The meeting of the Board of Directors To be held on ... · The meeting of the Board of Directors To...

The meeting of the Board of Directors

To be held on Tuesday, 21 August 2018 at 10.00am

in the Boardroom, Montagu Hospital

AGENDA Part I

Enclosures Time

1. Apologies for absence

(Verbal) 10.00am

2. Register of interests and declarations

(Verbal)

3. Actions from the previous meeting Enclosure A

Presentation slot

4. Missed Appointments Update Emma Challans – Deputy Chief Operating Officer

Presentation 10.05am

Reports for decision

5. Hospital Sterilisation and Decontamination Unit (HSDU) Kirsty Edmondson-Jones – Director of Estates and Facilities

Enclosure B 10.30am

6. Completion of Contract Documents for Electrical Infrastructure Phase 2 - DRI Kirsty Edmondson-Jones – Director of Estates and Facilities

Enclosure C 10.50am

7. Appointment of Non-executive Director for Speaking Up Karen Barnard – Director of People and Organisational Development Matthew Kane – Trust Board Secretary

Enclosure D 11.05am

8. Use of Trust Seal Matthew Kane – Trust Board Secretary

Enclosure E 11.10am

Reports for assurance

9. Chairs’ Assurance Logs for Board Committees held 20 August 2018 Neil Rhodes – Chair of Finance and Performance Linn Phipps – Quality and Effectiveness Committee

Enclosure F (to follow)

11.15am

BREAK

11.30am

10. Finance Report as at July 2018 Jon Sargeant – Director of Finance

Enclosure G 11.45am

11. Performance Report – July 2018 Led by David Purdue – Chief Operating Officer

Enclosure H

12.15pm

Reports for information

12. Guardian for Safe Working Quarterly Report Karen Barnard – Director of People and Organisational Development

Enclosure I 12.45pm

13. Chair and NEDs’ Report Suzy Brain England – Chair

Enclosure J

14. Chief Executive’s Report Richard Parker –Chief Executive

Enclosure K

15. Minutes of Finance and Performance Committee, 23 July 2018 Neil Rhodes – Chair of Finance and Performance Committee

Enclosure L

16. Minutes of Quality & Effectiveness Committee, 21 June 2018 Linn Phipps – Quality and Effectiveness Committee

Enclosure M

17. Minutes of Management Board, 16 July 2018 Richard Parker – Chief Executive

Enclosure N

18. To note: Board of Directors Agenda Calendar Matthew Kane – Trust Board Secretary

Enclosure O

Minutes

19. To approve the minutes of the previous meeting held 31 July 2018

Enclosure P 12.50pm

20. Any other business (to be agreed with the Chair prior to the meeting)

21. Governor questions regarding the business of the meeting

1.00pm

22. Date and time of next meeting

Date: 25 September 2018 Time: 10.00am Venue: Boardroom, Montagu

23. Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Suzy Brain England Chair of the Board 15 August 2018

Action Notes

Meeting: Board of Directors

Date of meeting: 31 July 2018

Location: Boardroom, DRI

Attendees: SBE, RP, KB, PD, MH, DP, SS, AA, LP, JP, NR, JS, PS, KS

Apologies: None.

No. Minute No Action Responsibility Target Date Update

1. 18/01/13 Director of Education to share the Teaching Hospital phase two development plan at a future Board.

MK Following discussions at

QEC

Partially complete. Research and development discussions at QEC complete. Phase 2 subject to discussions on where research sits within management.

2. 18/4/44 Presentation to be given to Board on work in theatres and outpatients.

DP/MK August 2018 Timetabled for a future Board.

3. 18/6/47 18/7/27 18/7/64

Workshops to be organised on:

Digitising A&E

LEAN

Values based recruitment

KB/MK TBC Included in board development schedule.

No. Minute No Action Responsibility Target Date Update

4. 18/7/40 Age profile of prison members on PTL list to be provided.

DP August 2018 To be provided.

5. 18/7/70 Risk assess the impact of Brexit on the Trust with particular reference to workforce and medicine availability.

MK August 2018 To be undertaken.

Date of next meeting: 21 August 2018 Action notes prepared by: M Kane Circulation: SBE, AC, NR, KB, MH, KS, PD, DP, JS, SS, RP, LP, SM

Title Hospital Sterilisation and Decontamination Unit (HSDU)

Report to Board of Directors Date 21st August 2018

Author Kirsty Edmondson-Jones

Purpose Tick one as appropriate

Decision X

Assurance

Information

Executive summary containing key messages and issues

In late 2015, a high level internal review made the case for the market testing of the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) run Hospital Disinfection and Sterilisation Unit (HSDU) situated in the main block of the Doncaster Royal Infirmary (DRI). In May 2017 the Trust issued an Official Journal of the European Union (OJEU) advertisement for the provision of decontamination services. Following a lengthy and detailed evaluation, STERIS Instrument Management Services (STERIS IMS) have been selected as the preferred bidder. The bid represents a total net present value (NPV) service cost for the 15year contract of £34.1m, with a NPV benefit to the Trust of £4.8m over the life of the contract when compared to the Public Sector Comparator (PSC). Although the contract gives rise to a direct cost pressure of £912k over the life of the contract or £61k per annum, there is the opportunity to mitigate this with savings generated from variant bids for Pre-Sterile Consumables and Loan Kits. Savings initiatives have been identified and risk assessed at 50%, totalling £823k over the life of the contract, which will therefore reduce the cost pressure to £90k over the life of the contract, or £6k per annum. By outsourcing the service the Trust would transfer all risks associated with the decontamination of surgical instruments, and release valuable space within a clinical area adjacent to theatres.

Board of Directors are therefore asked to approve the award a 15year contract to STERIS IMS for the decontamination of surgical instruments and associated products using their facility in Sheffield. The full documentation relating to the case was reviewed by Finance and Performance Committee on 20 August 2018.

Key questions posed by the report

Is Board supportive of the award?

How this report contributes to the delivery of the strategic objectives

How this report impacts on current risks or highlights new risks

The paper updates BOD in the wider Corporate Risk (F&P4) relating to the failure to ensure a suitable estates infrastructure is in place due to the requirement to make substantial capital investment to should the HSDU service remain on the DRI site.

Recommendation(s) and next steps

Board of Directors are asked to award a 15 year contract to STERIS IMS for the decontamination of surgical instruments and associated products.

Title Completion of Contract Documents for Electrical Infrastructure Phase 2 - DRI

Report to Trust Board Date 21 August 2018

Author A White – Head of Capital Projects


Decision X

Assurance

Information


This paper requests the signing under deed of the Stage 3 and Stage 4 NEC3 contracts for the above. The contract relates to the continuation of the Electrical Infrastructure upgrade works, Phase 1 having been completed. The works are part of the trust upgrade of its critical electrical infrastructure which is essential in order to increase the supply to the site which is currently at full capacity and continuation of the replacement of High and Low Voltage site infrastructure. The works are commensurate with the programme for the eradication of backlog maintenance and addresses an element of significant risk. The increase in supply will be needed to ensure that the site has spare electrical capacity. The budget has been approved as part of the Trust’s 2017/18 and 2018/19 Capital Plans and the Business Case was approved at CIG in May 2018. It is being presented to the Board today as a result of the total value of agreed schemes being in excess £1m.


Board assurance that the contract offers good value for money and will appropriately serve the Trust’s infrastructure moving forwards


Key requirement for ongoing backlog eradication, reduction of infrastructure risk and enabling of expansion of the site and related infrastructure.


Electrical fault to DRI infrastructure will lead to loss of supply and operational disruption. The works will significantly contribute to a programme of estates infrastructure upgrades and mitigates one of the main BAF risks.


That Board endorses the contract for Electrical Infrastructure Phase 2 with IHP and delegates power to the Chief Executive to sign on behalf of the Trust.

Title Appointment of Non-executive Director for Speaking Up

Report to Board of Directors Date 21 August 2018

Author Karen Barnard (Director of P&OD) & Matthew Kane (Board Secretary)


Decision X

Assurance

Information


National guidance for boards on Freedom to Speak Up in NHS foundation trusts, and the Trust’s own Raising Concerns Policy – We Care, We Listen, We Act, requires DBTH to have executive and non-executive lead directors for ‘speaking up’ (known in the Policy as ‘raising concerns’ or ‘whistleblowing’). The executive role is fulfilled by Karen Barnard, Director of People and Organisational Development. Prior to 7 June, the non-executive lead was Alan Armstrong. Following recent changes on the Board, it is proposed that Pat Drake be appointed to the non-executive position which aligns with her role as Senior Independent Director already agreed by the Council of Governors with effect from 1 August 2018. Attached as an appendix to this report are details of the specific responsibilities of the non-executive lead taken from national guidance and the local policy. It is important to note that none of the rules negate the duty upon employees to raise issues they are concerned about with their line manager in the first instance.


Is Board supportive of the proposal?


The report supports all of the Trust’s strategic objectives by contributing to sound governance arrangements.


This report mitigates the risk of the Trust being non-compliant with national rules and its own policies.


That Pat Drake is appointed non-executive lead for speaking up with immediate effect.

Extract from Guidance for boards on Freedom to Speak Up in NHS trusts and NHS foundation trusts (National Guardian and NHSI, 2016):

Extract from RAISING CONCERNS: ‘We Care, We Listen, We Act” Policy (DBTH, 2016)

Title Use of Trust Seal

Report to: Board of Directors Date: 21 August 2018

Author: Matthew Kane, Trust Board Secretary

For: For approval

Purpose of Paper: Executive Summary containing key messages and issues

The purpose of this report is to advise of use of the Trust Seal in accordance with section 14: Custody of Seal and Sealing of Documents of the Standing Orders of the Board of Directors:

Seal No.

Description Signed Date of sealing

96 Lease of substation accommodation and easements at Doncaster Royal Infirmary for Northern Powergrid (Yorkshire) Plc

Richard Parker Chief Executive

8 August 2018

Alex Crickmar Deputy Director of Finance

97 Deed of variation of the contract for the provision of sexual health services with Nottinghamshire County Council


8 August 2018


98 Transfer of registered title – former nurses home, Mexborough for CW


8 August 2018


Recommendation(s)

The Board is requested to approve use of the Trust Seal.

Chair’s Log - Finance and Performance Committee 20 August 2018

Overview

One of the purposes of the board committees is to undertake deep dives to assure the Board and that was what Finance and Performance Committee aimed to do at this meeting, spending over an hour on the HSDU item, in addition to the usual suite of items.

Assurance area – HSDU

The Director of Estates and Facilities was accompanied at the meeting by the project officer for the HSDU project and both gave the context behind the proposal. It was soon clear that while there would be sizeable savings of through avoidance of future associated costs with maintaining an in-house facility, the guiding principle behind this proposal to outsource was quality. Key benefits from the case were increased visibility and resilience, ability to clean steam, risk transfer, release of space which would be useful for clinical reconfiguration, better management information and new, state of the art equipment. The Committee was assured that lessons from previous outsourcing exercises had been learned and that the proposal provided a fair deal for existing staff. The item was notable for good engagement and questioning from executives though it was clear that more engagement was needed with consultant colleagues. We were satisfied, having taken account of staffing issues and having received good levels of assurance from KPMG, that recommending the outsource to Steris was the right course to take.

Assurance area – Procurement

We received a brief report from the Acting Head of Procurement who led a team which had achieved some sizeable savings for the Trust over the last two years. Those savings were becoming harder to find but it was clear that they continued looking, with partners, to achieve efficiencies, standardisation and economies of scale with the ultimate aim of improving patient care. Of the £1.4m CIP for this year, approximately £400k remained outstanding. The team were working hard to find it through looking at system change, stocks and current contracts.

Assurance area – Performance

Performance presented a mixed picture with 2ww at 80.9%, largely attributable to a significant increase in referrals between end of May and June, but there was significantly improved performance in stroke. ED continues to see significant increases in attendances. In June, the Trust saw the highest number of attendances for the past five years. In line with recent thinking shared at the Board the biggest increase was seen amongst 29-35 year olds. As part of this year’s System Perfect the Trust would be engaging with local businesses to find out why people attend ED. The Committee discussed the need for action plans to address areas of underperformance, looking at where we need to get to, and decided to look at a new style performance report as well as proposing some future deep dives.

Assurance area – Workforce Management

The Committee noted that vacancy rates for admin and clerical had decreased but continued to be high in a number of the clinical areas. Work was being done at executive level on targets for agency expenditure and there was a brief discussion around ensuring that workforce and finance data in reports married up.

Assurance area –Finance

The Committee received a detailed version of the Board report. As per the plan, the Trust now needs to deliver on its back-loaded CIP plans in order to meet its 2018/19 target of £6.6m. Areas of overspend were being assessed. There was a discussion about the shortfall left by the recent pay deal and the impact of theatre cancellations on savings. Encouragingly the Trust had now appointed a senior clinical lead to provide leadership on Getting It Right First Time. The reprioritised capital programme was recommended to Board for sign off and an update was also received on strategic projects.

Assurance area – Strategy

Our strategy deep dive this month was on the clinical site strategy where the Committee was advised on a number of positive areas of progress around the extended ED, changes in operating procedures and in the introduction of Hospital@.

Assurance area – Governance

The risk register was noted along with the committee review arrangements.

Neil Rhodes Chair – Finance and Performance Committee

1

DBTH Board 21.8.18

DBTH Quality & Effectiveness Committee (QEC) 20.8.18 - Chair’s report

OVERVIEW

Welcome: to Suzy Brain-England (Chair of the Trust), Pippa Jackson (KMPG/IA), Neil

Rhodes (NED), and Anthony Jones, all observing QEC.

Appreciation: Lisette Caygill who is returning to her substantive post.

Escalation: No new items for escalation to QEC; or from QEC to the Board.

Enabling strategies: QEC reviewed the draft R&D strategy, on which all members had

already commented, and endorsed the strategy for final approval by the Board subject to

some final tweaks such as governance, outcome measures and University links.

Innovations: more use of information items for assurance; approach to Quality

Assurance Report including Mini-deep dive and Patient Story

ASSURANCES

QEC probed its standing Assurance reports on:

Workforce and Education Assurance Report

Quality Assurance Report (Quality Dashboard; Nursing Workforce Quality

Metrics Assurance Report (Hard Truths), which included a review of acuity

dependency across inpatient wards and the Emergency Departments utilising the

safer nursing care tool and BEST tool respectively ; and Clinical Governance

Report)

QEC probed reports for assurance on:

CQC Action Plan – process for how QEC will have Oversight of progress against

the CQC Action Plan and Provide assurance to the Board

Learning from Deaths – first Quarterly Report (Q4 2017/18) – trends, targets, and

assurance on learning

Inpatient survey Action Plan – and proposed additional Qs eg around complaints

Sepsis trends – mini-deep dive. Opportunity to be more proactive/pre-emptive re

media focus was noted, also to include improvements in our planned

“Infographic.”

Patient Story – learning process – very valuable

Key issues examined at QEC Sub-Committees

Internal Audit – Review of Clinical & Quality Governance - positive

Annual Appraisal & Revalidation Report

Trust process to assess the quality and clinical impact of proposed cost

improvement plans

2

Trust process to review Enabling Strategies and QEC role in QII.

RISK & GOVERNANCE

Scope of IA review of Committees’ Effectiveness - endorsed

Confirmed that the Executive team had risk-assessed all concerns raised in the

June QEC.

Noted that new risks have been include in CRR around CIPs’ potential impact on

quality, and on estates risks to patient care.

Deep dive on an increased risk: ‘Failure to engage and communicate with staff

and representatives in relation to immediate challenges and strategic

development’;

opportunity to engage new DDs in this area was noted.

FUTURE ASSURANCES needed for:

Staff turnover (voluntary versus non-voluntary)

Staff group – AHPs

Capability caseload – deep dive required

SIs and what has been learnt

Maternity/midwifery metrics and Maternity staff culture / morale

Appointment cancellations

Evidence on sustaining and improving quality - impact of the Trust proposed cost

improvement plans

Complaints trends – harvesting of deeper info from new Qs in Inpatient Survey

Governor questions

Peter Abell raised a number of questions, including how staff and the public view the

CQC report, and how we approach Regulatory recommendations from CQC.

Meeting reflections

What was good?

well structured and comprehensive

Good selection of agenda topics

Clarity on what to look for/ what assurances to seek

followed agenda well

Good NED/Chair challenge and discussion

Use of info items for assurance

What can we improve?

Demonstrate for every item how this addresses risks

Cover sheet with the ^ Qs or similar for every item

Review again approach to Quality Assurance report

Linn Phipps

Chair, Quality & Effectiveness Committee 20 8 18

3

Appendix 1

The core scope and structure of Assurance Reports and data reports is:

1. What is the data telling us (where are we now)? How are we triangulating data to give

a richer picture of what is happening (e.g. staff and quality data)?

2. What are our good practices and achievements?

3. What are the causes for concern (what are the problem issues, “the red areas”?)

4. Where there are concerns, are we assured on having action plans to address these/

improve and to monitor these?

5. What assurances are there on progress with mitigatory actions on the causes of

concern, and on next steps?

6. What is the future trajectory, better or worse?

Source: QEC meeting 22.8.17, minutes, Appendix 1.

Title Financial Performance – Month 4 (July 2018)

Report to Trust Board Date 21 August 2018

Author Jon Sargeant - Director of Finance

Purpose To update the Board on the financial position for the month of July 2018.

Tick one as appropriate

Decision

Assurance X

Information


The Trust’s deficit for month 4 (July 2018) was £1.24m, which is an adverse variance against plan in month of £94k. The cumulative position to the end of month 4 is a £7.4m deficit, which is £64k adverse to plan. However the Trust needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to essentially achieve a better than break even position for the rest of the year. There are still significant risks to delivery of the Trust’s financial control total, as set out at budget setting, including:

Delivery of CIP which has been back loaded in the plan and significant savings are still

required to be identified and delivered. Whilst work continues the gap in the plan is

not being closed quickly enough.

There is a significance variance on income growth assumptions of £3.5m between the

Trust’s financial plan and commissioner assumptions and contract values. Levels of

over performance and the further modelling of RTT suggest that with our main

commissioners the budget assumptions are fairly robust. Also the financial plan

assumes £2m of Commissioner QIPP plans are not delivered. It is too early in the year

to determine the impact of this, however the continued under performance against

associate CCG’s is of concern.

Control of agency spend, especially in medical needs further work as does a review of

the amounts being paid to agency staff (the Trust has concentrated on lowering hours

used).

A release of funds from the balance sheet relating to aged accruals of £1.4m has been

was required to ensure delivery of the Q1 control total. There is a risk these accruals

are needed, but this risk would seem small.

The Trust has assumed full achievement of PSF in its position. However part of this is

tied to A&E 4hr access performance, which is a challenge to achieve in Q2.

In addition, Finance and Performance Committee considered minor changes to capital

expenditure affecting estates, medical equipment and IT. As the body that approved the

original plan, Board is asked to confirm their agreement with these changes.


Are the Board assured by actions taken to bring the financial position back in line with

plan?


Identify the most effective care possible

Assist in the control and reduction of the cost of healthcare

Assist in developing responsibly and delivering the right services with the right staff


Update relating to delivery of 2018/19 financial plan.


The Board is asked to note:

The Trust’s deficit for month 4 (July 2018) was £1.2m, which is an adverse variance against plan in month of £94k. The cumulative position to the end of month 4 is a £7.4m deficit, which is £64k adverse to plan.

The progress in closing the gap on the Cost Improvement Programme.

The risks set out in this paper.

The Board is asked to approve the changes to the capital programme.

FINANCIA

Mont

1

AL PERFO

th 4 (July

ORMANCE

2018)

3

The Trust’s deficit for month 4 (July 2018) was £1.24m, which is an adverse variance against plan in month of £94k.

The cumulative position to the end of month 4 is a £7.4m deficit, which is £64k adverse to plan. However the Trust

needs to achieve a £6.6m deficit to deliver the year end control total, and therefore needs to essentially achieve a

better than break even position for the rest of the year.

