed at increasing membership in the public and patient constituencies the action plan should include strategies for increasing staff engagement and involvement.

• Recruitment strategies should be developed for the University College Hospital Macmillan Cancer Centre and RNTNEH.

• The previously named Recruitment Governor Champion should be renamed Membership Governor Champion to reflect the wider remit of the role (recruitment, communication and engagement and involvement).

The group endorsed membership targets of 5% and 3% for public and patient members respectively (see attachment 1 to this report). It agreed that for public members recruitment should focus on all London Boroughs. The Governing Body is asked to approve the revised strategy and note that a progress report on delivery against the action plan (appendix 2 of the strategy) will be presented to at its November meeting. Tonia Ramsden Director of Corporate Services

Attachment 1 2012/2013: Annual Membership Plan submitted to Monitor – May 2012

Membership size and movements

Public constituency 2011/12 2012/13

(estimated) At year start (April 1) +ve 1,663 1,893 New members +ve 315 95 Members leaving +ve 85 At year end (31 March) 1,893 1,988

Staff constituency 2011/12 2012/13

(estimated) At year start (April 1) +ve 6,752 6,418 New members +ve 470 Members leaving +ve 334 At year end (31 March) 6,418 6,888

Patient constituency 2011/12 2012/13

(estimated) At year start (April 1) +ve 7,983 8,241 New members +ve 724 247 Members leaving +ve 466 At year end (31 March) 8,241 8,488

Attachment 2

Membership Development Strategy

April 2012 - 2015

Making a difference together

UCLH Foundation Trust has 1893 Public and 8241 Patient members April 2012

Membership Development Strategy 2012‐2015  Page 1 

Content 1 Introduction

2

2 Background

2

3 Strategic objectives

2

4 Delivering the Strategy

3

5 Evaluating the Strategy

5

6

Comments and Questions 5

7 Appendix 1 – Membership Development Strategy 2009

6

This document should be read in conjunction with the Trust’s Annual Report which provides the following information: Membership report Definition of the membership constituencies Annual membership analysis Annual membership strategy – key deliverables for the year Names of the members of the Governing Body can be found at www.uclh.nhs.uk/members

Membership Development Strategy 2012‐2015  Page 2 

1. Introduction

University College London Hospitals NHS Foundation Trust (the Trust) which is situated in the heart of London, is one of the most complex NHS trusts in England, serving a large and diverse population. It became a Foundation Trust in 2004. It provides academically led acute and specialist services, both locally and to patients from throughout the United Kingdom. It balances the provision of highly rated, specialist services with providing acute services to the local populations of Camden, Islington, Barnet, Enfield, Haringey and Westminster, and other areas of London. As a Foundation Trust it recognises that the Governing Body directly represents the patients, staff and local communities it serves and that building and encouraging membership involvement provides a real opportunity for people to influence the work of the Trust and wider healthcare landscape. This membership development strategy 2012 sets out a series of objectives for the Trust to continue to maintain, grow and engage its membership, including the actions that it will take to meet these objectives. It also describes how the Trust will evaluate the delivery of the strategy. It should be noted that whilst this strategy is aimed and patients and public, the action plan includes staff engagement and involvement. The strategy will be delivered within the wider framework of Trust strategies which address the issues of equality and diversity, public and patient involvement, user engagement, and communications. Appendix 1 summarises what progress was made against the objectives set out in the Trust’s second membership strategy published in 2009.

2. Background

A membership development strategy steering group, comprising a small number of governors and the membership development manager, was established to consider how;

• Communication with members can be improved • The benefits of UCLH membership can be communicated to the public and

patients more widely including informing people about the role of governors and the Governing Body

• To increase a representative membership, particularly with younger people • To increase engagement • The Governing Body can contribute to developing the membership and

engagement strategy • Best to develop the role of the member and encourage involvement The group agreed that not all members would want to be actively involved and that the Trust would need to keep all members up-to-date with what was happening at UCLH and show how being involved could make a difference. It also agreed that representing the interests of members and stakeholders and engaging with members was a key responsibility of Governors.