The YTD income position at the end of Month 4 is £2,297k adverse to plan (excluding donated asset income). In

month 4, NHS Clinical Income (including non‐PbR drugs) was £301k behind plan. Whilst Doncaster and Bassetlaw

CCGs have favourable income variances against contract of (£377k) and (£918k) respectively (£486k adverse and

(£526k) favourable against the Trust’s plan respectively), these are offset by adverse variances with associate CCGs

and also Non‐PbR Hep C drugs. Non NHS Clinical Income and other Income is £100k ahead of plan in month 4 (£197k

adverse YTD). PSF is assumed at 100% in the position.

The expenditure position in Month 4 was £112k lower than budgeted levels, however employee expenses were

higher than plan, driven by agency spend. Non‐PbR drugs were significantly lower than planned levels (£1,387k

which is offset by underperformance on income). Please note that the YTD position reflects the release of non‐

recurrent monies in Month 3 of (£1.4m against reserves) following the review of prior year accruals being held. This

mainly relates to accruals for agency doctors (through Holt).

Capital expenditure YTD is £1,298k against the YTD plan of £2,788k (£1,490k behind plan). The cash balance at the end of July was £14.8m against a plan of £3.2m. This is largely due to the receipt of Q4 STF

funds (£8.4m) in July.

The Trust’s year to date financial position at Month 4 is a £64k adverse variance compared to plan. There are

significant risks to delivery of the forecast and the financial control total, including:

Delivery of CIP which has been back loaded in the plan and significant savings are still required to be

identified and delivered. Whilst work continues the gap in the plan is not being closed quickly enough.

Income GroupAnnual Budget

In Month

BudgetIn Month Actual

In Month

VarianceYTD Budget YTD Actual

Commissioner Income ‐312,460 ‐26,496 ‐26,425 72 A ‐104,593 ‐103,835 758 A

Drugs ‐24,089 ‐1,895 ‐1,666 229 A ‐8,104 ‐6,761 1,342 A

STF ‐16,238 ‐1,083 ‐1,083 0 F ‐3,517 ‐3,517 0 F

Trading Income ‐34,931 ‐2,924 ‐3,024 ‐100 F ‐11,623 ‐11,427 197 A

Grand Total ‐387,717 ‐32,399 ‐32,198 201 A ‐127,837 ‐125,540 2,297 A

YTD Variance

Subjective Code In Month

Budget

In Month

Actual

YTD

Budget

YTD

Actual

Annual

Budget

1. Pay 21,197 21,531 334 A 83,484 85,508 2,024 A 250,220

2. Non‐Pay 10,034 10,493 459 A 40,737 41,890 1,153 A 117,945

3. Reserves 1,197 292 ‐905 F 6,530 1,142 ‐5,388 F 12,834

Total Expenditure Position 32,427 32,316 ‐112 F 130,751 128,539 ‐2,212 F 380,998

In Month

Variance

YTD

Variance

1. Executive Summary

2. Conclusion

4

There is a significance variance on income growth assumptions of £3.5m between the Trust’s financial plan

and commissioner assumptions and contract values. Levels of over performance and the further modelling

of RTT suggest that with our main commissioners the budget assumptions are fairly robust. Also the financial

plan assumes £2m of Commissioner QIPP plans are not delivered. It is too early in the year to determine the

impact of this, however the continued under performance against associate CCG’s is of concern.

Control of agency spend, especially in medical needs further work as does a review of the amounts being

paid to agency staff (the Trust has concentrated on lowering hours used).

A release of funds from the balance sheet relating to aged accruals of £1.4m has been was required to

ensure delivery of the Q1 control total. There is a risk these accruals are needed, but this risk would seem

small.

The Trust has assumed full achievement of PSF in its position. However part of this (30%) is tied to A&E 4hr

access performance, which is a challenge to achieve in Q2.

The Board is asked to note:

The Trust’s deficit for month 4 (July 2018) was £1.2m, which is an adverse variance against plan in month of

£94k. The cumulative position to the end of month 4 is a £7.4m deficit, which is £64k adverse to plan.

The progress in closing the gap on the Cost Improvement Programme.

The risks set out in this paper.

3. Recommendation

Title Performance Report

Report to Board of Directors Date 21st August 2018

Author David Purdue, Chief Operating Officer

Sewa Singh, Medical Director

Moira Hardy, Director of Nursing, Midwifery and AHPs

Karen Barnard, Director of People and Organisational Development


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance: Cancer 62 day classic, measured on average quarterly performance 4hr Access, measured on average quarterly performance 18 weeks measured on monthly performance against active waiters, performance measured

on the worst performing month in the quarter Diagnostics performance against key tests Infection control measures, C Diff and MRSA Bacteraemia The Quality report highlights the ongoing work with Care Groups and external partners to improve patient outcomes and a focus on mortality rates. The Workforce report identifies vacancy levels, agency spend and usage, sickness rates, appraisals and SET training.

The performance report contains a deep dive in to the reasons for the increase in ED attendances.


Is the Trust maintaining performance against agreed trajectories with NHSi? Is the Trust providing a quality service for the patients? Are Governors assured by the actions being taken to maintain a quality service?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


The corporate risks supported by this report are related to NHSi single oversight framework, especially in line with quality, patient experience, performance and workforce.


That the report be noted.

PERFORMANCE REPORT – July 2018

RB/DP 06/08/18

1

Cancer Performance The following information relates to Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust performance in May. The Trust has updated the action plan to improve 62 day and 2 week wait performance. June Performance

Standard Local Performance % Position from Previous Month

TWW 80.9%

31 Day 100.0%

62 Day 86.4%

31 Day Sub ‐ Surgery 93.3%

31 Day Sub ‐ Drugs 100.0%

31 Day Sub ‐ Other 100.0%

62 Day Screening 90.9%

62 Day Con Upgrades 95.0%

Breast Symptomatic 84.7%

62 day Cancer performance The 62 day standard was achieved by the Trust in June at 86.4%, this is an improvement on May’s position. The One Stop Prostrate Clinic is on target to commence in September. A pilot of Straight To Test for colonoscopy is being assessed to improve performance for lower GI cancers. The Cancer management team are currently being restructured to support operational delivery of cancer.


RB/DP 06/08/18

2

The graphs below compare 62 day performance in June at Doncaster and Bassetlaw compared with National performance.

Two Week Wait Performance The June position for two week wait was 80.9% which was not compliant with the national target of 93%. The Capacity and Demand tool continues to be developed, providing a planning tool based on previous referral trends, activity and capacity. Care groups are now using the tool proactively in order to plan two week wait capacity. Weekly PTL meetings with each specialty are ongoing to jointly track patient booking, pathways and to review breaches. The two week wait process has been value stream mapped and an option appraisal is being shared with the cancer leads to agree. In the interim the planning of colorectal pathways is now being piloted back in the service. A straight to MRI pilot for prostate cancer is being planned for BDGH.


RB/DP 06/08/18

3

TWW Performance by specialty

2WW

Non 2WW

Symptomatic

Breast Referrals

31 Day ‐

Classic

31 Sub ‐

Surgery

31 Sub ‐

Drugs

31 Sub ‐

Palliative

62 Day ‐

Classic

62 Day

Screening

62 Day

Consultant

Upgrades

Operational Std 93% 93% 96% 94% 98% 94% 85% 90% TBA

Breast 93.1% 84.7% 100.0% 87.5% 100.0% 90.0% 100.0%

Gynaecological 93.4% 100.0% 100.0% 100.0%

Haematological 100.0% 100.0% 83.3%

Head & Neck 77.4% 16.7%

Lower GI 57.9% 100.0% 100.0% 100.0% 83.3% 100.0%

Lung 100.0% 100.0% 80.0% 90.0%

Other 100.0% 100.0%

Skin 88.0% 100.0% 100.0% 100.0%

Upper GI 75.0% 100.0% 100.0% 100.0% 88.9% 100.0%

Urological 69.7% 100.0% 100.0% 100.0% 80.7% 91.7%

EXCEPTIONS 62 DAY There were delays in Lower GI, Head and Neck, Urology, Lung and Haematology with reasons for the breaches predominantly due to shared care pathways, complex diagnostic pathways or patient choice. TWO WEEK WAIT Head and Neck, lower GI, skin, Upper GI and Urology did not achieve the standard in June. Capacity issues were predominantly the issues in Lower GI, Dermatology and Urology as a result in a continued increase in referrals. A large number of breaches were carried forward from May due to loss of capacity over the bank holiday. The reasons for breaches in relation to two week wait appointments can be seen in the table below:


RB/DP 06/08/18

4

CWT Standard Tumour GroupPerformance against CWT

standardHigh Level View

Two Week Wait H&N 77.4%19 Breaches ‐ 7 Admin Delay, 7 Clinic Cancellations, 1 OP

Capacity, 4 Patient Choice relating to 1st OPA

Lower GI 57.9%

99 Breaches ‐ 1 Admin Delay, 1 Clinic Cancellations, 80 OP

Capacity, 5 Patient Cancellation, 12 Patient Choice relating to

1st OPA

Skin 88.0%26 Breaches ‐ 4 Admin Delay, 2 Clinic Cancellations, 7 OP

Capacity, 13 Patient Choice relating to 1st OPA

Upper GI 75.0%30 Breaches ‐ 13 Admin Delay, 7 OP Capacity, 10 Patient Choice

relating to 1st OPA

Urology 69.7%

53 Breaches ‐ 17 Admin Delay, 7 Clinic Cancellations, 23 OP

Capacity, 5 Patient Choice relating to 1st OPA, 1 Patient

declines

62 Day Classic Haematological 83.3% 1 Breach ‐ Other Reason

H&N 16.7% 5 Breaches ‐ Other Reasons

Lower GI 83.3% 2 Breaches ‐ Other Reasons

Lung 80.0%2 Breaches ‐ 1 Diagnosis delayed for medical reasons, 1 Other

Reasons

Urology 80.7% 8 Breaches ‐ 7 Other Reasons, 1 OP capacity inadequate

4hr Access Target The Trust achieved 92.1% in July 2018 against the 4hr access standard of 95%.

The graphs below compare 4 hour access performance at Doncaster and Bassetlaw with

National performance


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5

The Trust saw 15794 attendances in July, which is 1259 more than in July 2017 and 935 more

than June 2018.

The 3rd National Action on A&E programme has commenced with a focus on one of 4 key work‐streams. We are focussed as a system, on understanding the highest attendance age groups 20‐35s and 45‐60s and then developing alternative pathways to be streamed to. System Perfect will be held from 2‐9 October 2018. Work is continuing with both CCGs to understand the recent increases in attendances. Streaming Doncaster FDASS The number of patients streamed directly from the front door increased in July to 16.1%. The graph below shows the percentage of patients streamed each month. Bassetlaw Streaming commenced at Bassetlaw on 1 October 2017. The % streamed for June was 6.69%. EXCEPTIONS

In July, 1244 patients failed to be treated in 4hrs, with the main breach reason was wait to see

ED doctor/ ED review which accounted for 801 of the 1244 breaches. 147 breaches were due

to bed pressures.


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6

Referral to Treatment (RTT) The Referral to Treatment Target, active waiters below 18 weeks set at 92%. DBTH contract for

2018/19 expects to Trust to maintain the March position of 89.1% and the waiting list size to be

lower than at the end of March 2018. Though performing above the National average, the

Trust position remains at 89.6% in July.

The graphs below and on the next page show Doncaster and Bassetlaw’s performance compared with the National picture:

The total number of Incomplete Pathways has increased by 399 between June and July, however the number of incomplete pathways over 18 weeks increased by 42 hence the performance has remained the same. The total number of Incomplete Pathways with a decision to admit for treatment has gone down by 40 between June and July 2018.


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7

Specialty level RTT performance 92% in July can be found in the table below:

Specialty Group

Under 18

Weeks

18 Weeks &

Over Total PercentageGeneral Surgery 2633 374 3007 87.6%Urology 1520 169 1689 90.0%T&O 5356 666 6022 88.9%ENT 2929 636 3565 82.2%Ophthalmology 3019 239 3258 92.7%Oral Surgery 1564 78 1642 95.2%General Medicine 1749 363 2112 82.8%Cardiology 1834 240 2074 88.4%Dermatology 1752 80 1832 95.6%Thoracic Medicine 907 59 966 93.9%Rheumatology 753 174 927 81.2%Geriatric Medicine 231 20 251 92.0%Gynaecology 1659 86 1745 95.1%Others 3771 265 4036 93.4%Trust Total 29677 3449 33126 89.6%

At the end of July 2018 there were 2 Incomplete Pathways over 52 Weeks. Diagnostics The Trust has achieved the Diagnostic performance standard of 99% in July at 99.69%. In July there were 25 breaches overall out of 7948 patients.

Waiters <6W

Waiters >=6W

Total Performance

Trust 7923 25 7948 99.69%

NHS Doncaster 5234 17 5251 99.68%

NHS Bassetlaw 1914 6 1960 99.69%


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Stroke Performance in May The Trust level percentage for direct admission to the Stroke Unit has improved significantly to78.6% in May which is the highest Trust performance.

Performance in May also saw an improvement in the 1 hour to scan at 66.7% compared to 58.6% for April. The number of patients who were discharged through Early Supported discharge also continues to improve at 80% in May. The overall SSNAP performance for Stroke Dec‐March 2018 outcomes has improved to A. Benchmarking against peer group trusts is presented in the table below.


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9

Trust

Barnsley Hospital NHS

Foundation Trust

Bradford Teaching Hospitals NHS

Foundation Trust

Calderdale and

Huddersfield NHS

Foundation Trust

Doncaster and

Bassetlaw Hospitals NHS

Foundation Trust

Rotherham NHS

Foundation Trust

Sheffield Teaching Hospitals NHS

Foundation Trust

Team Barnsley Hospital

Bradford Royal

Infirmary

Calderdale Royal

Hospital

Doncaster Royal

Infirmary

Rotherham Hospital

Royal Hallamshire Hospital

SSNAP level D E B A C B

SSNAP score 54 38 75 83 63 72.2

Case ascertainment band

A A A A A A

Audit compliance band A A A A A B

Combined indicator level

D E B A C B

EXCEPTIONS In terms of exceptions, there were several pathway issues including delays in transfer from Bassetlaw. There were some late requests for CT scans that prevented patients from being scanned within 1 hour. Direct admissions within 4hrs, target 90%

Category Sub Category TotalDirect Admission within 4 Hours Bassetlaw Doncaster Other Total Organisational BedsYes 7 24 2 33 Pathway 5No 3 5 1 9 Staff Availability

Grand Total 10 29 3 42 ClinicalPatient

Presentation 3

Performance 70.0% 82.8% 66.7% 78.6% Patient Needs 1Patient Choice DeclinedAwaiting further validation

CCG


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Scan within 1hr, target 48%

Category Sub Category TotalScan 1 hr Bassetlaw Doncaster Other Total Organisational Scanner 1Yes 7 20 1 28 Pathway 9No 3 9 2 14 Staff Availability

Grand Total 10 29 3 42 Clinical Criteria 2

Performance 70.0% 69.0% 33.3% 66.7% Patient NeedsPatient

Presentation 2Patient Choice DeclinedAwaiting further validation

CCG

Cancelled Operations In July, 1.46% of Trust operations were cancelled. This demonstrates deterioration in performance compared with the previous month with 67 patients cancelled out of a total of 5130. 63 patients were cancelled for theatre reasons and 12 for non theatre reasons.

Indicator Standard

May‐18

Jun‐18 Jul‐18

Cancelled Operations (Total) 0.80% 1.21% 1.19% 1.46%

Cancelled Operations (Theatre)

1.06% 1.08% 1.23%

Cancelled Operations (Non Theatre) 0.16% 0.10% 0.23%

Cancelled Operations‐28 Day Standard 0 2 1 0

The reasons for the non‐clinical cancellations are displayed in the graph below:


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DNA and CNA Rates In July, the overall DNA rate across the Trust increased to 9.78% compared with the previous month’s position at 9.41%. The table below shows the New Patient DNA rates and numbers of patients not attending by outpatient clinic. For this report, only areas performing worse than 9% have been selected although a complete list is available. Some areas have seen improvement in DNA rate over the past 6 months (green arrow) and others have seen a deteriorating trend (red arrow).

Indicator May 18

June

July

Outpatients: DNA Rate Total 9.21% 9.41% 9.78%

Outpatients: Hospital cancellation Rate 5.86% 5.19% 5.66%


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12

Out Patient Clinic Percentage first DNA rate

Number of patients not attending

Trend

PAED ENDOCRINOLOGY 25.0% 1 ↑

COMMUNITY PAED PATHWAY 21.1% 4 ↑

RESPIRATORY PHYSIOLOGY 20.8% 5 ↓

GENERAL GERIATRIC MED 20.6% 14 ↑

ORTHOPTICS 20.0% 2 ↓

AUDIOLOGY 19.2% 23 ↑

PAIN MANAGEMENT 17.6% 46 ↓

GENERAL MEDICINE 16.7% 89 ↑

VASCULAR NURSE 16.7% 1 ↑

ORAL SURGERY OMFS 16.1% 76 ↑

PAEDIATRICS 16.0% 63 ↑

ORTHODONTICS 16.0% 4 ↓

DIABETIC ENDOCRINE MEDICINE 16.0% 31 ↑

MEDICAL OPHTHALMOLOGY 15.1% 22 ↑

PREOP ASSESSMENTS 14.6% 6 ↑

JOINT UROLOGY 14.3% 2 ↑

MIDWIFE EPISODE 14.3% 1 ↑

BARIATRIC SURGERY 13.6% 3

NEPHROLOGY 13.6% 8 ↓

RESPIRATORY 12.1% 49 ↑

VASCULAR SURGERY 11.6% 28 ↑

OPHTHALMOLOGY 11.2% 146 ‐

PALLIATIVE MEDICINE 11.1% 1 ↓

ENT 11.0% 123 ↓

TRAUMA AND ORTHO SURGERY 10.8% 141 ↑

GENERAL SURGERY 10.3% 109 ↑

JOINT CARDIOLOGY 10.2% 5 ‐

RHEUMATOLOGY 9.6% 19 ↑

COLPOSCOPY 9.6% 10 ↓

Delayed Transfers of Care


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13

Significant work has been underway in Doncaster and Bassetlaw to improve patient discharge processes, and to reduce the number of medically fit patients waiting in hospital. This work will also impact on the number of formally reported Delayed Transfers of Care (DTOCs).

The chart below shows the number of reported delayed bed days by site.

Performance against the Better Care Fund trajectory for 2017/18 into 2018/19 is shown by the chart below. Confirmation of the trajectory from April 2018 onwards is awaited. Data up to May 2018 has been published and included within the report. The data includes all Doncaster patients at all providers. Total delay days for Doncaster improved again during May by 76 days to 236 days, the lowest all year. The rate per 100,000 population has now fallen below 100. Social Care attributable days decreased to 32, NHS attributable days decreased to 176 with joint delays decreasing to 28.

The top 10 reasons for formally reported delays across Doncaster are:


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Out of area social care

Care package

Continuing Healthcare (CHC)

Awaiting PSU bed

Social Care DMBC

Family Delay

Discharge to assess bed

Awaiting adaptations

Independent Mental Capacity Advocates (IMCA)

Fast track care

Emergency Department – Attendance Profiles Day of attendance On both sites, the most frequent day of arrival for attendances to ED by patients is Monday, followed by Sunday and Saturday. Further analysis has shown that it is the younger age groups who tend to attend over the weekends and on Mondays. Reasons for Attendance Reasons for Attendance


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The following information is for Sept 2017 – Feb 2018 and shows the main reasons for patients attending ED. The most frequent presenting complaint for all age groups and on both sites is Unwell Adult, followed by Abdominal Pain and Chest Pain.

Bassetlaw Presenting Complaint Number of Attendances

% of Attendances

Unwell Adult 2,483 11.0%

Abdominal Pain 1,397 6.2%

Chest Pain 1,362 6.0%

Breathing Problem 1,288 5.7%

Unwell Child 968 4.3%

Falls 861 3.8%

Head injury 808 3.6%

Hand injury 763 3.4%

Ankle Injury 639 2.8%

Finger Injury 609 2.7%

Doncaster Presenting Complaint Number of Attendances

% of Attendances

Unwell Adult 5,453 11.0%

Abdominal Pain 3,319 6.7%

Chest Pain 3,317 6.7%

Breathing Problem 3,187 6.4%

Unwell Child 2,174 4.4%

Head injury 1,889 3.8%

Falls 1,574 3.2%

Other 1,316 2.6%

Back Pain 1,271 2.6%

Atraumatic Limb Pain/Problem 1,217 2.4%

Arrival Mode


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16

The charts below show how patients presented at ED with the greatest numbers making their own way to the department.

Bassetlaw Arrival Mode

Number of Attendances

% of Attendances

Own Transport 15,241 67.7%

999 Ambulance 5,337 23.7%

Other Arrival Mode

1,326 5.9%

Walked 213 0.9%

Self Handover/999 Ambulance

188 0.8%

Public Transport 86 0.4%

Police 72 0.3%

Prison Service 44 0.2%

Non Urgent Ambulance

12 0.1%

Outcome of Attendance At Bassetlaw, 60.9% of patients are discharged home following their attendance. At Doncaster this figure is 47.6%.

Bassetlaw Attendance Outcome Number of Attendances

% of Attendances

Discharged 13,710 60.9%

Referred to Clinic/Elsewhere 3,054 13.6%

Admitted 2,974 13.2%

Left 791 3.5%

ANP Discharge 724 3.2%

Inpatient Transfer 693 3.1%

FDASS 413 1.8%

Transferred to other Health Care Provider 117 0.5%

Died in department 32 0.1%

Other 11 0.0%

Doncaster Attendance Outcome Number of Attendances

% of Attendances

Doncaster Arrival Mode

Number of Attendances

% of Attendances

Own Transport 28,460 57.2%

999 Ambulance 15,383 30.9%

Other Arrival Mode

1,773 3.6%

Self Handover/999 Ambulance

1,643 3.3%

Public Transport 1,161 2.3%

Walked 799 1.6%

Police 253 0.5%

Prison Service 208 0.4%

Non Urgent Ambulance

37 0.1%


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17

Discharged 23,656 47.6%

Admitted 9,644 19.4%

FDASS 7,774 15.6%

Referred to Clinic/Elsewhere 5,393 10.8%

Left 1,900 3.8%

Inpatient Transfer 946 1.9%

Transferred to other Health Care Provider 235 0.5%

Died in department 98 0.2%

ANP Discharge 35 0.1%

Other 33 0.1%

Dead on Arrival 3 0.0%

Streaming On the Doncaster site, 16% of patients were able to be streamed to the Urgent Treatment centre from the front door. The table below shows a list of presenting conditions which were successfully streamed away from ED.

Presenting Problem Yes No Grand Total

Rashes 1119 317 1436

Sore throat 507 261 768

Ear problems 610 424 1034

Crying Baby 12 11 23

Unwell child 2827 2632 5459

Abdominal Pain in Children 390 378 768

Irritable child 3 3 6

Sexually acquired infection 4 4 8

Worried parent 55 63 118

Abscesses and Local Infections 520 632 1152

Shortness of breath in Children 404 725 1129

Allergy 254 471 725

Bites & Stings 379 802 1181

Asthma 105 236 341

Diarrhoea & Vomiting 223 584 807

Back Pain 1009 2799 3808

Urinary problems 495 1564 2059

Abdominal Pain in Adults 1597 6323 7920

Headache 394 1616 2010

Dental Problems 38 158 196


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18

Between 60‐70% of patients attending ED are classified as ‘minor’ and of these patients it has been found that up to 40% of patients are streamed to the Urgent Treatment Centre. This demonstrates that a significant number of patients attend ED with complaints which could have been assessed and managed in a Primary Care setting. Appropriate numbers of patients are being redirected to the Urgent Treatment Cente, and through other established pathways following initial presentation at the front door.

Performance Executive Summary Board of Directors June 2018

The performance report is against operational delivery in May, June and July 2018.

Provide the safest, most effective care possible

Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to

Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored

quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is

monitored each month of the quarter and must be achieved each month.

The report also highlights key local targets which ensure care is being provided effectively and safely

by the Trust.

Referral to Treatment

The Referral to Treatment Target, active waiters below 18 weeks set at 92%, following contracting

with the CCGs, the Trust is required to achieve 89.1% by the end of March but is required to

maintain the waiting list size to 1 less than at the end of March 2018.

July

Though performing above the National average, the Trust position remains above the target set at

contracting at 89.6%, which is same as June.

The total number of Incomplete Pathways has increased by 399 between June and July, however the

number of incomplete pathways over 18 weeks increased by 42 hence the performance has

remained the same. The total number of Incomplete Pathways with a decision to admit for

treatment has gone down by 40 between June and July 2018.

The specialty groups with the largest increase in the number of waiters over 18 weeks are:

ENT – increase of 68 over 18 weeks

Others – increase of 16 over 18 weeks

Thoracic Medicine – increase of 13 over 18 weeks

Urology – increase of 9 over 18 weeks

Gynaecology – increase of 9 over 18 weeks

At the end of July 2018 there were 2 Incomplete Pathway over 52 Weeks General Surgery and T&O.

Improvements in theatre utilisation have been maintained, though orthopaedics continue to cancel

electives due to the number of Trauma patients.

Diagnostics

The diagnostic target was achieved at 99.69%.

From 7948 waiters there were 25 patients who were not seen within 6 weeks.

4hr Access

The target is based on the number of patients who are treated within 4hrs of arrival into the

emergency department and set at 95% and reported quarterly as an average figure. This target is for

all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at

BDGH and DRI and 1 type 3 facility at MMH.

July Performance

Trust 92.1%,

PSF funding for quarter 2 dependent on performance of 93.4%

The Trust saw 15794 attendances in July, which is highest recorded following the new model in

October 2015, which is 1259 more than in July 2017. This is a 7.9% increase in attendances.

In July, 1244 patients failed to be treated in 4hrs, with the main breach reason was wait to see ED

doctor/ ED review which accounted for 803 of the breaches. 160 breaches were due to bed

pressures.

Information has been reviewed to further understand the increases in attendances which is from the

20‐29 year age range followed by paediatrics. Events are organised to try to understand behaviours

in the System Perfect week planned for 2nd‐9th of October..

15.9% of patients at DRI were streamed to UCC from FDASS.

The Trust jointly with Notts Healthcare Trust have presented a model for the front door at

Bassetlaw.

NHSI Additional Reporting Requirements

18.1% of all of DRI discharges take place at a weekend and 15.2% at BDGH

If the rest of the week was at the same level as Mondays then we would see an extra 175 patients a

week at DRI and an extra 108 patients at BDGH

A&E attendances on a Monday at DRI account for 15.6% of weekly activity rising to 15.9% at BDGH

Non Elective Admissions on a weekday that GP admissions account for is 20.7% of all Emergency

Admissions on a weekday at DRI but only 8.2% at BDGH.

When we move into the weekend this drops to 11.2% at DRI and 2.5% at BDGH

Cancer Performance

June Performance and Q1

62 day performance June 86.4%, Q1 86%

The 62 day standard was achieved by the Trust in June at 86.4%. The quarter 1 performance was therefore achieved. The One Stop Prostrate Clinic for urology is on target to commence in September. There were delays in Head and Neck, lung and Haematology with reasons for breaches predominantly due to shared care pathways, complex diagnostic pathways or patient choice. The Jnue position for two week wait was 80.9% which was the worst performance in the Trust. There has been a significant increase in referrals for lower GI, skin and prostate which resulted in capacity issues in these areas, coupled with patient availability. The two week wait process has been value stream mapped and an option appraisal is being shared with the cancer leads to agree. Due to the breaches due to administration delays in the interim the planning of colorectal pathways is being piloted back in the service. A straight to MRI pilot for prostate cancer is being planned for BDGH and straight to colonoscopy for lower GI.

David Purdue Chief Operating Officer July 2018

Indicator Standard Current Month Month ActualNHS England

%DBTHFT Month Peer Groups % DBTHFT Month Current Month

Month

Actual

(TRUST)

Month

Actual (DRI)

Month Actual

(BDGH)

Data Quality RAG

Rating

31 day wait for second or subsequent treatment: surgery 94.00% 93.30% 94.20% 93.30% 93.30% 93.30% % of patients achieving Best Practice Tariff Criteria Jul‐18 68.8% 71.4% 50.0%

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

treatments98.00% 100.00% 99.40% 100.00% 100.00% 100.00%

31 day wait for second or subsequent treatment: radiotherapy 94.00% 100.00% 96.90% 100.00% Not Available 100.00% 36 hours to surgery Performance 68.8% 71.4% 50.0%

62 day wait for first treatment from urgent GP referral to treatment 85.00% 86.40% 79.20% 86.40% 75.50% 86.40% 72 hours to geriatrician assessment Performance 100.0% 100.0% 100.0%

62 day wait for first treatment from consultant screening service

referral90.00% 90.90% 89.30% 90.90% 85.10% 90.90% % of patients who underwent a falls assessment 100.0% 100.0% 100.0%

31 day wait for diagnosis to first treatment‐ all cancers 96.00% 100.00% 97.30% 100.00% 97.20% 100.00% % of patients receiving a bone protection medication assessment 100.0% 100.0% 100.0%

Two week wait from referral to date first seen: all urgent cancer

referrals (cancer suspected)93.00% 80.90% 91.10% 80.90% 88.40% 80.90%

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

patients (cancer not initially suspected)93.00% 84.70% 83.50% 84.70% 92.00% 84.70%

Infection Control C.Diff4 Per Month ‐

45 full yearM

Infection Control MRSA 0 L

HSMR (rolling 12 Months) 100 N Mar‐18

Never Events 0 L Jul‐18

VTE 95.0% N Jun‐18

Avoidable Pressure Ulcers Cat 3&4 21 Full Year L May‐18

Ambulance Handovers Breaches ‐Number waited over 15 & Under 30

Minutes745 Falls that result in a serious Fracture

2 Per Month 23

full YearL

Ambulance Handovers Breaches‐Number waited over 30 & under 60

Minutes50

Ambulance Handovers Breaches ‐Number waited over 60 Minutes 7

Proportion of patients scanned within 1 hour of clock start (Trust) 48.00% 66.70%

Proportion of patients directly admitted to a stroke unit within 4 hours

of clock start (Trust)90.00% 78.60%

Percentage of eligible patients (according to the RCP guideline

minimum threshold) given thrombolysis (Trust)20.00% 9.50%

Percentage of patients treated by a stroke skilled Early Supported

Discharge team (Trust)40.00% 83.90%

Percentage of those patients who are discharged alive who are given a

named person to contact after discharge (Trust)95.00% 87.10%

Implementation of Stroke Strategy ‐ TIA Patients Assessed and Treated

within 24 Hours60.00% July 53.70%

Cancelled Operations 0.80% 1.46%

Cancelled Operations‐28 Day Standard 0 0

Out Patients: DNA Rate 9.78% 8.03% 10.33% March 7.42% 10.33% March

f

6.63% 5.96% Feb 7.28% 5.96% Feb

78.35%

SET Training 81.43%

Liabilities to Third Parties Scheme (LTPS) 1

Claims per 1000 occupied bed days 0.27

Indicator Current Month YTD (Cumulative)

Clinical Negligence Scheme for Trusts (CNST)

No Benchmarking available

No Benchmarking available ‐ data not submitted to Secondary Uses Service by all

Trusts

405

84.0%

7

Complaints Performance

554

Complaints & Claim

sWorkforce

Jul‐18

Concerns Received (12 Month Rolling)

SSNAP performance for December to March improved to A rating.

Data Quality RAG

Rating

AppraisalsJul‐18

Indicator Current Month

Effective

Emergency Readmissions within 30 days (PbR Methodology) June 5.60%

Stroke

May

Theatres & Outpatients

July

Out Patients: Hospital Cancellation Rate 5.66%

Ambulance Han

dover Times

June

0

Catheter UTI Snap shot audit

Month Actual

Jul‐18

0.42%

99.35% June

95.6%

1

90.10% June

0

88.7

0

IndicatorStandard (Local,

National Or Monitor)

94.70%

Mortality‐Deaths within 30 days of procedure 3.10% 0.00%

Data Quality RAG

Rating

Complaints received (12 Month Rolling)

Current Month Month Actual

Jul‐181

92.10% July 86.90% 92.10% July

Safe

90.10% June 83.69%

99.35%

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

transfer / discharge (Trust)92.10% 89.30%

% of Patients waiting less than 6 weeks from referral for a diagnostics

test99.00% July 99.67% 97.10%

Maximum time of 18 weeks from point of referral to treatment‐

incomplete pathway92.00% July 89.60% 87.80%

95.00% July

UCL: 796 & LCL: 659

UCL: 122 & LCL: 56

UCL: 29 & LCL: 2

June

Data Quality RAG

Rating

At a Glance July 2018 (Month 4)Doncaster & Bassetlaw Teaching Hospital NHS Foundation Trust

NHS England

BenchmarkingPeer Group Benchmarking

Monitor Complian

ce Framework

Direction of

travel

compared to

previous

Month

Fractured Neck of Femur

Indicator

June

25.00%

June June

Best Practice Criteria

Jun‐18

Monitor Compliance Framework: Cancer ‐ Graphs ‐ June 2018 (Month 3)

Monitor Compliance Framework: A&E ‐ Graphs ‐ July 2018 (Month 4)

Monitor Compliance Framework: 18 Weeks & Diagnostics ‐July (Month 4)

Stroke ‐ Graphs May 2018 (Month 2)

Mr S Singh

Mrs M Hardy

Hospital Acquired Pressure Ulcers: The data for HAPU's has been reviewed and revised this month so that only validated HAPUs are reported to Board. This will result in a lag in

data being available to Board and processes are being reviewed in minimise this. The revalidated position shows a higher number of HAPUs for

both April and May.

Executive Summary ‐ Safety & Quality ‐ July 2018 (Month 4)

HSMR: HSMR data for April and May is not available as yet. Data presented is that presented at last Board meeting

Fractured Neck of Femur: Focused attention on getting patients into theatre as early as possible has seen a significnt improvement in BPT achievement. The national

benchmark sits at 60%.

Serious Incidents: 6 SIs reported in month. Two of these were HAPUs. Four arising out of care issues are being reviewed. There were no serious falls in month

Executive Lead:

C‐Diff The rate is below that of the same period last year and the national trajectory

Fall resulting in significan harm: The rate is the same for the month of July 2018, but higher than YTD

Complaints and Concerns The number of complaints and concerns remain within normal variation. Complaints resolution has improved in July to 84%.

Friends & Family Test: Response rates for both inpatients and ED patients has fallen in June whilst positivity of responses continues to be higher than the national

average for both inpatients and ED

Executive Lead:

2015 2016 2017 2018

January 116.80 99.21 94.86 92.70

February 99.94 97.73 105.44 84.77

March 90.54 97.37 82.66 84.52

April 105.91 88.50 83.85

May 101.15 96.60 82.47

June 80.27 93.67 90.60

July 92.56 97.73 94.70

August 100.27 87.52 74.31

September 90.26 95.34 87.55

October 90.29 88.66 98.35

November 88.98 82.30 87.54

December 82.30 93.52 98.79

Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 Apr‐18 May‐18 Jun‐18 Jul‐18

Trust 1.01% 1.22% 1.45% 1.46% 1.99% 2.11% 1.52% 1.48% 1.46% 1.23% 1.06% 1.37%

Donc 1.01% 1.28% 1.41% 1.42% 2.13% 2.29% 1.63% 1.46% 1.51% 1.33% 1.08% 1.40%

Bass 1.27% 1.31% 1.95% 1.90% 1.94% 1.86% 1.45% 1.87% 1.60% 1.19% 1.23% 1.53%

HSMR Trend (monthly) Crude Mortality (monthly) ‐ July 2018 (Month 4)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) ‐ March 2018 (Month 12)

Overall HSMR (Rolling 12 months) HSMR ‐ Non‐elective Admission (Rolling 12 months) HSMR ‐ Elective Admission (Rolling 12 months)

88.7

86

88

90

92

94

96

98

May 16 ‐ Apr 17

Jun 16 ‐ May 17

Jul 16 ‐ Jun 17

Aug 16 ‐ July 17

Sep 16 ‐ Aug 17

Oct 16 ‐ Sep 17

Nov‐16 ‐ Oct‐17

Dec 16 ‐ Nov 17

Jan 17 ‐ Dec 17

Feb 17 ‐ Jan

18

Mar 17 ‐ Feb 18

Apr 17 ‐ M

ar 18

89.06

86

88

90

92

94

96

98

May 16 ‐ Apr 17

Jun 16 ‐ May 17

Jul 16 ‐ Jun 17

Aug 16 ‐ July 17

Sep 16 ‐ Aug 17

Oct 16 ‐ Sep 17

Nov‐16 Oct‐17

Dec 16 ‐ Nov 17

Jan 17 ‐ Dec 17

Feb 17 ‐ Jan

18

Mar 17 ‐ Feb 18

Apr 17 ‐ M

ar 18

56.77

40

50

60

70

80

90

100

May 16 ‐ Apr 17

Jun 16 ‐ May 17

Jul 16 ‐ Jun 17

Aug 16 ‐ July 17

Sep 16 ‐ Aug 17

Oct 16 ‐ Sep 17

Nov‐16 Oct‐17

Dec 16 ‐ Nov 17

Jan 17 ‐ Dec 17

Feb 17 ‐ Jan

18

Mar 17 ‐ Feb 18

Apr 17 ‐ M

ar 18

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Crude Mortality(Trust)

0.5%

1.5%

2.5%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Crude Mortality(BDGH)

1.0%

1.5%

2.0%

2.5%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Crude Mortality(DRI)

NHFD Best Practice Pathway Performance ‐ July 2018 (Month 4)

Best Practice Criteria Performance 36 Hours to Surgery Performance 72 hours to Geriatrician Assessment Performance

Bone Protection Medication Assessment Falls Assessment Performance

Relative Risk Mortality (HSMR) ‐ Fractured Neck of Femur

Rolling 12 month

0%

10%

20%

30%

40%

50%

60%

70%

80%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

% achieving best practice tariff criteria (Trust) % achieving best practice tariff criteria (DRI)

% achieving best practice tariff criteria (BDGH)

40%

60%

80%

100%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Trust DRI BDGH

40%

60%

80%

100%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Trust DRI BDGH

60%

70%

80%

90%

100%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Trust DRI BDGH

60%

70%

80%

90%

100%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Trust DRI BDGH

81.54

81.45

81.83

40

50

60

70

80

90

100

110

120

130

140

Apr‐17

May‐17

Jun‐17

Jul‐17

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Trust DRI BDGH

Current YTD reported SI's (April‐July 18) 16 21

Current YTD delogged SI's (April‐July 18) 0 13

Serious Incidents ‐ July 2018 (Month 4)(Data accurate as at 10/08/2018)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr‐July 17)

Number delogged SI's (Apr‐July 17)

Themes

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Pressure Ulcers ‐ Category 3 & 4 (HAPU)

Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Care Issues

Care Issues per 1000 occupied bed days

0

0.01

0.02

0.03

0.04

0.05

0.06

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Serious Falls

Serious Falls per 1000 occupied bed days

0

0.1

0.2

0.3

0.4

0.5

0.6

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days ‐ Previous years performance

0

2

4

6

8

10

12

14

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Number Serious Incidents Reported(Trust & Care Group)

Emergency Care Group MSK & Frailty Care Group

Surgical Care Group Children & Family Services

Diagnostic & Pharmacy Speciality Services

Chief Operating Officer Number Reported SI's

Number Reported SI's ‐ Previous years performance

Standard Q1 Jul YTD

2018‐19 Infection Control ‐ C‐diff 39 Full Year 6 1 72017‐18 Infection Control ‐ C‐diff 40 Full Year 7 4 11

2018‐19 Trust Attributable 12 0 0 02017‐18 Trust Attributable 12 1 1 2

Standard Q1 Jul YTD

2018‐19 Serious Falls 10 Full Year 1 0 1

2017‐18 Serious Falls 6 Full Year 0 0 0

Standard Apr May YTD

2018‐19 Pressure Ulcers 21 Full Year 3 2 5

2017‐18 Pressure Ulcers 27 Full Year 2 2 4

Monitor Compliance Framework: Infection Control C.Diff ‐ July 2018 (Month 4)

(Data accurate as at 09/08/2018)

Pressure Ulcers & Falls that result in a serious fracture ‐ July 2018 (Month 4)

(Data accurate as at 09/08/2018)

Please note: At the time of producing this report the number of serious falls reported

are prior to the RCA process being completed.