3. Strategic objectives

This strategy sets out objectives that will be achieved to develop an engaged membership. There are three strands to the strategy these are;

Membership Development Strategy 2012‐2015  Page 3 

• Build and maintain membership numbers to meet /exceed annual plan

targets ensuring the membership is representative of the population the Trust serves,

• Communicate effectively with members, • Engage with members and encourage involvement. The previous strategy evolved as the membership developed and the Governing Body will review the ongoing delivery of these objectives at least annually.

4. Delivering the Strategy

The Governing Body with the Director of Corporate Services will have responsibility for ensuring the objectives and actions of this strategy are carried out. The Membership Development Manager who will ensure that specific Governor led projects, which focus on issues of recruitment or membership engagement, are incorporated in the action plan, will lead implementation. The Governing Body may establish a group which, if required, will oversee implementation of the Strategy

Objective 1 Build and maintain membership numbers to meet / exceed annual plan targets ensuring the membership is representative of the population the Trust serves

The Trust’s aim remains to steadily recruit and increase representative

membership. Key objectives include: i. To meet the annual targets as set out in the Trust’s Annual Plan each

year. ii To maintain an accurate membership database which meets regulatory

requirements and can aid membership development iii. To encourage membership across the public and patient constituencies iv. To take steps to ensure the membership reflects the diversity of the

population the Trust serves v. To develop a simple and accessible process for becoming a member. Actions to achieve this include: • Targeted and regular recruitment drives in the Trust’s Hospitals and at the

annual open event • Use of membership recruitment material e.g. letter from the

Chairman should be sent to all new patients across our hospital sites • Review recruitment material at least bi-annually to ensure it remains

relevant and design site specific posters and banners for new sites, for example the University College Hospital Macmillan Cancer Centre and RNTNEH

• Continue to use membership champions and governors to recruit members at key hospital locations and consider membership champions to assist in recruiting at hospital events

Membership Development Strategy 2012‐2015  Page 4 

• Identify initiatives to raise the profile of membership in the local community e.g. advertising in local borough publications or attending local community events

• Develop strategies to identify and address under-representation, working with equality and diversity organisations.

• Continue visits to community groups to attract new members (this is also an opportunity for engagement)

• Develop strategies to encourage youth members to join the membership; • Increase membership in the public constituency to ensure more even

representation across London; • Make the members/governors webpage more visual; • Organise a series of visits to GP surgeries to recruit new members (also

an opportunity for engagement)

Objective 2 Communicate effectively with members

The Trust is committed to maintaining a two-way dialogue with its

membership. Through this it will encourage members to help influence developments within the Trust.

Key objectives include: • To promote the work of the Trust and its Governors • To identify opportunities for two-way communication between members

and Governors • To ensure communications encourage the engagement with members Actions to achieve this include: • Promote the work of the Trust and its Governors on the Trust’s website,

through UCLH News and the Annual Review • Identify opportunities for members to meet Governors e.g. at Trust events • Provide all new members with relevant information about the Trust, the

benefits of membership and the role of members • Provide opportunities for members to give their views on a range of issues

e.g. membership issues, UCLH News and patient care • Make UCLH news and other membership publicity material available in

other languages and formats as required through the Trust’s membership engagement work

The Trust will consider the needs of its diverse membership when assessing its methods of communication and aim to provide material in appropriate and accessible formats.

Objective 3 Engage with members and encourage involvement

The Trust’s aim is to ensure that the membership has an opportunity to get involved with the Trust and through this engagement help shape the services it provides.

Membership Development Strategy 2012‐2015  Page 5 

Key objectives include: • To ensure the views of members are understood • To identify opportunities for members and Governors to get involved in the

Trust • To encourage more members to stand for election to the Governing Body. Actions to achieve this include:

• Increase opportunities for members to engage in Trust work e.g. ward observation work, recruit more membership champions, patient environment action teams (PEAT) inspections

• Link with the Trust’s existing strategies, for example patient and public involvement (PPI) and “making a difference together” campaign.