0

10

20

30

40

50

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

C‐diff 2018‐19

2018‐19 C‐diff Cumulative total 2017‐18 C‐diff Cumulative total Standard

02468

1012

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Falls that result in a serious fracture

2018‐19 Falls Cumulative Total 2017‐18 Falls Cumulative Total Standard

0

10

20

30

40

50

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

2018‐19 Pressure Ulcer Cumulative Total 2017‐18 Pressure Ulcer Cumulative Total Standard

0

5

10

15

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Trust Attributable C‐diff 2018‐19

2018‐19 Trust Attributable Cumulative Total 2017‐18 Trust Attributable Cumulative Total Standard

‐2

0

2

4

6

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

Mean UCL LCL

Safe Effective Caring Responsive Well Led

Care Group Matron Ward

No of

Funded

Beds

CHPPD Variance Total score Total score Total score Total scoreQM total

scoreWork‐force Quality

NS B6 16 7.3 100% 2.0 0.0 0.5 1.5 4.0

NS 20 27 5.9 120% 1.0 0.0 0.5 1.5 3.0

NS 21 27 4.7 95% 1.0 0.0 1.0 2.0

LM S12 20 5.7 103% 0.5 0.0 1.0 1.5 3.0

RF SAW 21 8.3 97% 0.0 2.0 3.0 1.5 6.5

LC ITU DRI 20 26.9 91% 1.0 0.0 0.0 1.0 2.0

LC ITU BDGH 6 29.7 86% 0.5 0.0 3.0 0.5 4.0

97%

SS A4 24 6.0 98% 0.0 0.0 1.0 2.0 3.0

SS B5 30.7 7.5 100% 0.5 0.5 0.0 1.5 2.5

AH St Leger 35 6.9 101% 1.5 2.5 1.0 1.0 6.0

AH 1&3 23 8.3 99% 1.0 0.0 0.5 2.0 3.5

SS Mallard 16 8.8 107% 2.0 0.0 1.0 1.5 4.5

SS Gresley 32 5.8 100% 2.0 0.5 1.0 2.0 5.5

SS Stirling 16 7.8 104% 1.0 1.0 1.0 2.0 5.0

KM Rehab 2 19 5.5 100% 3.0 0.0 0.0 2.0 5.0

KM Rehab 1 29 4.9 102% 0.5 0.0 0.0 1.5 2.0

101%

JP 18 12 7.3 101% 2.0 0.0 2.0 1.0 5.0

JP 18 CCU 12 7.5 99% 2.0 0.0 0.0 2.0 4.0

AW 32 18 6.3 96% 1.5 0.0 2.0 1.5 5.0

AW 16 24 7.6 95% 1.5 0.0 0.0 1.0 2.5

RM 17 24 6.7 101% 0.0 0.0 0.5 3.0 3.5

JP CCU/C2 18 7.0 114% 2.0 0.0 0.0 2.0 4.0

RM S10 20 5.1 97% 1.0 0.0 1.0 1.0 3.0

RM S11 19 5.7 103% 0.0 0.0 1.5 1.5

100%

MH ATC 21 7.3 93% 2.0 2.0 3.0 2.0 9.0

SS AMU 40 8.8 105% 0.0 0.0 1.0 2.0 3.0

MH C1 16 6.7 118% 0.5 0.0 1.0 2.0 3.5

SC 24 24 6.0 107% 0.0 0.0 3.0 1.5 4.5

SC 25 16 7.8 118% 1.0 0.0 0.5 1.0 2.5

SC Respiratory unit 56 6.6 108% 1.5 1.5 3.0 1.0 7.0

107%

AB SCBU 8 18.9 98% 0.0 0.0 0.5 0.0 0.5

AB NNU 18 12.5 96% 0.0 0.0 0.0 0.0 0.0

AB CHW 18 11.8 98% 0.0 0.0 0.0 0.5 0.5

AB COU/CSU 21 9.4 98% 0.5 0.0 1.0 1.0 2.5

SS G5 24 7.6 89% 1.0 0.0 1.0 0.5 2.5

SS M1 26 15.8 88% 0.0 1.0 1.0 1.0 3.0

SS M2 18 7.2 84% 1.0 2.0 2.0 1.0 6.0

SS CDS 14 23.2 87% 1.0 0.0 1.0 1.0 3.0

SS A2 18 13.7 87% 1.0 2.0 1.0 0.5 4.5

SS A2L 6 23.3 89% 1.0 0.0 1.5 1.0 3.5

91%

Children and Families

Hard Truths ‐ July 2018 (Month 4)(Data accurate as at 15/08/2018)

Planned v Actual ProfileThe workforce data submitted to UNIFY provides the actual

hours worked in July 2018 by registered nurses or midwives,

and health care support workers compared to the planned

hours. The Trusts overall planned versus actual hours

worked was 99% in July 2018; similar to recent months.

The data for July 2018, demonstrates that the actual

available hours compared to planned hours were;

• Within 5% 22 wards (55%) 3 less than June

• Between 5‐10% 7 wards (17.5%) the same as June

• Surpluses over 10% 4 wards (10%) 1 less than June

• Deficits over 10% 7 wards (17.5%) 4 more than June

The wards where there were deficits in excess of 10% of the

planned hours in July 2018, are ITU at BDGH, Ward G5 and

all of Maternity Unit locations. When there have been lower

levels of bed occupancy these areas have supported safe

staffing in other departments. ITU at BDGH had a reduced

occupancy so staff were redeployed. Ward G5 and the

maternity locations have an increased sickness absence rate

and vacancies, some of which will be improved over

September and October with newly qualified recruitment.

The wards with surpluses in excess of 10% in July were

Wards 20, CCU/C2, C1 and 25. These are due to enhanced

care needs.

Quality and Safety Profile

There are no wards flagging as Red on Quality in the May

Quality Metrics data.

.

Surgical

MSK and Frailty

Specialty Service

Emergency

Registered

midwives/

nurses

Care Staff Overall

4.85 3.56 8.41

4.47 3.44 7.90

2.47 2.66 5.13

4.41 3.41 7.82TRUST

The CHPPD care hours data for July 2018 shows a slight improvement from June 2018 across the registered and non‐registered

workforce and across all sites

Care Hours Per Patient Day (CHPPD) ‐ July 2018 (Month 4)(Data accurate as at 14/08/2018)

Utilising actual versus planned staffing data submitted to UNIFY and applying the CHPPD calculation the care hours for July 2018 are

shown below

Site Name

BASSETLAW HOSPITAL

DONCASTER ROYAL INFIRMARY

MONTAGU HOSPITAL

Month

`

2016/17 0

2

1

0

0

2

2

0

0

0

0

3

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

2018/19 10 7 8 6 31

2017/18 11 8 8 18 11 15 8 9 7 6 6 9 116

2018/19 1 6 2 1 10

2017/18 2 3 1 1 1 1 1 3 1 2 2 2 20

Number referred for

investigation

YTD

Outcomes

YTD

Complaints & Claims ‐ July 2018 (Month 3)(Data accurate as at 09/08/2018

Complaints

Complaints ‐ Resolution Perfomance (% achieved resolution within timescales)

Parliamentary Health Service Ombusdman (PHSO)

Number of cases

referred for investigationNumber Currently Outstanding

Jul‐18 3 3

8 Outstanding

2017/18 7

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Not Investigated

Outstanding

2018/19 3

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Outstanding

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current

investigations that have not gone over deadlines are excluded data.

Claims

Clinical Negligence Scheme for Trusts (CNST) Not including

Disclosures

Liabilities to Third Parties Scheme (LTPS)

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

July 2018 Complaints ReceivedRisk Breakdown

Low Risk

Moderate Risk

High Risk

Year to DateComplaints ReceivedRisk Breakdown

0

10

20

30

40

50

60

70

80

Apr 2014

Jun 2014

Aug 2014

Oct 2014

Dec 2014

Feb 2015

Apr 2015

Jun 2015

Aug 2015

Oct 2015

Dec 2015

Feb 2016

Apr 2016

Jun 2016

42583

42856

42948

43009

43070

43132

43191

43252

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Apr 2014

Jun 2014

Aug 2014

Oct 2014

Dec 2014

Feb 2015

Apr 2015

Jun 2015

Aug 2015

Oct 2015

Dec 2015

Feb 2016

Apr 2016

Jun 2016

42583

42856

42948

43009

43070

43132

43191

43252

Concerns Received

Concerns Mean UCL LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Complaints Resolution Performance

0.00

0.20

0.40

0.60

0.80

1.00

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Number of Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days ‐ Previous years performance

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family ‐ July 2018 (Month 4)(Data accurate as at 09/08/2018)

Inpatients

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

0%5%

10%15%20%25%30%35%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Response Rates (%)

Trust Rate NHS England Yorkshire & the Humber

0.930.940.950.960.970.980.99

1

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Likely to recommend (%)


0%

2%

4%

6%

8%

10%

12%

14%

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Response Rates (%)


0.75

0.8

0.85

0.9

0.95

Aug‐17

Sep‐17

Oct‐17

Nov‐17

Dec‐17

Jan‐18

Feb‐18

Mar‐18

Apr‐18

May‐18

Jun‐18

Jul‐18

Likely to recommend (%)


Executive summary ‐Workforce ‐ July 2018 (Month 4)

Sickness absence SICKNESS DATA FOR MONTH 4 NOT YET AVAILABLEFollowing the reduction in April to 4.05% in month, rates remained at 4.05% in May (this was slightly higher than the equivalent period in 2017/18) and there has a further reduction in month 3 to 3.91% resulting a cumulative year to date figure of 4.1% . Whilst there has been a reduction in short term absence rates, the number of absences in excess of 6 months has risen. The Deputy Director of P&OD will review all such cases to ensure there are plans in place to reduce this number.

AppraisalsThe Trusts appraisal completion rate has continued to see a further rise to 78.85% as at the end of July 2018 with all Care Groups and Directorates now above 65% . and 6 directorates above 90%.

SET We have seen a further small rise in compliance with Statutory and Essential Training in July to 81.43% . Specific focus is being given to topics and Care Groups where compliance rates are low and is included in the CQC action plans.

Staff in post ‐ NOT YET AVAILABLE FOR MONTH 4Please see attached tab covering staff in post by staff group. Vacancy rates are provided to both Finance & Performance and Quality & Effectiveness Committees.

Workforce: Sickness Absence ‐ June (Month 3)

Workforce: SET Training ‐ July (Month 4)

Workforce: Appraisals ‐ July (Month 4)

Workforce: Staff in post ‐ June (Month 3)

1

Title Report from the Guardian for Safe Working

Report to Board of Directors Date August 2018

Author Dr Jayant Dugar, Guardian for Safe Working

Purpose Tick one as

appropriate

Decision

Assurance

Information √


The 2016 national contract for junior doctors encourages stronger safeguards to prevent doctors

working excessive hours, during negotiations on the junior doctor contract agreement was reached on

the introduction of a 'guardian of safe working hours' in organisations that employ or host NHS trainee

doctors to oversee the process of ensuring safe working hours for junior doctors. The Guardian role

was introduced with the responsibility of ensuring doctors are properly paid for all their work and by

making sure doctors aren’t working unsafe hours.

The 2016 contract continues to be implemented with 112 junior doctors employed by this Trust on the

2016 contract as at June 2018. This contract changes how safe working is delivered compared to

previous contract. This relies on exception reporting by junior doctors and proactive changes by the

Trust to avoid unsafe working. This is done through an electronic system called DRS4 provided by Skills

for Health. The Trust is moving onto the Allocate system for rostering which includes doctors in

training and the exception reporting process.

The Guardian is required to provide the Board of Directors with quarterly reports. No gross safety

issues have been raised with the Guardian by any trainee. There have been 34 exceptions raised this

quarter by junior doctors ‐ 4 of which were education related re missed education meetings which

have been taken note of by the educational supervisors.

Members will recall concerns previously being raised with regard to Stroke and Diabetes. Within this

update is detailed a piece of Qii work undertaken by the junior doctors and supervised by Dr

Mallaband and Mr Pillay.

The Guardian for Safe Working advises that that the trainees have safe working practice as designed by

the 2016 contract.

2


Is the Board assured that the Trust has safe working in place for doctors in training?


People ‐ As a Teaching Hospital we are committed to continuously develop the skills, innovation and leadership of our staff to provide high quality, efficient and effective care

Junior doctors will have improved support and education through the implementation of the new

junior doctor’s contract which is designed to ensure doctors are working safely and receiving the

appropriate training. By having appropriately trained doctors patients will receive a good experience

whilst receiving care.


Workforce. By having a safe workforce we remain an attractive employer to current trainees and to help future recruitment.


The Board of Directors are asked to note this update for the first quarter of 2018/19 and be assured

that trainee doctors have a safe working practice as envisaged by the 2016 contract.

QUARTERLY REPORT ON SAFE WORKING HOURS

3

April 2018 – June 2018: DOCTORS AND DENTISTS IN TRAINING

1. Introduction This report sets outs the information from the Guardian of Safe Working as part of the 2016 Terms

and Conditions for Junior Doctors to assure the board of safe working for junior doctors. This report

is for the period 1st April 2018 to 30st June 2018

The Board should receive a quarterly report from the Guardian as per 2016 contract, which will

include:

• Aggregated data on exception reports (including outcomes), broken down by categories such as specialty, department and grade

• Details of fines levied against departments with safety issues

• Data on rota gaps / staff vacancies/locum usage

• A qualitative narrative highlighting areas of good practice and / or persistent concern.

2. High level data Total number of training posts in DBTH 290

Number of posts contracted by DBTH 161

Number of posts contracted by other Organisations 129

Number of doctors / dentists in training on 2016 TCS 112

Amount of time available in job plan for guardian to do the role: 2 PAs

Admin support provided to the guardian (if any): provided through HR

Amount of job‐planned time for educational supervisors: 0.25 PAs per trainee.

3. Exception reports

By working hours:

Care Group No. exceptions

carried over from last report

No. exceptions raised

No. exceptions closed

No. exceptions outstanding

Medicine 3 12 14 3*

General Surgery 4 13 16 1

Emergency Medicine 2 1 2 1

Haematology 0 9 4 5*

Total 9 35 37 10*

*Incorrect supervisor chosen by junior doctor‐ not responding to contact


4

For these quarters, exception reports have been submitted by individuals across Specialties, Surgical

and Medicine Care Groups. A total of 35 exception reports have been raised within this quarter of

which two have been related to Education and two for hours and missed educational opportunity ‐

all of which are related to missed attending meetings which have been taken note of by the

educational supervisors.

By grade:

Grade Exceptions

F1 23

F2 10

StR (CT) 2

Doctors still on the 2002 contracts the hours monitoring information is as below:

Specialty Site

Rota ID

# on Rota

# of Drs on old

contract

monitoring

% Return

Ban

d

Monitoring

outcome

Comments

Emergency DRI ST3+ 9 1 0

General Medicine DRI ST3+ 5 0

General Surgery DRI ST3+ 9 4 75% 1B 1B

2 long day shifts did not achieve EWTD requirement of 11 hours undisturbed rest in 24 hours. 10 shifts reported to not achieved a break

Obstetrics & Gynacology

DRI ST3+ 6 2 0

Obstetrics & Gynacology

BDGH ST3+ 7 3 0

Ophthalmology DRI ST3+ 1 0

ENT DRI ST3+ 7 2 50% 3 3 Breaks and on‐calls not getting

sufficient rest

4. Work schedule reviews

The work schedule review in medicine has been progressed as a QIP under the leadership of Dr. N. Mallaband and Mr. W. Pillay. This has been taken up by the Trust and will be implemented from August 2018. This is aimed at addressing the issues noted with Stroke and Diabetes in terms of Junior Doctor cover as detailed in previous reports. Please note Table 3 in this report for changes to be achieved with the new arrangements. The report is enclosed as Appendix A to this report.


5

5. Vacancies – training grade rotation

6. Locum and bank usage

The data below details bank and agency shifts covered by training grade doctors.

Mar‐18 Apr‐18 May‐18

Acute Medicine 40 36 43

Anaesthesia Obs 5 1 5

Anaesthetics 33 8 9

Anaesthetics and Critical Care 6 10 10

Cardiology 1

Care of the Elderly 94 100 117

Community Paediatrics 11

Emergency Medicine 428 325 392

Endocrinology and Diabetes 48 30 10

Endoscopy ‐ Surgical 2 1 2

ENT/ENT Theatre 12

Gastroenterology 24 2

General Surgery 2 42 1

Genitourinary Medicine 16 16 1

Obstetrics and Gynaecology 118 178 196

Orthopaedic and Trauma Surgery 174 246 181

Paediatrics 3 1

Paediatrics and Neonates 178 127 106

Renal Medicine 21

Respiratory Medicine 6 15 23

Stroke Medicine 26 17 50

Urology 22 10

VACANCIES January February March April May June July August

Medicine 3 3 4 5 5 5 5 6

Anaesthetics 2 1 1 2 1 1 1 3.7

Emergency medicine 6 5 5 5 5 5 5 1

Obstetrics & Gynaecology

7 8 8 10 10 10 10 12.4

Paediatrics 1 6 6 8 7 7 7 1.9

GU Medicine 0 1 1 0 0 0 0 0

Elderly Medicine 1 1 1 1 1 1 1 1.2

Radiology 2 2 1 0 0 0 0 0

General Surgery 1 0 0 5 5 6 6 1.5

Trauma & Orthopaedics 1 1 1 1 1 1 1 1

ENT 0 0 0 0 0 0 0 1

ICT 1 1 1 1

Total 25 29 29 37 35 36 36 30.7


6


Orthodontics 4

Breast Surgery 4 25

Grand Total 1239 1182 1193


Additional Session & Admin 5 3 Additional session to meet both contract activity and RTT performance

2 5 2

Annual Leave 35 30 36

Exempt from On Call 2

Compassionate/Special leave 5

Extra Cover 26 15 9 Maternity/Pregnancy leave/Paternity

3 1 22

Paternity Leave 5

Restricted Duties 2 5 4

Seasonal Pressures 31

Sick 26 44 23

Study Leave 5 7 13

Vacancy 1097 1085 1077

Grand Total 1237 1195 1193

7. Fines

No fines have been levied in this quarter. £139.84 is cumulative fine this year. The Junior Doctors

Forum has agreed to carry this amount forward for discussions with the new intake in August.


7

8. Qualitative information

It is reassuring that no instance of immediate safety concern has been brought to my notice by

junior doctors on 2002 or the 2016 contract.

Four instances of missing educational meeting due to busy ward have been reported and noted by

educational supervisors. This level of missed training opportunities seems to be low and may

indicate under reporting.

I have been assured by medical recruitment department that all doctors are rostered on a rota

which is compliant with 2002 and 2016 contracts as applicable.

9. Engagement

The Regional guardian forum is planned in July 2018 which I am planning to attend .This Trust has

low number of exception reports possibly explained by compliant rotas and safe working practices.

The fourth meeting of junior doctor’s forum was planned on 10th April 2018 which was not quorate

due to non‐attendance by Junior Doctors. I have had discussions with junior doctor’s

representatives about this and was informed that this was unintended and future meetings will have

better attendance.

I have also attended 2 trainee forum meetings to engage with the junior doctors.

Training sessions and induction for junior doctors and supervisors are planned in July and August for

junior doctors and supervisors

10. Software System

Trust has invested in a reduced Erostering system from Allocate software. This will change the exception reporting system used for this report from August change over for junior doctors. Online and drop in sessions for training and engagement are planned. I hope that in future this system will ensure better compliance with safe working.

11. Issues arising & Actions

1. The hours monitoring indicated problems in ST3 rotas for General surgery and ENT. Changes

within ENT have been made to address the matter raised with a new note being introduced

from July 2018. The Divisional Director for Surgery has been advised of the issues within

General Surgery and the Doctors have been advised of the importance of the breach.

2. Change to Allocate will need the supervisors and remaining trainees to learn a new system with

training being arranged.

12. Recommendation

The Board of Directors can be assured that the trainee doctors have a safe working practice as envisaged in the 2016 contract.

8

Quality Improvement Project:

Developing an innovative rota to optimise patient to doctor ratios across

medical specialties.

Authors

Sheharyar Baig, Core Medical Trainee, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation

Trust

Noor Sharrack, Core Medical Trainee, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation

Trust

Supervisor

Nicholas Mallaband, Consultant, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

May 2018.

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Background

There is a national shortage of junior doctors wishing to pursue Core Medical Training and further

their careers in several medical specialties. Additionally, many hospital trusts are experiencing a

challenge in appointing appropriately trained trust grade doctors to vacant posts. As such, a vicious

cycle can develop whereby chronically understaffed hospital wards contribute towards employee

dissatisfaction and burnout, exacerbating the primary problem.

Anecdotal evidence from Core Medical Trainees at Doncaster Royal Infirmary suggested that some

specialties were disproportionately affected by perceived understaffing and that this was a

contributor towards trainee dissatisfaction and fatigue. Following discussions between trainees,

supervisors and the hospital’s management team, the current quality improvement project (QIP)

was suggested as a means to identifying, quantifying and solving the differential workload between

junior doctors working in medical specialties.

‘SMART’ Objectives

1. To quantify the degree of variation in the workload, as represented by the average daily patient to junior doctor (F1‐CT2 equivalent) ratio, between medical specialties at Doncaster Royal Infirmary.

2. To design a novel medical on‐call rota, based on empirical evidence, that fairly distributes resources across medical specialties and can be implemented before the arrival of new Foundation Year 1 doctors in August 2018.

Methodology

The current QIP was carried out at Doncaster Royal Infirmary between January and May 2018. The

QIP methodology was developed in line with the ‘Plan, Do, Study, Act’ template suggested by the

JRCPTB.

The following medical specialities were included in the analysis: Acute General Medicine, Respiratory

Medicine, Gastroenterology, Care of the Elderly, Diabetes & Endocrinology, Haematology, Stroke

Medicine, Cardiology, Renal Medicine and Rheumatology/Dermatology.

Identifying and quantifying the degree of variation between junior doctor workload

Preliminary resources used to identify variation in junior doctor workload included informal

interviews with trainees and junior doctor forums and historical patient lists.

Quantification of the variation between the variation in junior doctor workload first necessitates the

designation of a metric that reliably represents junior doctor ‘workload.’ The agreed metric that was

used to signify workload is the average, daily patient to junior doctor ratio1’ for each speciality. This

was calculated by dividing the determined average number of inpatients per speciality by the

average number of junior doctors present on the ward per day after accounting for on‐call

commitments, study leave and annual leave. For brevity, this will be referred to as the ‘patient to

doctor ratio’ for the remainder of this report.

Whilst recognising that inpatient numbers fluctuate and that medical specialities are differentially

affected by seasonal variations in admissions due to to the presence of medical outliers, a consensus

1 Here, the term ‘junior doctor’ refers to trainee or trust grade doctors between F1 and CT2‐level.

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was reached on the estimated average of the number of inpatients under the care of each specialty.

These summary statistics were calculated both for baseline bed numbers and for the maximum

average number of inpatients thereby simulating the number of inpatients during summer and

winter pressures. Several streams of evidence were used in this process: evidence from inpatient

ward lists, designated inpatient bed numbers for each speciality, feedback from junior doctors and

feedback from medical consultants. Unfortunately, due to missing data from incomplete medical

inpatient lists, precise figures for each speciality could not accurately be determined.

Estimating the daily average number of junior doctors present for each medical specialty provided

by the current medical rota was a more complex undertaking. Medical junior doctors working across

the eight specialties analysed in the current study had on‐call commitments to one of five different

on‐call rotas, each of which had a different degree of on‐call versus ward commitments (the AMU

on‐call rota, the general medicine on‐call rota, the F1 trainee on‐call rota, the Renal Medicine rota

and the Care of the Elderly on‐call rota; summarised as Rota Patterns A to E, respectively). The

calculated average number of junior doctors present on the ward was determined using the

following sequence:

1. Calculating the number of weekdays per year assigned to ward‐based work for junior doctors working on Rota Pattern A.

2. Multiplying the number of weekdays worked in a given year by a ratio of 42/52 (based on an established theoretical assumption that, on average, medical doctors have up to 10 weeks (50 weekdays) a year where they are unavailable to perform ward work due to a combination of annual leave, study leave, compassionate leave and sickness) to determine the realistic, estimated number of weekdays assigned to ward‐based work by Rota Pattern A.

3. Using this information to determine the average number of weekdays worked per week by junior doctors on Rota Pattern A.

4. Repeating Steps 1 to 3 for Rota Patterns B, C, D and E.

5. Calculating the average number of weekdays worked per week by all doctors within each specialty by combining the figures obtained in Steps 3 and 4.

6. Dividing each figure by a factor of 5 to determine the average number of junior doctors present on the ward per weekday for each specialty.

The designated metric, the junior doctor to patient ratio, was determined from the ratio of the two

figures calculated above for each specialty.

Medical Staffing and Rota Development

Following the identification of junior doctor shortages and suboptimal patient to doctor ratios, a

concerted effort was made to recruit new candidates to roles in the relatively understaffed

specialties.

Following the dissemination of information regarding the development of a new medical rota,

opinions and suggestions of staff members were collated through the local junior doctors’ forum and

informal discussions. A thematic analysis of the key suggestions formed the underlying principles of

the new rota. Two individuals independently analysed the rota patterns and assigned roles to

doctors from different specialities in order to minimise the impact of on‐call shifts to junior doctor

staffing on the ward.

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Progress and Results

Qualitative variation in the patient to doctor ratio

Thematic analysis of the information gained through the junior doctors’ forum suggested the

following:

(1) Doctors working in Diabetes & Endocrinology and Stroke Medicine had a disproportionately high workload and often found themselves looking after more patients than they felt was optimal and manageable.

(2) A maximum patient to doctor ratio of 15:1 was suggested as being manageable, safe for patients and optimal for training and development.

(3) Some rota patterns contain fewer on‐call shifts leading to a perceived differential workload over the course of a clinical rotation.

Quantitative variation in the patient to doctor ratio

On‐call rota patterns and the average number weekdays worked in each rota pattern are

summarised in Table 1.

The calculated metrics of average number of junior doctors per day, average inpatient numbers

(both base bed numbers and average inpatient beds during winter pressure) and the patient to

doctor ratio are summarised in Table 2. The base bed patient to doctor ratio varied between 6.1 to

13.8 (median 10.5, IQR 9.2 – 11.8). The maximum average patient to doctor ratio varied between 5.5

and 17.3 (median 12.2, IQR 9 ‐ 14). This indicated that, after including the number of outlying

medical patients, two specialties (Stroke Medicine and Diabetes & Endocrinology) had a patient to

doctor ratio exceeding the manageable level established by prior discussions in the junior doctors’

forum.

The principles of a new rota

Successive junior doctors forum meetings and discussions between the authors and the medical

directorate led to the development of a new medical rota based on the following agreed underlying

principles:

(1) Redundancy – sufficient flexibility in the on‐call rota to temper the impact of short term absences. This is achieved through: a. Adding to the junior doctor workforce through the appointment of new core medical

trainees and trust grade doctors. b. The use of ‘float’ doctors who are flexible in their roles and are able to offer support in

different areas when required. c. Team‐based responsibilities to allow for the transfer of a single individual at short notice if

required. d. Creating a 1 in 16 SHO rota to tessellate with the existing 1 in 8 F1 rota in order to be able

to develop a rota where concurrent on‐call periods for juniors within the same speciality are minimised thereby creating fewer periods of short‐staffing on the ward.

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(2) Equity and fairness a. There should be a similar patient to doctor ratio between specialties. b. Doctors should work a similar number of on‐call shifts throughout the year. c. The different on‐call patterns should be minimised and the nature and workload of on‐call

shifts should be similar between trainees. d. Designated ‘minimum staffing’ for each specialty and proactive identification of days

where a certain team is short‐staffed and the development of a sequential process that the medical staffing team can follow in order to arrange cover in advance.

(3) Prioritisation of training requirements a. Dedicated clinic weeks for core medical trainees b. Providing a range of on‐call experience in different ward areas to improve the breadth of

experience gained by trainees.

(4) Compliance with the new junior doctors’ contract.

Development of a new medical rota

Workforce expansion and rota patterns

Analysis of the rota patterns identified that the 21 ‘SHO‐level’ doctors on Rota Pattern B had more

on‐call commitments than the four ‘SHO‐level’ doctors working on Rota Pattern C. With the addition

of three further ‘SHO‐level’ doctors from August 2018 (Core Medical Trainees and Trust Grade roles),

there was an opportunity to create a 28 person general medical rota for on‐calls. Given that a typical

four month rotation exceeds 28 weeks, there would likely be an unfair distribution of on‐call shifts in

a given rotation if a single 28 person medical rota was adopted. Therefore, two separate 16 person

and 12 person rotas were developed. The underlying principles as above were adhered to enabling a

relatively reduced number of on‐call commitments for most doctors (i.e. those previously on Rota

Pattern B), increased ward availability for most specialities and an improved patient to doctor ratio

for most specialties. These are summarised in Tables 3 and 4, Figure 1.

On‐call work

Qualitative analysis of the current rota identified that new F1 doctors may find it difficult to manage

the workload on the Respiratory, Stroke and Cardiology wards during the weekend medical‐on calls.

As such, a team‐based approach was promoted during the development of the new on‐call

responsibilities. The hospital was divided into four working areas; doctors of suitable experience

were assigned to each working area with the supplemental addition of an F1 ‘float’ doctor who is

able to provide cross‐cover and support colleagues in the busiest working area.

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Tables and Figures

Table 1: The cycle length and average number of weekdays worked per week by junior doctors in each

existing rota pattern.

Rota Pattern

Specialties Number of doctors per rota (Cycle Length)

Average days per week working on the ward

A Acute Medical Unit 10 2.02

B Core Medical Trainees working in general medical specialties

21 2.77

C Care of the Elderly (GPVTS) Haematology (CMT) Rheumatology/Dermatology (GPVTS)

4 3.72

D Renal Medicine 6 1.82

E Foundation Year 1 Doctors 8 3.13

F Care of the Elderly Trust Grade Doctors 2 4.04

Table 2: The average junior doctor to patient ratio per day in each speciality.

Specialty Average number of doctors on the ward per day

Baseline inpatient bed numbers (minimum)

Maximum average inpatient bed numbers (maximum)

Patient to junior doctor ratio (minimum)

Patient to junior doctor ratio (maximum)

Acute Medical Unit

4.66 40 42 8.6 9.0

Respiratory 4.58 54 64 11.8 14.0

Gastroenterology 3.95 24 48 6.1 12.2

Diabetes 2.29 24 38 10.5 16.6

Cardiology 1.18 12 9 10.2 7.6

Stroke 1.73 24 30 13.8 17.3

Renal 2.18 20 12 9.2 5.5

Care of the Elderly

6.69 80 88 12.0 13.2

Haematology 0.74 8 7 10.8 9.4

Median 10.5 12.2

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Table 3: The cycle length and average number of weekdays worked per week by junior doctors in the new

rota patterns.

Rota Pattern

Specialties Number of doctors per rota (Cycle Length)

Average days per week working on the ward

A Acute Medical Unit 10 2.02

B General Internal Medicine 16 16 2.93

C General Internal Medicine 12 12 2.69

D Renal Medicine 6 1.82

E Foundation Year 1 Doctors 8 3.13

F Care of the Elderly Trust Grade Doctors

2 4.04

Table 4: A comparison of average number of junior doctors on the ward and minimum to maximum

inpatient to junior doctor ratios per specialty under the old and new medical rota.

Specialty Average number of junior doctors on the ward per day

Patient to doctor ratio per day (minimum)

Patient to doctor ratio (maximum)

Old Rota New Rota Old Rota New Rota Old Rota New Rota

Acute Medical Unit 4.66 4.66 8.6 8.6 9.0 9.0

Respiratory 4.58 4.77 11.8 11.3 14.0 13.4

Gastroenterology 3.95 3.32 6.1 7.2 12.2 11.1

Diabetes 2.29 2.87 10.5 8.4 16.6 13.2

Cardiology 1.18 1.21 10.2 9.9 7.6 7.4

Stroke 1.73 2.38 13.8 10.1 17.3 12.6

Renal 2.18 2.18 9.2 9.2 5.5 5.5

Care of the Elderly 6.69 6.69 12.0 12.0 13.2 13.2

Haematology 0.74 0.81 10.8 9.9 9.4 8.7

Figure 1A

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16

Discussion

Summary

The current study utilises a quantitative analysis of junior doctor staffing and availability to highlight

an inequitable distribution of resources and proposes a solution through the adoption of a

consensus of agreed principles and the development of new medical rota. The benefits of this

include an increase in the number of junior doctors available for ward based work and training, a

more even distribution of medical on‐call work between individuals and a reduction in the variable

patient to doctor ratio between specialties.

Limitations

There are several limitations of the current study. Firstly, the metric used to signify junior doctor

workload (the patient to doctor ratio) assumes that the average workload for each patient within

each specialty is the same. Clearly, the responsibilities related to managing each individual patient

cannot easily be quantified, however, for the purposes of the present study, this metric was agreed

upon as being a useful and easily accessible indicator of overall workload. The second significant

limitation is that, due to the unpredictable nature of the acute medical take, the number of medical

outliers and, therefore, total number of patients on the ward cannot accurately be predicted or

averaged over the course of a year. The confounding effect of outlier medical inpatients has been

buffered against by providing summary statistics for base bed inpatients and maximum average total

inpatients.

Future work

The implementation of the rota will begin in August 2018. The impact of the rota will be ascertained

through the feedback of the medical staffing team, junior doctors and trainee survey results.

Title Chair’s and NEDs’ Report

Report to Board of Directors Date 21 August 2018

Author Suzy Brain England, Chair


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work in July and August 2018 and includes updates on a number of activities.


N/A


The report relates to all of the strategic objectives.


N/A


That the report be noted.

Chair’s and NEDs’ Report – August 2018

Evaluating how we do business Following the Board of Directors’ development session in July, we have now received Karl’s analysis of our board pack and observation of the Part 1 meeting. There are a lot of positives as well as some of areas for further refinement. We will now consider the report and bring back to Board the recommendations along with an action plan for how they will be implemented. Board members will know that, as part of this years internal audit programme KPMG are embarking on a review of board committee effectiveness. Together, these pieces of work will contribute to the annual evaluation of board and its committees that we are required to do as governance best practice, and which is reported through the annual report as assurance to our members and regulators that we continue to have in place appropriate board‐level capability and capacity. Individual evaluations of directors’ performance have already been undertaken and the NEDs’ objectives and performance has been reported to governors as part of the appraisals process. Governor update Three seats will be contested in Doncaster and two in Bassetlaw as part of the latest round of elections for our Council of Governors. Ballot papers were dispatched by our independent scrutineer last week and members in both constituencies have until 6 September to cast their ballots using the Single Transferable Voting system. Serving governors Phil Beavers and Bev Marshall are both up for election in Doncaster and we wish them the best of luck. A full list of all the candidates is available via the website. In my absence, Mike Addenbrooke chaired the Governor Forum where Simon Marsh, Chief Information Officer, gave an overview of his team’s work to make the Trust more technologically proficient as well as keep us safe from cyber security issues. I would like to bid David Cuckson, Governor for Rest of England and Wales, a speedy recovery following a short stay in hospital. And, finally, thank you and goodbye to Maureen Young who is stepping down as a Public Governor for Doncaster after 12 years. I know the Trust has meant a lot to Maureen and she leaves us having achieved some real benefits for the people and patients of Doncaster. I have written to thank her. This month’s meetings During the month, I met with David Pratt, Efficiency Director, and held one‐to‐ones with the Directors for Strategy and Improvement and Estates and Facilities. On the day prior to Board I am meeting with the Principal of DN (Doncaster and North Lindsey) Colleges, Anne Tyrell, and with Richard Thomas, who leads on technology at PWC.

Before the last Board meeting I observed a lively debate at Finance and Performance Committee and will be dropping in on Quality and Effectiveness Committee this month as part of a regular insight into the work of the Trust’s board committees. NED Reports Pat Drake Pat Drake had a tour of Montagu Hospital and visited the day unit, podiatry, outpatients, minor injuries and the rehabilitation unit. She noted some excellent facilities for patients and in particular the amenities and rehabilitation opportunities. She also met some very welcoming and professional staff and thank you to Janice Edees for her time. Pat also visited Bassetlaw Hospital supported very ably by Rick Dickinson, the Deputy Director of Nursing, Midwifery and AHPs. Once again she met some very welcoming and professional staff in ED, maternity, paediatrics and the library. She met with Suzanne Bolam and visited key therapy areas at DRI and saw presentations of best practice. Pat also had her first meeting with Mr Singh to establish their buddying relationship and observed the Clinical Governance Meeting to better understand the assurance and governance processes reporting into the Quality and Effectiveness Committee. Kath Smart Kath Smart attended the Governors CEM (Communications, Engagement & Marketing Group) to hear about membership plans, evaluation of the Governor time out & discuss Charitable Funds. Kath was also present for the Governors IM&T briefing given by Simon Marsh with discussions about IT risks, plans and challenges & participated in the appointment panel for the Corporate Governance Officer. Following recent concerns regarding patient food provision Kath was invited to participate in the food audit process (at Bassetlaw) and will also be representing DBTHFT at the SYB ACS Governance Review Group in Sheffield on 15th August.