• Identify initiatives where members can be used as a source of feedback on patient and quality issues

• Continue to encourage a high number of members to stand for election in future years.

• Link with Local Councils to encourage stronger engagement. • Invite members to engage in patient experience programmes in the Trust. • Develop the ‘membership governor champion’ role to extend this to

include governor champions for patient and public recruitment and staff engagement.

5. Evaluating the strategy

The overriding objective will be to ensure the strategy is delivered. The Governing Body will monitor delivery of the objectives set out in the strategy. An action plan, Appendix 2, sets out what steps will be taken to meet these objectives. In monitoring the effectiveness of the strategy, the Governing Body and the Director of Corporate Services will ensure that it remains meaningful and relevant. A progress report was submitted to the Governing Body by the Membership Development Manager in November 2011 and will continue to be presented at least 12 monthly intervals thereafter.

6. Comments and Questions

The first point for contact with the Trust regarding membership information is the Membership Development Manager on 020 3447 9290 and via email foundation.trust@uclh.nhs.uk

Ros Waring Membership development manager Following consultation with the Membership Development Strategy Working Group: Christine Chapman – Non-London based Patient Governor Fiona McKenzie – London-based Patient Governor John Green – London-based patient Governor Dee Carter – London-based patient Governor Bill McAlister – London based patient Governor Tom Hughes – Staff Governor

Membership Development Strategy 2012‐2015  Page 6 

Appendix 1 Membership Development Strategy 2009

1. Introduction

This paper summarises the achievement of the objectives set out in the membership development strategy which were agreed by the Governing Body in 2009. Regular reports were submitted to the Governing Body meeting on progress against delivery, providing assurance to the Trust that the specific objectives were being delivered; achievement of the overall goals were reported annually in the Trust’s annual plan.

2. Build and maintain membership numbers to meet/exceed annual plan

targets ensuring the membership is representative of the population the Trust serves

One of the key objectives in delivery of this was:

• To take steps to ensure the membership reflects the diversity of the

population it serves

Considerable progress has been made in this area. The public membership is now represented by more than 15% of members from the Asian community. This has largely been due to the successful engagement programmes organised through the membership office. Strategies to improve this across more ethnicities will be included in the 2012 plan.

Examples of engagement undertaken to improve representation are listed below.

i. Visits to Bengali and Chinese communities followed by a series of

health talks in the communities ii. Membership stand at local events, for example Spencer House Open

Day. Spencer House is part of Circle 33 which provides Supported Housing.

ii. Members from local communities signing up more members

As a result of the above work UCLH News is now regularly translated into Bengali, Chinese and Turkish.

2. Communicate effective with members One of the key objectives in delivery of this was:

• To ensure communications encourage the engagement of members

Considerable progress has been made in this area. Regular communication with members has resulted in a more engaged membership. This has been achieved by: i; Effective and timely communications to members on email informing

them of the forthcoming MembersMeet. An increased number of

Membership Development Strategy 2012‐2015  Page 7 

members now to use the Foundation Trust inbox as a method of communication, not only for MembersMeets but also to advise of the change of address/circumstances, information, standing for governor. Members generally respond to the Membership office communications, even if it’s to send their apologies to a MembersMeet.

ii. There has been an increased number of new applications coming through the inbox, this could be as a result of the QR code (quick response code which when scanned with smart phones take people directly to the membership website page) that has been added to the membership posters.

iii. UCLH news continues to be an effective and well received communication to the members.