1

Chief Executive’s Report

21 August 2018

Trust secures higher than national average scores in PLACE assessment Doncaster and Bassetlaw Teaching Hospitals has bettered the national average scores in all six domains of this year’s PLACE assessment. The PLACE assessment measures improvement by providing a clear message, directly from patients, about how the environment or services of the Trust might be enhanced. The assessment involves inspections of the Trust’s approach to cleanliness, appearance and maintenance, dementia, disability, food and hydration, and privacy, dignity and well-being. Inspections are undertaken by teams involving governors, patients and other stakeholders. The Trust’s 2018 scores were as follows:

Domain DBTH National average

Cleanliness 99.99% 98.47%

Condition, appearance and maintenance 97.81% 94.33%

Dementia 85.05% 78.89%

Disability 88.39% 84.19%

Food and hydration 90.20% 90.17%

Privacy, dignity and wellbeing 85.78% 84.16%

Across South Yorkshire and Bassetlaw the Trust was the highest ranked in five of the assessed standards and above the national average in every standard. A significant improvement on the result achieved in previous years. Developing the 10 year plan NHS England and NHS Improvement have published a document on developing the long term plan for the NHS. Back in March, the Prime Minister committed to a “sustainable long term plan” for the NHS backed by “a multiyear funding settlement”. She expanded on this in June, confirming a new funding settlement for the NHS of an average of 3.4% real terms increase over the next five years. She also tasked the NHS with producing a 10 year plan in return for the increase in funding. The Prime Minister set a number of priorities for the 10 year plan which included:

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• “getting back on the path to delivering agreed performance standards – locking in and further building on the recent progress made in the safety and quality of care • transforming cancer care so that patient outcomes move towards the very best in Europe • better access to mental health services, to help achieve the government’s commitment to parity of esteem between mental and physical health • better integration of health and social care, so that care does not suffer when patients are moved between systems • focusing on the prevention of ill-health, so people live longer, healthier lives The government also set the NHS five financial tests to show how the NHS will move onto a more sustainable footing. Those tests are: 1. improving productivity and efficiency 2. eliminating provider deficits 3. reducing unwarranted variation in the system so people get the consistently high standards of care wherever they live 4. getting much better at managing demand effectively 5. making better use of capital investment A delivery plan to underpin the first few years of the 10 year strategic plan, is also being developed. Ian Dalton then identified a number of issues that he wanted to address through this planning guidance/delivery plan including: • Productivity levels – providers are likely to achieve more than last year, with Mr Dalton highlighting GIRFT as well as “transformation projects, and further cuts to agency, procurement, back office and corporate costs” as further savings opportunities • Sector deficit – the national bodies may have to consider writing off some of the trust sector’s debts • Control totals – these will be replaced with a new financial architecture from April 2019, with Mr Dalton commenting that the current approach to control totals encourages non-recurrent savings rather than a focus on underlying financial sustainability • Fines and sanctions –are likely to be reviewed (including the marginal rate for emergency care) • Tariff – the gap between tariff prices and costs of provision needs to be addressed

3

• Provider Sustainability Fund – will be reviewed as “the distributional effects of that have again not necessarily been equal across the system” The timelines are expected to be:

Understanding why people come to A&E As Board as aware that over the past three months, the Emergency Departments at Doncaster and Bassetlaw Teaching Hospitals (DBTH) have seen a surge in demand. In May, over 15,000 people attended the urgent service, almost 1,000 more than the previous year, while a similar number came in June, another annual rise of around 600. While the majority of those attending the Emergency Department use the service as intended, the number of individuals attending for non-urgent health matters is increasing, particularly amongst young adults. To understand this recent development, health partners across Doncaster and Worksop have launched a new survey to ask for feedback on when local people use medical services. The survey is available online at dbth.nhs.uk and takes just a few minutes to complete.

https://www.dbth.nhs.uk/news/when-do-you-go-to-the-emergency-department/

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7Day Services Survey Results Last week I received a letter from NHS England and NHS Improvement congratulating the Trust on its excellent seven day service staff survey results. Our compliance against the four clinical standards was as follows:

Key – CS2 - Percentage of patients who had an initial consultant review within 14 hours of admission CS5 - Percentage of patients that had access to diagnostic tests CS6 - Percentage of consultant directed interventions available to patients CS8 - Percentage of patients that received ongoing daily consultant reviews Extended ED opened Earlier this week it was my pleasure to open a new ‘extended ED’ at Doncaster Royal Infirmary. The area is run by dedicated and highly skilled Emergency Nurse Practitioners who provide care for less serious injuries, such as sprains, cuts, grazes, minor burns, bites and stings. Many people go to an Emergency Department, when they could be treated much more quickly elsewhere. The area can also arrange X-Rays for possible broken bones and treat minor eye and ear injuries. CP-IS goes live The Trust is pleased to announce that a new information sharing service has gone live across all its sites. The Child Protection – Information Sharing (CP-IS) service is an NHS England sponsored work programme dedicated to developing an information sharing solution that will deliver a higher level of protection to children who visit NHS unscheduled care settings such as: accident and emergency; maternity; minor injury units; out of hours; walk-in centres and some paediatric wards.

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The information sharing focuses on three specific categories: • Children with a Child Protection Plan (CPP) • Children that are Looked After by the Local Authority (LAC) • Any unborn child that has a Child Protection Plan NHS Digital has now listed Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust as fully live with CP-IS after our first patient was inputted. NHS Providers publish STP/ICS Guide The recently published briefing tackles some of the outstanding questions surrounding STPs and their future development and, tentatively, supplies some suggestions. The briefing summarises recent developments relevant to system working, sets out the state of play for STPs and integrated care systems (ICSs) and seeks to offer answers to a number of questions arising from the national policy focus on collaboration and integration. The briefing is available on the NHS Providers website along with an infographic which provides feedback from Trusts on the development of STPs. Star Awards nominations announced The stage will soon be set for the 2018 Star Awards which takes place on Thursday 20 September at the Keepmoat Stadium. Tickets have now sold out. There are 12 awards up for grabs this year, covering awards for staff in every role. The event is an opportunity to recognise those individuals and teams that go above and beyond, ensuring patients receive the highest quality of care. Details of staff nominated can be found on the website. All 14 of our sponsorship packages have also sold out. I would like to thank all staff and sponsors for getting involved in what promises to be a great night and a great celebration of the NHS.

DONCASTER & BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

Minutes of the Finance & Performance Committee held at 9:00am on Monday 21 June 2018

in the Boardroom, DRI

PRESENT : Neil Rhodes, Non-Executive Director (Chair) Pat Drake, Non-Executive Director Kath Smart, Non-executive Jon Sargeant, Director of Finance

Karen Barnard, Director of People & Organisational Development David Purdue, Chief Operating Officer ALSO IN ATTENDANCE: Suzy Brain England, Chair of the Board (part)

Marie Purdue, Director of Strategy & Transformation Ken Anderson, Head of IT Programmes and Development (for Simon Marsh)

Ruth Bruce, Head of Performance (part) Matthew Kane, Trust Board Secretary Alex Crickmar, Deputy Director of Finance Kate Sullivan, Corporate Governance Officer OBSERVERS : Bev Marshall, Governor Observer APOLOGIES : Simon Marsh, Chief Information Officer

Action Apologies for Absence

18/7/1 Apologies were noted from Simon Marsh.

Action Notes from Previous Meeting

18/7/2 The action list was noted.

Any Other Business

18/7/3 In response to a query from Pat Drake, the Chief Operating Officer gave assurance that weekend breast screening was now up to date.

CIP Work Stream – Patient Administration

18/7/4 The Committee received a presentation from the Chief Operating Officer (COO) on the Patient Administration CIP work stream. The presentation had been circulated with the papers and at the request of the Committee it was presented in a new standard format which the Committee endorsed; it was agreed for all future CIP deep dive presentations to use the template which should include key elements from the PID, key issues and challenges.

18/7/5 At the request of new Committee members the presentation provided some contextual background information. The COO outlined the scheme which aimed to identify the changes required to the clinical admin workforce / functions to ensure patient information was communicated and shared in the most efficient and cost effective manner making best use of technology (currently available) to support the patient pathway from referral to discharge. The new model would deliver administrative support services for all divisions which would be ‘patient focused’, dedicated to providing excellent customer service, user friendly, cost effective, and provide expert administration facilities to support DBTH’s core mission of providing safe and quality services to our patients. An overview of the following was provided:

Objectives

Scope

Benefits

Milestones (including dates)

Risks

Key issues

Key tasks completed to date

Current state of plan

18/7/6 I The scheme would ensure a consistent and standardised administration model across all divisions; early in the project the Trust had found there to be 64 different job descriptions for staff working in administrative roles at bands 1-4 and this had now been rationalised to four. This had been a significant piece of work. Furthermore, across specialities there were found to be inconsistent or no standard operating procedures or training programmes for staff and no consistency in approach to similar areas with specialities within the same care group found to be using different staffing models. The Trust had undertaken a significant programme of work to understand this which had included activity flows, work diaries, time and motion studies and looking at best practice and admin reviews undertaken at other trusts.

18/7/7 Risks and Key Issues - There had been some nervousness amongst senior staff and consultants to proposals to introduce new clinical admin staffing models and ways of working. Pat Drake had recently observed a workforce meeting and she had picked up on this; some consultants had raised the matter with her and she shared their feedback. The COO advised that the key risks to the plan centred on support from consultants, senior management in the Divisions and staff. Without their support business change would not be enabled, efficiencies and savings would not be realised and improvements to the quality of services would not be achieved.

18/7/8 Due to the inherent complexity of the scheme the Trust continued to work hard to address the issues. There had been many meetings with staff groups and the COO had addressed the Local Negotiation Committee (LNC) and Trust Medical Committee (TMC) directly. It had come to light that there had been miscommunication of key messages with admin staff and this had been unhelpful. There had been workshops with staff to provide encouragement and support and a programme of engagement events were to be held.

18/7/9 The Committee recognised that with the exception of IT solutions, the key risks identified were behavioural and Pat Drake asked if there were any risks to patients, for example to patient flow and patient letters. The COO explained that this had been one of the key issues the Trust had aimed to address. He gave examples of improvements already achieved in medical records where all issues had been resolved. Pat Drake recognised the challenge faced by the Trust and in light of the behavioural issues described the Trust should remain focussed on patients and their experience.

18/7/10 A key issue had been the length of time it had taken to conduct the admin review which was now over two years; during this time permanent recruitment to admin roles had been paused until the review had been completed and new staffing models agreed. There was now good engagement in the central admin team but there was more work to do in terms of consultant secretarial staff. All staff would go through a programme of retraining once in their new roles.

18/7/11 Saving - Planned savings were £347,000 from reduction in banding and posts. To meet CIP the Trust planned for apprentices to make up between 5-10% of staffing in each division and Bev Marshall welcomed this, he recognised why staff might be anxious about the changes, particularly at this time when there had also been changes to the Agenda for Change pay scales and this was echoed by the Chair.

18/7/12 The Committee reflected on the update focussing on delivery of CIP; the COO gave assurance that planned savings would come in stream in time to align with the Trust’s CIP plans. The Director of Finance provided details of those elements of savings that were rated ‘Red’, ‘Amber’ and ‘Green’.

18/7/13 The Committee considered and discussed the CIP presentation for the Patient Administration Work Stream which was NOTED.

Performance Report

18/7/14 The Committee received the report which focussed on the three main performance areas for NHSI compliance; Cancer, 4hr Access and 18 weeks Referral to Treatment (RTT). The report also highlighted the ongoing work with Care Groups and external partners to improve patient outcomes. The COO presented the report by exception focussing on challenges.

18/7/15 In response to previous requests form the Committee further information and metrics had been included in the report and this was welcomed. This included some benchmarks and parameters for ambulance handovers to indicate whether performance was within control limits. The parameters were based on historical normal variations and an explanation of how these had been determined was provided. It was agreed to include the benchmarking data on the ‘at a glance’ table. In response to an observation from Pat Drake it was agreed to entitle areas of exception reporting ‘Exception Report’.

RB

18/7/16 Cancer - The 62 day standard was achieved by the Trust in May at 85.6%, with urology achieving the standard for the first time and this was commended. The May position for two week wait was 88.8% which was not compliant with the national target of 93% but was an improvement compared with April 2018. The reasons for breaches in relation to two week wait appointments were provided in the report. The Committee discussed cancer performance in the context of the ICS where urology was the biggest issue. Meetings had taken place with NHS England (NHSE) and NH Improvement (NHSI) to discuss cancer performance and an update on the outcome of this was provided.

18/7/17 4hr Access Target - The Trust achieved 94.9% in June 2018 against the 4hr access standard of 95%. Performance for quarter 1 was 93.9% which saw the Trust meeting the Provider Sustainability Fund (PSF) target for 2018/19 and this was commended. However the Trust was currently experiencing a very busy period, largely owing to an extended period of hot weather.

18/7/18 Did not attends (DNAs) - In June, the overall DNA rate across the Trust improved again to 9.21% compared with the previous month’s position at 9.47%. It was recognised that the overall Trust DNA rate was higher in some specialties than the national picture. Work was ongoing to improve attendance within those specialties with the highest DNA rates. It was agreed to provide DNA rates by speciality in future reports.

RB

18/7/19 The Committee discussed the report in detail and considered further information and metrics that would be helpful. Following a wide ranging discussion it was agreed to provide the following in future reports:

Delayed Discharges including super stranded

Non-medial Waits – For example for Physiotherapy, ADHD and community paediatrics. Provide update in future report including waiting list details and length of waits.

RB

18/7/20 The Performance Report was NOTED.

Workforce Report

18/7/21 The Director of People and Organisational Development provided an update to the Committee in relation to month 2 (May 2018) including vacancy levels, agency spend and usage, sickness rates, appraisals, SET training, turnover and retention rates and rostering data.

18/7/22 In summary the report detailed a vacancy rate in month 2 of 7% against a target of 5%; when taking into account the use of temporary staff this reduced to a 4.2% vacancy rate, although this varied by staff group. Agency spend continued to reduce since the introduction of confirm and challenge meetings. Further analysis of the NHSI benchmarking data was awaited and would be included in a future report. Month 2 sickness levels were 4.05% (4.13% cumulative).

18/7/23 In response to a query from the Chair it was noted that due to the timing of availability of data the report used month 2 (May) data and was therefore not aligned to data within the finance reports.

18/7/24 Agency Costs – The senior nursing leadership of the Trust had committed to ceasing the use of agency workers for nursing support gaps. There continued to be discussions with qualified agency nursing staff who had been working on a regular basis at the Trust to explore how the Trust might encourage them to work through the bank and their reasons for wanting to remain on agency; a key reason was flexibility of working arrangements.

18/7/25 Reflecting on the report in the context of the Trust’s aim to maximise the use of nursing and midwifery bank staff though NHSP, Bev Marshall asked if there was a cohort of bank staff for other staff groups and this was discussed; it was clarified that the Trust did use bank staff for Allied Health Professionals and also had its own administration and clerical bank staff on ‘as and when’ contracts. The plan was to move these staff to NHSP. In terms of medical and dental bank staff, in the main gaps in rotas had been covered by the Trust’s own doctors working extra shifts. Work was now underway to set up regional collaborative banks and this was starting to be used in the region.

18/7/26 Reflecting on the agency spend in the finance report it was noted that this was increasing and the grip and control processes to manage that were discussed by the Director of Finance. The Trust had invited internal audit back in to the Trust to review the embeddedness of the new processes and corrective action would be taken if this was not the case.

18/7/27 The ‘at-a-glance’ dashboard continued to develop and the Committee looked forward to the inclusion of targets for agency spend being disaggregated to staff groups in future reports and there was a lengthy discussion about how this could meaningfully be achieved. The Director of Finance provided details of progress to agree a fixed establishment of input hours for Care Groups to be mapped across to the new divisions; this information was used to set budgets and was managed though grip and control meetings. The new divisions were having a second round to look at the information, there were to be further discussions at Management Board and budgets would be signed off by the next meeting. The Committee wished to understand areas where this was being managed well and there needed to be a mechanism to gain assurance. It was agreed to consider how best to present agency targets and spend by staff group, including trends, and provide assurance that controls to manage agency spend were working.

KB

18/7/28 In response to a query from the Chair of the Board an update was provided on consultant recruitment. She reflected on comments she had received from local MPs that they did not see very many adverts for staff. She asked how the Trust could be assured that the recruitment process was as slick as it should be and this was discussed. The Trust regularly held recruitment open days and advertised jobs on the NHS Jobs website and work had been undertaken to improve recruitment material, particularly for hard to recruit to posts. An overview of some ongoing Qii work on the recruitment process was provided, this included looking at an on-boarding process and work across the ICS to look at passport arrangements between trusts, for example so that staff did not have to go through occupational health checks and SET Training if it had been completed at another ICS trust.

18/7/29 The Workforce Report was NOTED.

Finance Report

18/7/30 The Director of Finance (DoF) presented to the Committee a paper which summarised performance in month 3. In month performance was a deficit of £1.5m, which was a favourable variance against plan in month of £445k. The cumulative position to the end of month 3 was a £6.2m deficit, which was £30k favourable to budget. However the Trust needed to achieve a £6.6m deficit to deliver the year end control total, and therefore needed to essentially achieve a break even position for the rest of the year.

18/7/31 It was noted that the quarterly position had been achieved after the release of non-recurrent monies of £1.4m in month following the review of prior year accruals being held. This mainly related to accruals for agency doctors (through Holt) which were no longer required following review. Prior to the adjustment Month 3 performance had been circa £1.5m over plan, driven by underperformance of some elements of income, particularly elective work, and also a movement on agency spend which was of particular concern. There had also been multiple instances of underperformance throughout all cost centres and these were being investigated; overall the financial position was of grave concern. It had been important to close end the Q1 position ahead of budget in order to achieve Provider Sustainability Funding (PSF) and for this reason it had been agreed with the Chief Executive to make the adjustment outlined above. Further details of the accruals released was provided.

18/7/32 Consistent use of agency staff was being addressed through grip and control meetings. The Committee reflected on discussions earlier in the meeting (18/7/26) and noted that it was key to not only look at performance in comparison to previous months but also to set targets for agency usage and this was acknowledged.

18/7/33 The YTD income position at the end of Month 3 was £2,096k adverse to plan (excluding donated asset income); the Director of Finance provided a detailed update on each element of income variances and what they were for. The key specialties delivering the underperformance were General Medicine, Trauma and Orthopaedics (T&O) and GI Surgery; The Director of Finance drew attention to the graphs on page 43 of the report which illustrated the total elective activity against plan for the Trust.

18/7/34 The Committee considered the report in depth focussing on several areas including Care Group positions against budget, outsourcing, the outpatient CAP, and estates budgets; work was ongoing with the Director of Facilities and Estates to review overspent lines on estate budgets and utilities contracts.

18/7/35 There was a significance variance on income growth assumptions of £3.5m between the Trust’s financial plan and commissioner assumptions and contract values and the continued under performance against CCG’s was of concern. Levels of over performance and the further modelling of RTT suggested that with the Trust’s main commissioners the budget assumptions were fairly robust. There

was a lengthy and detailed conversation about the potential yield of work around block contracts with commissioners. The Trust was undertaking a significant amount of work for which it was not being fully remunerated. Discussions with commissioners were at an advanced stage and there was acceptance that the activity must be fully paid for. The sums involved were significant and the Committee would follow progress carefully. The Chair would escalate the matter to the Chair and the Board and the committee would consider the matter as a future Deep Dive Topic in future.

Planning Group

18/7/36 CIP – Delivery of CIP had been back loaded in the plan and significant savings were still required to be identified and delivered. The Committee spent a considerable length of time understanding the current position. Progress had been made and of the £17.8m CIP target only £2.6m remained unidentified and work was in hand to reduce that sum. An in depth analysis of the plans in place had been undertaken with assessment of complexity, yield and degree of challenge being mapped and RAG rated. A useful balloon chart provided a good visual picture and a table showing the status and RAG Rating of the work up of the overall CIP plan was also provided. The Director of Finance provided further details of work to realise CIP opportunities through Getting it Right First Time (GiRFT) and Patient Level Information and Costing (PLICS).

18/7/37 Pat Drake noted that the Quality Impact Assessments (QIAs) for CIPs were not seen at Board or its sub-committees and she queried where assurance was received for these. It was noted that the QPIA rag rating for each scheme was included in the table on page 58 of the report. The Director of Strategy & Transformation outlined the QIA process, which included a review by the CCG, and this was discussed. It was noted that the matter had been discussed at QEC that a new risk relating to ‘failure to mitigate the impact of an ambitious effectiveness and efficiency programme on quality of patient care’ had been added to the Corporate Risk Register. The matter would be escalated to the QEC for further consideration about how best to receive assurance on QIAs and any mitigation.

MK/PD

18/7/38 Capital programme – The Trust had been advised by NHSI that it could use its STF monies to cover its capital plan so the previously reported risk on capital was now no longer an issue provided the Trust maintained the cash balances to support the expenditure. This had enabled the Trust to address the matter of the lift failures which had now been included in capital plans for 2018/19; the Director of Finance provided an update on this. It was agreed to receive a deep dive on the capital programme in Q2 to include information on the impact on quality of service.

18/7/39 The Committee NOTED the Trust’s deficit for month 3 (June 2018) of £1.5m, which was a favourable variance against plan in month of £445k. The cumulative position to the end of month 3 was a £6.2m deficit, which was £30k favourable to budget. The release of prior year accruals of £1.4m to ensure delivery of the Q1 control total and progress to close the gap on the Cost Improvement Programme was also NOTED.

Annual Costing Submission

18/7/40 The Committee received the report which was provided for information.

18/7/41 The Committee NOTED the contents of the paper and were assured that the points highlighted in section 2.1 of the paper would be completed by the time of submission on the 15th August.

Financial Monitoring Framework

18/7/42 The Committee received the report of the Director of Finance which set out a proposed financial control escalation process. The Trust was faced with an unprecedented financial challenge whereby difficult decisions were required to minimise expenditure, reduce costs and maximise income in order to deliver sustainable services and deliver the Trust’s control total. The Trust was responsible for ensuring that public money provided value for money and was being spent robustly. To achieve this, it was absolutely essential that control over spending was strengthened and improved. The paper set out the proposed process and explained the key financial indicators and scoring framework that would determine the frequency and level of escalation. The Committee endorsed the framework.

18/7/43 The Committee NOTED the paper.

Corporate Risk Register and BAF Highlights

18/7/44 The Committee considered a report of the Trust Board Secretary which set out for consideration the Board Assurance Framework (BAF) and Corporate Risk Register (CRR). The report set out three changes to the BAF and CRR; two risks had added by executives in the month, one risk relating to risk of critical lift failure was at an extreme level and was proposed to be included on the corporate risk register, the second related to the risk of failure to mitigate the impact of an ambitious effectiveness and efficiency programme on quality of care; both risks were to be considered in detail at the forthcoming Audit & Non-clinical Risk Committee (ANCR) meeting. The Committee recognised the concerns of governors in terms of the lift issues, it was noted that a full update was to be given to the Council of Governors later that week.

18/7/45 The Corporate Risk Register and BAF Highlights was NOTED.

Strategy & Transformation Update

18/7/46 The Committee received the report of the Director of Strategy & Transformation which highlighted progress made with the implementation of the Trust’s Strategic Direction 2017 – 2022 (including enabling strategies) on an exception basis. It included progress made with the delivery and monitoring of the Enabling Strategy key milestones and where these had not be achieved and updated on mitigations from the lead for that Enabling Strategy. Enabling Strategy deep dives had been scheduled to be received by Management Board and then by the board committees.

18/7/47 The Committee welcomed the report. It was agreed to provide further context and commentary on enabling strategy progress reviews in future reports.

MP

18/7/48 The Committee received and NOTED the Strategy & Transformation Update.

Information Management & Technology Strategy Deep Dive

18/7/49 Ken Anderson, Head of IT Programmes and Development, delivered a presentation which provided an overview of the IM&T strategy and progress to achieve key milestones and deliverables. The presentation had been included in the papers and was assumed to have been read, it included the following:

Milestones

Progress to date

Key Challenges included o Lack of financial commitment will curtail the achievement of perceived

benefits. o Ability to engage at an appropriate level within Care Groups. o Inability to recruit skilled individuals into current vacant posts

Current Position

Benefits Realisation

18/7/50 A detailed update was provided for each IT scheme including progress so far and what was expected to be delivered in 2018/19 and 2019/20. There had been good progress to deliver the strategy. Progress on the schemes were RAG rated. Of the 19 schemes 15 schemes were rated ‘Green’, 2 were rated ‘Amber’ and two were rated ‘Red’; a more detailed update on these was provided on elements not yet completed.

18/7/51 The Committee considered the report focussing on key issues and there was a detailed discussion about the reasons for inability to recruit skilled individuals into current vacant posts and what was being done to mitigate this. The key factor was that similar roles outside of the Trust attracted higher salaries than could be offered in the NHS due to the agenda for change pay structure. Recently several students on placement from Sheffield Hallam University had been working at the Trust on a project which had been hugely beneficial to both the Trust and the students.

18/7/52 In response to a query form the Chair assurance was provided that processes were in place for ensuring things had actually moved forward and examples were given. When elements were completed benefit realisation and post implementation work continued and issues were reported back through the IT Governance Group. The significant work being undertaken was recognised by the Committee. Concern was raised about the amount of time required for staff to undertake adequate training on new systems and the Committee asked for assurance that staff were being supported appropriately. The COO acknowledged that this had been an issue in the past, going forward training time had been taken in to account and new ways of delivering training were being developed to minimise the amount of time staff needed to be released for training.

18/7/53 In response to a query from Pat Drake it was clarified that IT Governance was considered through the IT Governance meeting which fed though to MB and ANCR.

18/7/54 The Committee NOTED the Information Management & Technology Strategy Deep Dive.

Estates & Facilities Strategy Deep Dive

18/7/55 Kirsty Edmondson-Jones delivered the presentation which provided an update on the following:

Strategy Overview & Assurance

Strategy Milestones 18/19

Key Challenges

Key Interdependencies

Opportunities


What’s next - including key risks.

There were 8 key milestones each of which had a detailed action plan. All milestones were rated ‘Green’ having either been completed or on target. An overview of each milestone was provided.

18/7/56 The Committee noted the key risk to the delivery of Estates and Facilities Services remained the high levels of backlog maintenance work (£80m) and Critical Infrastructure Risk (CIR) (£70m) and the combined level of risk this posed to the delivery of services to patients. It was therefore vital that investment in the Infrastructure continued to be recognised as a key Board priority going forwards. There were currently three high level risks relating to this on the Trust’s risk registers, the Trust had recently separated out a risk relating to the lifts, for which funding had now been agreed, and there was to be further discussion by the executive team about potentially separating out other elements of the overall risk to the delivery of Estates and Facilities Services. The Trust was awaiting the outcome of a £130m ICS bid; if this was not successful the Trust may need to consider other borrowing mechanisms/partnerships in order to address backlog maintenance and infrastructure risks.

18/7/57 Opportunities – The NHSI LEAN programme presented some significant further opportunities to increase quality and greater efficiencies and examples of this were provided.

18/7/58 Bev Marshall raised the matter of recent lift failures at the Trust; he thanked the Director of Facilities and Estates for writing to Governors about the matter. It was noted that Governors would receive a more detailed update later the same week.

18/7/59 The Committee DISCUSSED and NOTED the Estates & Facilities Strategy Deep Dive.

Minutes of the meeting held on 21 June 2018

18/7/60 The minutes of the meeting held on 21 June 2018 were APPROVED as a correct record.

Items for escalation to the Board of Directors

18/7/61 None

Time and date of next meeting:

Date: 20 August 2018 Time: 9:15am Venue: Boardroom, DRI

Signed: …………………………………………….. …………………………………. Neil Rhodes Date

DONCASTER & BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

Minutes of the Quality & Effectiveness Committee

held at 2pm on Thursday 21 June 2018 in the Boardroom, DRI

PRESENT : Linn Phipps, Non‐executive Director (Chair) Pat Drake, Non‐executive Director Sewa Singh, Medical Director Karen Barnard, Director of People & Organisational Development

Moira Hardy, Director of Nursing, Midwifery & Allied Health Professionals David Purdue, Deputy CE & Chief Operating Officer (part)

IN ATTENDANCE : Kath Smart, Non‐executive Director

Peter Abell, Governor Observer Andrew Beardsall, Doncaster and Bassetlaw CCGs Lisette Caygill, Acting Deputy Director of Quality & Governance

Ray Cuschieri, Deputy Medical Director Rick Dickinson, Acting Deputy Director of Nursing, Midwifery & Quality (part)

Karen Humphries, Clinical Governance Coordinator (observing) Matthew Kane, Trust Board Secretary Kate Sullivan, Corporate Governance Officer Clive Tattley, Governor Observer APOLOGIES: Marie Purdue, Director of Strategy & Improvement Action Introduction

18/6/1 The members, officers and governor observers were welcomed to the meeting. The Chair welcomed Kath Smart, new Non‐executive Director who was attending this meeting as part of her induction; and also Karen Humphries, Clinical Governance Coordinator, who had a key role in collating the evidence for the Committee’s assurance reports and introductions were made around the table. Andrew Beardsall would be joining the meeting later.

Agenda Review & Terms of Reference

18/6/2 The terms of reference were NOTED. The agenda was reviewed; the agenda included a strategic discussion item which had been moved to accommodate the availability of executives to present the report. The Chair thanked executives and report authors for the quality of the papers, which were largely excellent, and she acknowledged the work that had been done to develop the reports. However the timeliness of receiving some of the reports had been an issue in terms of the Committee having adequate time to review the papers and this would be picked up outside the meeting. It was also agreed to ensure all abbreviations were explained.

ALL

UNAPPROVED

Apologies

18/6/3 Apologies were received from Marie Purdue

Action Log

18/6/4 The action log was reviewed and updated. The minutes had been received later than usual and there was still some work required to cross reference them to the action log and there was also some further work to do on consolidating the actions and closing down the historic items; it was agreed that the Chair would work on this with the Corporate Governance Officer outside the meeting. The Committee focussed on those actions that were not yet complete:

LP/KS

18/6/5 17/10/83 – Access to B Drive for NEDs to view the Quality Dashboard (QD) ‐ The Extranet was still under development and the target date for roll out was now September. In the meantime the current work‐around of sending out a PDF version of the QD would continue. 18/4/21 – Infographic – A meeting had taken place to look at the metrics and information to go under each element. This would be rolled in to the new divisional structure and fed in to the balanced scorecard and would go to the Patient Engagement & experience Committee (PEEC) in the first instance. 18/6/62 – It had been agreed for lead Directors to review all of the areas of concern flagged in reports to ensure they had been risk assessed and appeared appropriately in the risk registers held at Care Group level and this had been taken forward. The Chair sought assurance that all concerns previously raised had been reviewed. The Trust Board Secretary gave assurance that this had been undertaken and processes were now in place where this was monitored; it was agreed that this would be noted in the covering report of the Risk Report each month. 18/4/52 – The Risk Report had been developed to include risk rating for each quarter. This would be developed further to show future direction of travel.

MH MK MK

Patient Experience & Engagement Assurance Report Q4

18/6/6 The Committee received the report of the Director of Nursing, Midwifery & Allied Health Professionals and the Acting Deputy Director of Quality & Governance which used the assurance questions format. It provided the Committee with information relating to Quarter 4 2017/18 performance using the information available from Datix and the learning points from the organisation and summarising the end of year activity. It aligned key priorities and outcomes that were measured through patient feedback, and outlined the Trust’s intentions to implement and monitor performance against the Patient Experience & Engagement Strategy.

18/6/7 It was noted that it had not been possible to open the appendices embedded in the report and these had been tabled.

18/6/8 The Director of Nursing, Midwifery & Allied Health Professionals (AHPs) drew

attention to the following: there had been a significant reduction in the overall number of formal complaints since October 2017 to date with a reduction across all Care Groups. In January, the Trust held a Patient Experience Day; it had been a very positive event. Complaints response performance compliance to timescale was first reported as being sub‐optimal in Q2; this had continued to be addressed through robust weekly Care Group engagement meetings with the Patient Experience Team (PET) to agree/review timescales and improve communication and documentation of progress for monitoring of compliance and escalation purposes. There had been a reduction in complaints from MPs in the quarter.

18/6/9 There had been a dip in performance in March due to an increase in sickness absence and vacancies within the Patient Experience Team. Both vacant posts had been recruited to and were due to commence employment within the next 6‐8 weeks. Additionally the Head of Patient Safety & Experience post was being advertised. One ward had flagged red on the quality metrics in the quarter but there was no correlation between a higher complaints rate against trajectory in conjunction with low staffing or quality concerns. It was agreed to provide an update on the timescale to meet trajectory at the next meeting.

MH

18/6/10 Some examples of learning from patient stories and complaints had been included in the report and this was commended; the Chair expressed a wish to see more of this kind of content in the future. Karen Barnard raised the issue of how assured the organisation was that non‐clinical staff were aware of their role in patient experience and this was discussed. There was more work to do in this area. Staff did not always see the positive impact they were having on patient experience; an example was given of the positive experience of a family member in dealings with a Medical Secretary that had helped a member of their family.

18/6/11 The Committee considered the report and questions were raised about the global #endPJparalysis initiative and the Virtual Fracture Clinic, Kath Smart shared a positive story about a mother and child who had a very positive experience of using the virtual clinic as it had meant they had not had to come in to the hospital.

18/6/12 The Committee considered the significant reduction in complaints being reported from October 2017 and this was discussed. In response to a concern about whether this may be due to data quality or non‐compliance with process the Director of Nursing, Midwifery and AHPs advised that the Trust had considered this and assurance had been received from Heads of Nursing (HoNs) that patients were being advised how to raise concerns and make complaints; it was believed that the reduction was due to the Trust getting better at dealing with concerns at an early stage so that they did not escalate to complaints.

18/6/13 It was noted that the complaints response times were now included on the quality dashboard by care group. This would be mapped over to the new divisions and each area would be expected to review their data and monitor

performance.

18/6/14 The Patient Experience & Engagement Assurance Report Q4 was NOTED.

QUALITY & CARE

Quality Assurance Report

18/6/15 The Committee received the report which comprised three parts that brought together information across a range of areas. The report used the six assurance questions and was set out to provide a response to each question for each of the three areas: a. Quality dashboard b. Hard Truths (nurse staffing and quality metrics) c. Clinical Governance

18/6/16 The cover paper combined all sections together for each of the six assurance questions, and assurances on each question were reviewed with a focus on areas for concern. The Chair commended the clarity of the cover report.

18/6/17 (a) Quality Dashboard

Fracture Neck of Femur (#NOF) performance remained below expectations. This was tracked monthly through the Clinical Governance Committee (CGC) and although the Trust was not an outlier nationally the Trust was still working hard to meet the trajectory. An update was provided on work to ensure the role of the Trauma Coordinator, who was currently on retire and return, was being fulfilled. An update was provided on issues relating to the complexity of patients in terms of frailty and condition upon arrival that meant the Trust did not always meet the required timescale to get patients to theatre within 36hrs. Sometimes, for patient safety reasons, more time was needed to optimise patients for theatre. The Committee was assured that the Trust was doing all it could to meet the standard.

18/6/18 Friends & Family (FFT) response performance remained below target for the Emergency Department (ED). Inpatient response rates had increased in May but ED performance remained a challenge. The Trust had worked hard to improve this and had exhausted a number of approaches to encourage patients and visitors to complete the forms and this was discussed. This was a national comparator and the Trust would continue to look at approaches used by other trusts.

18/6/19 Duty of Candour – Overall, the Trust’s performance in terms of initial communication and first letter was below target. Significant work had been undertaken and this was set out in the report. Care Groups were now taking a purposeful approach of weekly reporting that triggered a follow‐up letter and the central Patient Safety Team were supporting wards in providing data, guidance, prompts and advice for timely completion. In one care group new performance management processes had driven performance to over 80% and this was being shared at clinical governance meetings and with other Care

Groups.

18/6/20 Clinical Negligence Scheme for Trusts (CNST) Maternity Incentive Scheme – Although not highlighted as an area of concern it was noted that there was a risk around compliance with one of the 10 standards for the Maternity CNST incentive scheme; the standards would be added to the quality dashboard for ongoing monitoring purposes.

18/6/21 (b) Hard Truths (nurse staffing and quality metrics) The Care Hours Per Patient Day (CHPPD) rate for registered nurses was lower than the national rate, with mitigation of the outcome of acuity and nurse staffing levels to be in line with the existing establishments for adult ward areas. There was a variance in the staffing planned v actual in Maternity services, which related to roster management and agreeing of budgets. The Committee had asked for assurance in terms of the triangulation of staffing ratios and quality metrics. There had been a slight improvement in CHPPD with some issues being identified in maternity.

18/6/22 There was more work to do to look at the analysis from safer staffing which looked at acuity and dependency of patients. There had been a delay with the data but this would be included in the August report and the next report would take a closer look at maternity. Pat Drake commented the Trust should expect senior staff to make professional judgements when it came to staffing ratios and she asked for assurance that the Trusts staffing strategy was to ensure quality of patient care; this was noted and the Director of People & Organisational Development and the Director of Nursing, Midwifery & Allied Health Professionals acknowledged that there was more work to on this. The planning group would consider future assurance questions on CHPPD and safer staffing.

MH Planning group

18/6/23 (c) Clinical Governance

There were long standing incidents on Datix which remained open. Significant work had been undertaken by the Deputy Medical Director and his team to review all long standing open incidents on logs. A detailed update on the work undertaken was provided. Many of the open incidents were no longer relevant as measures had been put in place to address issues. There had also been a push with Care Group teams to review clinical risks on registers and agree actions. The matter was discussed at length and the Deputy Medical Director gave assurance that all long standing incidents up to 2016 were now closed; only incidents from 2017 onwards remained open. Over 500 incidents had been reviewed none of which had resulted in any concerns; in many cases all that was lacking was the act of closing them down. Around half a dozen basic learning points had been taken from the exercise and these would be shared, the majority were housekeeping issues that needed a disciplined approach.

18/6/24 It was noted that near misses were also reported and this was discussed; it was agreed to report on the percentage of near misses in the future as this provided an indication of staff reporting culture.

RC

18/6/25 The Committee asked for assurance that work would continue to ensure incidents were regularly reviewed. The key issue was staff awareness and behaviour; expectations had been made very clear through the CGC.

18/6/26 One if the incidents related to a leak in the roof of the tower block which continued to leak in multiple places. Details of the wards affected were provided. The Director of Infection Prevention and Control (DIPC) was doing some tests to ensure there were no additional infection risks. This was discussed and the Chair asked for assurance that the matter had been risk assessed. The Medical Director advised that the work being undertaken by the DIPC was part of this; the risk could then be fully assessed and would be put on the risk registers.

SS/MK

18/6/27 It was noted that the Quality Dashboard identified the Trust’s Induction of labour, perineal tear rates and emergency section rates as being higher than the national average. In contrast, the Trust’s still birth rates were better than the national benchmark.

18/6/28 The Quality Assurance Report was DISCUSSED and NOTED.

STRATEGIC DISCUSSION ITEM

Strategic thematic discussion: Patient Experience of the Discharge Process

18/6/29 The Committee received a presentation from the Deputy Chief Executive and Chief Operating Officer on the patient’s experience of the discharge process; the presentation was included in the papers. The Integrated Discharge Team (IDT) routinely contacted patients by telephone following their discharge from the Trust. This feedback had been used to gain insight into their experience and to inform change and improvement to the current discharge processes. The presentation provided an overview of the questions asked, responses by site and some examples of the responses.

18/6/30 It was noted that overall feedback from patients had been positive but some areas of focus identified through the feedback included:

Discharge medication – TTO process.

Discharge passport – specific feedback from patients about how the passport could be improved would be useful.

New discharge passport to be developed and co‐produced with partners.

The use of the discharge passport should also be investigated and promoted as it would appear that not all patients were being provided with all the relevant information.

18/6/31 An overview of some of the barriers to patient discharge was provided; these included not having a key to their home and not having any clothes to be discharged home in. This led to discussion about the age and gender profile of patients and it was agreed to provide details of this outside of the meeting via the Trust Board Office.

DP

18/6/32 There was an in depth discussion about discharge pathways; examples of the different pathways and examples of some of the extensive improvement work undertaken by the Trust over several years was provided.

18/6/33 Reflecting on the presentation Peter Abell commented that during a PLACE visit he had taken part in at Bassetlaw Hospital he had been very impressed with the work the Trust was doing on the Achieving Reliable Care (ARC) project, which included a clear, visual, plan for each patient that was communicated to the multidisciplinary team and a mechanism for collecting information about each delay at individual and ward level allowing targeted interventions to be tested to reduce causes of delays across the system. He had found this patient centred work to be excellent.