3. Engage with members and encourage involvement One of the key objectives in delivery of this was:

• To identify opportunities for members and governors to get involved in the Trust

Considerable progress has been made in this area. The Trust has developed ways for members and governors to work together on a number of projects; these include: i. PEAT inspections ii Ward observation work as part of the quality improvement framework iii Membership recruitment champions

Conclusion This review shows that the strategy agreed by the Governing Body has broadly been delivered. In areas where progress has been more difficult to accomplish the Membership Development Strategy Steering Group developed alternative strategies some of which will be built on in the 2012 membership strategy. RW/April 2012

Appendix 2

Membership Development Strategy – Action plan The list of actions is not exhaustive – it will be reviewed and revised as required.

Membership Development Strategy 2012‐2015  Page 8 

Objective 1 - Build and maintain membership numbers to meet / exceed annual plan targets ensuring the membership is representative of the population the Trust serves Objective What we will do Action Lead/s Timescale Set and meet annual target to increase the membership as set out in the Trust’s Annual Plan

Set realistic membership targets by using current and historical information to inform the decision i.e. previous years data Recruit a representative membership Promote the membership to the UCH Macmillan Cancer Centre and RNTNEH

Monitor membership size and movement throughout the year. Review membership and set target annually Targeted and regular recruitment drives in the Trust’s Hospitals and at the annual open event.

Run recruitment campaigns on the new sites.

Membership Development Manager Director of Corporate Services Membership Development Manager/Governors Membership Development Manager/’Membership Governor Champion

October and March each year Ongoing year round 30 November 2012

To take steps to ensure the membership reflects the diversity of the population

Develop engagement with a number of communities Develop strategies to encourage youth members to join the membership;

Organise visits to the Turkish and Somali community and other communities. Organise visits to schools to promote membership to youth groups.

Membership Development Manager Membership Development Manager/governors

31 March 2013 31 March 2013

Membership Development Strategy 2012‐2015  Page 9 

Consider setting up a membership Facebook page could help this. (this is also an opportunity for communication) Consider collaborating with the Teenage Cancer Trust

Membership Development Manager/Lead governor Membership Development Manager/Lead governor

31 March 2013 31 October 2012

Maintain an accurate membership database which meets regulatory requirements and can aid membership development

Encourage members to inform the membership office of any change to their demographics

Place regular messages in UCLH News Work with Capita to ensure and agree timely data cleanses

UCLH News Editor / Membership Development Manager Membership Development Manager

Ongoing At least 3 times a year and prior to each election

Increase membership in the public constituency across London

Continue to build contacts with local groups, local authorities and to work with them to engage the public and encourage membership Raise awareness to staff Continue to advertise membership and elections in newspapers

Identify initiatives to raise the profile of membership in the local community e.g. advertising in local borough publications or attending local community events and advertising MembersMeets on LINKs Identify initiatives for staff to encourage eligible neighbours and friends to join. Advertise elections in a number of newspapers to encourage people from communities to join the membership and stand

Membership Development Manager Membership Development Manager/staff governors Membership Development Manager

On going On going Before call for nominations each year

Membership Development Strategy 2012‐2015  Page 10 

Improve and promote the Governors/Members webpage www.uclh.nhs.uk/members

for governor. Develop a video of governors and members talking about how they have made a difference and motivation to stand (this is also an opportunity for communication) Continue the use of quick response (QR) codes across the membership publicity material.

Membership Development Manager Membership Development Manager

30 June 2012 Ongoing

To develop a simple and accessible process for becoming a member

Produce an online membership application form in conjunction with Capita.

Insert the word “Free” on the outside of the membership form Update membership application forms to reflect the Trust’s “Making a difference together” patient experience campaign

Membership Development Manager

When the forms are next re-done When the forms are next re-done

Objective 2 - Communicate effectively with members To promote the work of the Trust and its Governors

Regularly update the website. Feedback to members about the governors work through UCLH News and other Trust publications

Update website monthly Promotion on the Trust’s website, through UCLH News and the Annual Review

Membership Development Manager Membership Development Manager/in discussion with Governors

Monthly Ongoing

Membership Development Strategy 2012‐2015  Page 11 

Invite members to contribute to UCLH News via the magazine

Membership Development Manager/UCLH news Editor

Ongoing

To identify opportunities for two-way communication between members and Governors

Consider the use of social networks to improve communication Ensure members know how to contact governors Promote engagement at the Annual Open Event through emails and invitations Make UCLH news and the membership publicity material available in other languages

Work with communications to consider establishing a governor blog and facebook page, as well as using Twitter more effectively. Ensure Website and other material clearly displays how members can contact Governors Provide all new members with relevant information about the Trust, the benefits of membership including NHS discounts, and the role of members Ensure all relevant material is translated into other languages as requested, which may extend to election and nomination material. This is also an opportunity to take translated material when engaging with communities

Membership Development Manager/Lead governor Membership Development Manager Membership Development Manager Membership Development Manager

31 March 2013 Ongoing Ongoing Ongoing

To ensure communications encourage the

Ensure UCLH news remains relevant

Consider surveying members on their views of UCLH news as to whether the content is

Membership Development Manager/Editor of UCLH news

Ongoing

Membership Development Strategy 2012‐2015  Page 12 

engagement with members

relevant and of interest to members, or whether they would prefer more staff focused stories

Objective 3 - Engage with members and encourage involvement To ensure the views of members are understood

Capture members’ interests and inform them of ways of get involved as and when opportunities arise.

Record those members who are interested in getting involved and ensure they are given opportunities e.g. through focus groups and surveys

Membership Development Manager

Ongoing

To identify opportunities for members and Governors to get involved in the Trust

Continue the member involvement interest document Identify work streams where members can get involved in Trust work.

Record those members who are interested in getting involved and ensure they are given opportunities e g through focus groups and surveys Increase opportunities for members to engage in Trust work e g PEAT inspections, ward observations work, membership champions Link with the Trust’s existing strategies and work on PPI and “making a difference together” campaign Identify initiatives where members can be used as a source of feedback on patient and quality issues e.g. consider the involvement of members in the handheld feedback system

Membership Development Manager Membership Development Manager/PPI Lead/Patient experience project manager Membership Development Manager

Ongoing Ongoing 31 March 2013

at the NHNN To engage members in the patient experience programme in the Trust, including “in your shoes”

Membership Development Manager

Ongoing

To encourage more members to stand for election to the Governing Body

Promote the work and importance of being a Governor throughout the year, through UCLH News, the website and at events that the Governors attend Raise awareness of Governors to staff.

Continue to encourage more members to stand for election in future years. Contact candidates from the previous year who were not elected Consider holding events on hospital sites to raise awareness and develop initiatives to encourage staff to sign up neighbours/friends to the public membership. Work with HR/communications to promote interest in Governing Body at induction Presentations to divisions prior to staff elections each year to ensure staff are briefed on the role and opportunities to get involved

Governors/ Membership Development Manager Membership Development Manager/Staff Engagement Governor Champion Membership Development Manager Membership development manager/ Staff Engagement Governor Champion

Ongoing Ongoing 31 July 2012 Ongoing

Membership Development Strategy 2012‐2015  Page 13 

J

Agenda Item 11

Foundation Trust Governors Association Report

05/07/2012

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REPORT TO UCLH GOVERNING BODY – 16THJULY 2012

REPORT FROM THE FOUNDATION TRUST GOVERNORS ASSOCIATION

[FTGA]

1. Introduction This report provides an update on the work of the FTGA, specifically the FTGA Board of Trustees [FTGABT] and reports information I feel it is relevant to bring to the attention of the UCLH Governors.

2. Board of Trustees

The FTGABT met on 14th and 15th May 2012 holding Strategic meetings which also incorporated a Board meeting.

2.1 Strategic Away Day The Strategic meetings were very productive. We undertook a SWOT analysis

and discussed and agreed, finance, board processes, administration, research, policy, communications and governance strategy. The main outcome was the restructuring of sub-groups in order to improve governance and communications making the FTGA a more effective organisation for its members. We have replaced five steering committees with three which are: Membership and External Affairs [Communications] Steering Committee –

to ensure effective communication and engagement with member trusts Finance Steering Committee – to review funding structure Governance Steering Committee – to ensure the FTGA works effectively - I

will lead this group Task and Finish Groups National Governors Training Bid – [see below] Good Practice - to produce policies following constitution change to

charitable status - I will lead this group

Other issues were: Member’s survey, to be trialled at UCLH, agreed with Fiona McKenzie. Improved communications: informing members about what the FTGA does,

improving the FTGA Newsletter, asking members what they want. improving the website.

3. Training and Development Programme for Governors and Foundation

Trusts 3.1 Background

On 27th March 2012, the Health and Social Care Bill became law. The Health and Social Care Act brings added responsibilities for foundation trust governors.

3.2 The main changes to the governor’s role are:

To hold non-executive directors individually and collectively, to account for the performance of the board of directors, and to represent the interests of its members as a whole and the interests of the public.

Governor bodies are renamed ‘councils of governors’.

Governors are required to vote on issues concerning the FT’s/directors’ performance, and a corresponding duty is imposed on directors to publish such information in the FT’s Annual Report.

Governors will now have powers to approve amendments to their constitution, ‘significant transactions’, mergers, acquisitions and separations.

Any amendment to the constitution of the trust regarding the powers or duties of the governors [or their role] is subject to a members’ vote. More than 50% of those voting must be in favour and a governor must put the motion.

The Act brings with it a need and opportunity to develop a governor training programme to prepare all governors for their forthcoming role as well as their current responsibilities. A programme which is strategically focused, responsive to change and sustainable is essential. Both the Foundation Trust Network [FTN] and the FTGA have provided training and information exchanges for a number of years feedback on which is generally good or very good. A survey by the FTN advised that many foundation trusts provide excellent support to their governors [and in my view this is particularly the case at UCLH], however, a need was identified for a national governor training programme. Monitor and the DoH recognised this need. The FTGA have decided to bid to provide this programme.

3.4 Training packages

The Objective is to provide 3 training packages: INDUCTION: material for the trust’s own induction programme and pre-

election communications strategies. CORE: A general skill base for all governors building on some induction

material and outlining what the NHS is, and the governors’ role within it; its funding and governance, national policy and regulatory framework as well as foundation trust policy and its governance and the role of members and governors within that.

SPECIALIST: A selection of specialist options [e.g. audit selection] to enable governors to focus on specific aspects of the role, where governor colleagues want them to act in the capacity as advisers to the governing body or to act as part of a working committee.

The specification provided some interesting information about FTs in the future

There are approximately 4,200 governors. By 2014, there will be nearly 100 more foundation trusts, each with a new council of governors; an estimated 8,000 governors in total requiring training.

Governors come from many walks of life and bring different skills and aptitudes to the performance of their responsibilities, as one would expect from an elected body of people. Many have previous professional experience and possess business and commercial skills, the majority do not.

Governors will be at different stages in their understanding of the NHS and their role, from those new to their role in new FTs, through new governors in existing FTs, to governors who may have been in post for between six and in some cases up to nine years. [this depends on an FTs Constitution].

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They will have varying time availability and learning preferences. Some will not have experienced formal learning for many years; some groups may have specific training needs.

In surveys, governors have expressed preference, where possible, for being trained as whole Councils as well as on a face-to-face basis.

Some governors may not have online access. Learning material must remain fit for purpose and reviewed and updated

on an ongoing basis

4. The Good Practice Task Group I chair a group which produces and reviews FTGA policies and procedures in line with the Charities Commission, FTGA values and good practice guidance. The group comprises four directors including me. We presented three policies and procedures to the FTGABT, all were approved. 1. Expenses Policy and Procedure 2. Directors Induction Policy and Procedure 3. Websites and Social Media Policy and Procedure

For further information please contact me.

Tom Hughes Staff Governor & UCLH FTGA Representative

Member of the FTGA Board of Trustees

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