18/6/34 The Committee considered issues relating to take‐home medications. Andrew Beardsall provided details of where pharmacists were now working in some care homes and Peter Abell shared a story of a patient of the Trust who after discharge had experienced significant difficulties obtaining pain relief medication from their GP when they had found themselves to be in severe pain after discharge. The issues seemed to have been around communication with the GP Practice. The Chair welcomed the feedback.

18/6/35 The Committee considered what the Trust was learning from the routine surveys of discharged patients and in particular communication with patients, for example about take home medications and what could be done to better manage patient expectations. The Committee welcomed the examples of feedback provided (slide 4) but it was felt that the examples were too constrained and it was agreed that it would be helpful if in future some patient stories could be included so the Committee could see the whole patient experience and align this to the metrics. This was discussed and further to questions raised it was agreed to also include the time of day of discharge, information about communication with GPs and what a good patient discharge looked like.

DP

18/6/36 The Strategic thematic discussion: Patient Experience of the Discharge Process item was NOTED.

Claims Learning Annual Report 2017/18

18/6/37 The Committee received the new report which had been commissioned by the Committee and used the assurance questions format. The Trust continued to experience claims in line with national trends. The Trust had been working hard for several years undertaking a number of activities to mitigate such claims and reduce the likelihood of successful claims and this had led to a decrease in the total value paid out which had previously been steadily increasing from 2008 until 2013. The report identified some high risk areas for which more targeted attention was required. The development of the Quality Governance Dashboard ‐ which would incorporate data on claims ‐ was a way forward to ensuring that there was effective learning through the governance process, with the ultimate aim of ensuring that delivery of healthcare within the Trust was consistently safe.

18/6/38 There was more work to do to reduce claims and this would focus on making

the process of dealing with claims open and transparent so that learning could be shared with all clinical staff; it was the learning that would ensure future claims were prevented. There were still some targeted work to do around Getting it Right First Time (GiRFT) benchmarking which had been received for the first time.

18/6/39 In response to several queries the Committee heard a detailed update from the Medical Director and Deputy Medical Director on how the learning process worked in terms of reaching front line staff, how information was cascaded, how learning was generalised and the roles of the Clinical Governance Committee (CGC) and Patient Safety Review Group (PSRG) in this. There was more work to do on extracting learning and sharing this specific information with teams. One of the key issues was ensuring support staff understood the importance of keeping good records and recording consent so that evidence was available should a claim arise. Where there had been good examples of documentation, claims had been more easily defended.

18/6/40 The Trust continued to be at risk from clinical claims in line with what was happening nationally but it was noted that although the Trust’s claims pay outs had been on a steady downward trend, regrettably CNST premiums continued to go up reflecting the increasing cost of claims which was a national issue. Reflecting on this the Chair asked how the Trust could challenge the NHS Litigation Authority (NHSLA) on this and how much of this was driven by the national position and how much was about the NHSLA’s perception of the Trust’s position. The Deputy Director of Nursing Midwifery & Quality had discussed the matter with the Director of Finance and it had been agreed to meet with the NHSLA to discuss this. An update on those discussions would be provided.

RD

18/6/41 The Committee commended the excellent report, particularly the sample Datix report (anonymised) on how we learn from complaints.

18/6/42 The Claims Learning Annual Report 2017/18 was NOTED.

LEADERSHIP AND IMPROVEMENT CAPABILITY

Workforce & Education Assurance Report

18/6/43 The Committee received the report which used the assurance questions format and was accompanied by an additional detailed report which included sets of data for each area.

18/6/44 The Director of People & Organisational Development summarised the key areas of focus and areas for concern and assurance that mitigations were in place to address concerns. She also provided a detailed update on progress with consultant recruitment for each speciality since the time of reporting. Broadly the level of applications for consultant posts was improving and there had also been a good level of applications from nurses. Visa restrictions for doctors had

been lifted and as a result the Trust was revisiting work to recruit from overseas.

18/6/45 This was the first time the Committee had received the casework data; the Committee probed the level of capability cases. It was noted that the majority of these related to sickness absence. The volume of case work had increased and the Trust was supplementing the team to deal with this work. The Committee considered how it would examine further the casework data and it was agreed that the Committee may wish to receive further analysis and assurance/deep dive on this topic in the future. It was also the first time data from the Model Hospital portal had been included. Due to the variation in months a review of how this data would be provided in future would need to be undertaken.

Future discussion item

18/6/46 In response to questions raised by Pat Drake about work the Trust was doing in terms of Staff Health & Wellbeing (H&W) it was noted that the previous year the Trust had received the Gold Standard Health & Wellbeing in the Workplace award from Nottinghamshire County Council and the Director of People & Organisational Development provided assurance that the Trust undertook a range of work in terms of issues that came out of the staff survey.

18/6/47 The Committee reflected on reasons for sickness absence, particularly depression and anxiety, and what the Trust was doing to support staff at an early stage; it was key for the Trust to support staff before they became so unwell that they were unable to work and there was some work to do around managers spotting early signs.

18/6/48 The Committee commended the report, particularly the new analysis around casework trends.

18/6/49 The Workforce and Education Assurance Report was NOTED.

Maternity Staff Morale

18/6/50 The Committee received the report of the Medical Director which provided assurance of the work ongoing to address poor morale in Maternity Services. A series of listening events had commenced and following the initial round it had become apparent that the Trust would need to run more of these than had originally been anticipated. Feedback from staff at different bands for each part of service was different and the Trust was considering running separate listening events for different staff groups; an overview of key themes was provided. The Trust was also considering an electronic forum so staff could post comments as issues arose. The work from the listening events would inform future plans to improve the integrated services at both sites. The Committee commended this work to listen to staff. The Trust had agreed funding for a Leadership Fellow to support the maternity service integration and improvement of staff morale.

18/6/51 Staff had been very keen for their comments to be kept anonymous and the Trust had respected this but going forward the process needed to be completely transparent and it was important staff were able to embrace this.

18/6/52 In response to a query from the Chair it was agreed to provide confirmation that the risks relating to staff morale had been risk assessed and captured on risk registers; in terms of recruitment and retention issues these were captured on the risk registers. It was also agreed to provide dates for future listening events should NEDs be able to join.

SS

18/6/53 The staff survey would be repeated approximately bi‐annually to establish trends and the direction of travel.

SS

18/6/54 The Maternity Staff Survey Assurance Report was NOTED.

Nursing Workforce Staff Retention

18/6/55 The Committee received the report of the Director of People & Organisational Development which detailed the importance of reviewing the levels of retention and turnover amongst registered nurses and midwives across the Trust, current rates and the actions being taken or planned to improve retention rates. The covering report was set out in the six assurance questions format and this was welcomed.

18/6/56 The high level data indicated that the Trust’s turnover and retention rates were not of significant concern. However the data from the Model Hospital portal indicated that there was greater concern with regard to midwives, this linked with the work being undertaken and reported to QEC on maternity staff morale. There was no single action that would resolve staff retention issues, this required a combined approach and the Trust was currently participating in a number of workshops to explore approaches taken by other Trusts.

18/6/57 A key issue for maternity staff had been the matter of cross site working and the Committee discussed this in terms of how the Trust moved forward to ensure the flexibility of the workforce it required. The Medical Director gave assurance that the Trust was working hard to understand the issues for maternity staff, it was important for staff to be open so that the Trust could understand the full extent of the issues. Notices had been put up on staff notice boards inviting staff to share their ideas about cross site working, what it should look like and how they might expect to be compensated. Pat Drake welcomed this approach.

18/6/58 An overview of some of the approaches being taken by the Trust to address retention and support new starters was provided in the paper. The Director of Nursing, Midwifery & Allied Health Professionals and the Education Department were working with universities to make the Trust a more attractive employer to prospective employees. The Trust was also working with universities outside the normal range it had previously worked with, to offer students from the local areas placements at the Trust; 12 student nurses from Lincoln University were working at the Trust and it was hoped to achieve the same with Derby University. This had been a really positive piece of work.

18/6/59 Pat Drake enquired about the age profile of the Trusts nurses; It had not been

possible to provide the information in time for this report but it would be included in the future.

MH

18/6/60 The update was NOTED.

18/6/61 GOVERNANCE AND RISK

Board Assurance Framework and Corporate Risk Register

18/6/62 The Trust Board Secretary updated the Committee on changes to the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) since the last meeting of the Committee, both had been reviewed by executive and corporate directors for the start of the new financial year. A list of current risks and their alignment to the respective committees was provided for information.

18/6/63 One risk for the Finance & Performance Committee (F&P) had been removed from the BAF and three new risks, two for F&P and one joint risk for F&P and QEC, had been added to the CRR & BAF since the last meeting. Two further changes were also under consideration:

A new risk around Failure to mitigate impact on quality arising from Cost Improvement Programme.

Amend the existing CIP risk (F&P 3) to capture back‐loaded element of the Programme. This followed a discussion at Board on 22 May 2018.

18/6/64 The BAF and CRR had both been amended to include a quarterly tracker of progress. This followed a discussion at F&P in May 2018.

18/6/65 It was noted that there had been significant issues with a number of the lifts at DRI. This was captured within the generic risk relating to ‘Failure to ensure that estates infrastructure is adequately maintained and upgraded in line with current legislation, standards and guidance’ which captured all estates issues. Executives would now consider separating out the risk relating to lifts.

18/6/66 The Chair welcomed that executives were considering a new risk around failure to mitigate impact on quality arising from the cost improvement programme (CIP). There were significant unidentified CIPs and it was important for QEC to be assured on the quality impact assurance (QIA) process for CIPs.

18/6/67 The Board Assurance and Corporate Risk Register were NOTED.

Quality & Effectiveness Committee Annual Report 2017/18

18/6/68 The Trust Board Secretary presented the report which was to note. The purpose of the report was to provide the Board of Directors with a summary of the work of the Quality and Effectiveness Committee (“the committee”) for the year 2017/18. The Chair commended the quality of the report. Any comments were to be forwarded to the Trust Board Secretary.

18/6/69 The Quality & Effectiveness Committee Annual Report 2017/18 was RECOMMENDED to the Board.

Minutes of sub‐committees

18/6/70 The minutes of the following committees were NOTED:

Clinical Governance & Quality Committee held on 16 March 2018 and 20 April 2018.

Workforce & Education Committee held on 26 March 2018.

Minutes of the meetings held on 23 February 2018

18/6/71 The minutes were APPROVED as a true record subject to the following amendment: 18/4/11 – ‘The Trust was now seen as one of the front runners’ to be amended to ‘The Trusts and AHSN Y&H processes were now seen as one of the front runners’.

Any other business

18/6/72 No other business was declared.

Governor questions regarding the business of the meeting

18/6/73 Peter Abell raised a number of questions in relation to the Committee’s role in terms of Duty of Candour and the Care Quality Commissions (CQC) Regulation 20 which aimed to ensure that providers were open and transparent with people who use services. He sought assurance that the Trust was meeting the regulatory requirements particularly in terms of achieving the timeframes for written responses. The Acting Deputy Director of Quality & Governance provided some clarity on the compliance components, required timeframes, how this was measured and details of the Trust’s performance in this area; the Trust was able to evidence that it was working hard to ensure it was speaking to patients at the earliest opportunity and was monitoring response times.

18/6/74 Reflecting on the recent lift outage and leaking roof issues at DRI and questions raised by Peter Abell about CQC Regulation 15, which set out the requirement for providers to ensure, amongst other things, that equipment used to deliver care and premises where care and treatment was delivered was suitable for the intended purpose and maintained, the Committee explored QECs’ role in this area. The matter was discussed; in terms of such issues QEC needed to consider whether the issues presented a risk to the quality of patient care and outcomes and patient experience and also whether the Trust was compliant with the relevant legislation.

18/6/75 Peter Abell raised a number of questions about the role of QEC in terms of considering the CQC Inspection report; for example, would the Committee consider the report in the context of aligning issues/themes identified in the

report with the remit of the Committee’s work and would it look to identify how issues had been raised and whether the Committee was already aware of the issues, and if not why not. The Chair welcomed the valuable feedback, Peter had raised some good points and the Committee would look at this when the CQC inspection report was received.

18/6/76 Peter Abell shared some positive feedback from recent discussion with nurses at the Trust; they had spoken very positively about the support they had received from the Trust when that had new ideas.

Meeting Round‐up

18/6/77 It had been a good meeting which had covered a broad range of topics and the Committee felt that there had been some good discussions. Overall the quality of reports and report summaries had been excellent and the work of Directors and their teams was appreciated. Andrew Beardsall and Peter Abell commented that there had been a good level of robust challenge. The time for some agenda items had run over the time allocated to the individual item, and as a result the meeting had overrun but there had been some important discussions and some good questions had come out of the strategy presentation. Some of the meeting papers had been received later than usual and it was agreed to work to improve this in the future.

Identification of New Risks

18/6/78 No new risks were identified.

Future Discussion Topics

18/6/79 It was agreed to move the list of future discussion items identified for the Work Plan to an appendix rather than recording them in the minutes and noting them on the agenda.

KS

Items for Escalation to the Board

18/6/80 There were no new items for escalation to Board.

Time and date of next meeting:

18/6/81 Date: 21 June 2018 Time: 2pm Venue: Boardroom, DRI

Signed:…………………………………………….. …………………………………. Linn Phipps Date

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Minutes of the Meeting of the Management Board

of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

on Monday 16 July 2018 at 2:00pm

in the Boardroom, DRI

Present: Richard Parker (Chair) Chief Executive Andrew Barker Care Group Director – Diagnostic & Pharmacy Karen Barnard Director of People & Organisational Development Kirsty Edmondson-Jones Director of Estates & Facilities Antonia Durham Hall Care Group Director – Surgical Eki Emovon Care Group Director - Children and Families Nick Mallaband Care Group Director – Emergency Care Group Simon Marsh Chief Information Officer Tim Noble Associate Medical Director Gillian Payne Care Group Director – Speciality Services (Part) Willy Pillay Deputy Medical Director David Purdue Deputy Chief Executive & Chief Operating Officer Marie Purdue Director of Strategy & Improvement Jon Sargeant Director of Finance Jochen Seidel Acting Care Group Director – Surgical In attendance: Hellen Burroughs Deputy General Manager Children and Families (part)

Emma Challans Deputy Chief Operating Officer (part) Kelly Fairhurst Medical Workforce and Recruitment Lead (part) Matthew Kane Trust Board Secretary Alasdair Strachan Director of Education (part) Kate Sullivan Corporate Governance Officer Apologies: Sewa Singh Medical Director Action

Apologies

MB/18/7/1 Apologies as recorded above were noted.

MB/18/7/2 The minutes of Management Board on 11 June 2018 were approved as an accurate record.

UNAPPROVED

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Matters arising and action notes

MB/18/7/3 The action log was reviewed and updated. MB/2/18/28 - The vacancy control process was to be discussed further and brought back in September. MB/18/4/36 – Nick Mallaband and Karen Barnard had met to consider Study Leave allowance for ACPs / PAs and they provided an update. There was further work to do on this and a proposal would be developed and brought back in September. MB/6/18/34 – Simon Marsh provided an update on licences for video conferencing and an update on the rooms where there was now available. The Trust held 25 staff business licences, further licences would cost £20. Access would be set up for Divisional Directors and provided to anyone else that needed it on request.

Management Board Structure

MB/18/7/4 The paper set out the terms of reference for a refreshed Management Board from August 2018, taking into account a number of changes which were set out in the covering report and included the revised role of Management Board including the updated membership and the removal of certain functions as Management Board has evolved including investment / disinvestment which was now exercised through Corporate Investment Group and signed off by the Director of Finance. Also attached were the terms of reference for a new group known as Senior Leadership Forum that would have a membership including named executives, deputy medical directors, deputy chief operating officers, heads of nursing and general managers. An update was provided on progress to make key appointments within the new Divisional Structure; General Managers (GMs) had now been appointed with further posts advertised. It was noted that the Management Board Terms of Reference had been updated.

MB/18/7/5 The membership of the proposed Senior Leadership Forum was discussed. It had been proposed that the CE be present for the first half meeting and this was AGREED. It was clarified that corporate deputies would form part of the Senior Leadership Forum and it was noted that a Shadow Board was also being considered.

MB/18/7/6 The proposed membership of Management Board was discussed and it was clarified that Deputy Medical Directors would sit on the Senior Leadership Forum and Shadow Board if that came in to being. Concern was raised that with the reduction from 6 Care Groups to 4 Divisions and with Deputy Medical Directors no longer sitting on MB, medical representation on

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Management Board had been reduced by 4 members and this was discussed in detail. The Chief Executive reminded Management Board that, including the Medical Director, medical representation would be equal to non-clinical representation. During further discussion management Board debated the hierarchical structure of the divisions and Deputy Medical Directors; It was noted that the decision had been taken for all deputies to sit on the Senior Leadership Forum and Deputy Medical Directors were included in this; this also mirrored more closely the approach of other organisations. The matter would be discussed further outside of the meeting. It was clarified that Deputies, including Deputy Medical Directors would be expected to deputise in the absence of Divisional and Executive Directors.

Management Board discussed the Management Board Terms of Reference and AGREED to recommend to the Board of Directors the proposed changes to the Management Board structure subject to the outcome of discussions outside the meeting.

Financial Monitoring Framework

MB/18/7/7 Management Board received the report of the Director of Finance which set out a proposed financial control escalation process. The DoF noted that the Trust was faced with an unprecedented financial challenge whereby difficult decisions were required to minimise expenditure, reduce costs and maximise income in order to deliver sustainable services and deliver the Trust’s control total. The Trust was responsible for ensuring that public money provided value for money and was being spent robustly. To achieve this, it was absolutely essential that control over spending was strengthened and Improved. He outlined the proposed process and explained the key financial indicators and scoring framework that would determine the frequency and level of escalation.

MB/18/7/8 Reflecting on the thresholds for one of the basis for scoring, agency spend against plan (defined as agency spend vs cap / budget) Nick Mallaband queried whether a plan had yet been defined for agency spend and this was discussed in detail. The DoF acknowledged the concerns, it was a complicated issue and the finance team were working on it. Work was also underway on the workforce plan and plans were being developed for hard to recruit to posts after which it would be clearer what could be achieved in terms of reducing agency spend. Nick Mallaband asked to be involved in this work in terms of how determinations of workforce were made and this was welcomed.

MB/18/7/9 Reflecting on the basis for scoring that related to the Outpatient Cap, Gillian Payne raised concern about the impact of the variation in outpatient cap ratios of new to follow-up appointments across commissioners. This was discussed in detail and there was further discussion in the context of the ICS.

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The DoF and Chief Operating Officer provided an update on discussions with commissioners and action taken by the Trust.

Management Board considered and AGREED the proposed new arrangements for financial control.

CQC Report & Action Planning

MB/18/7/10 The Final CQC Inspection Report was included the papers. The Trust had been provided with a draft report in April 2018 for factual accuracy checks to be undertaken. The Trust had been successful in its challenges for a number of the ratings for Urgent & Emergency Services (UES) and for Children & Young People Services (CYP) at both Doncaster Royal Infirmary (DRI) & Bassetlaw Hospital (BDGH). The final CQC report was published on Tuesday 10 July and it recognised a number of areas of quality care and practice at the Trust. Overall, 72 per cent of the services inspected at Doncaster Royal Infirmary and 77 per cent at Bassetlaw Hospital were judged to be ‘Good’ with no service at DBTH rated as ‘Inadequate’. The CQC assessed whether the Trust’s services were safe, effective, caring, responsive and well-led across the four core services of Urgent and Emergency Care, Medical Care, Children and Young People and Maternity Services. Ultimately, as not all areas had been assessed, this had not changed the overall Trust rating of ‘Requires Improvement’ from the previous inspection which took place in 2015 and this was disappointing.

MB/18/7/11 The Trust would now work to complete action plans for all recommendations and complete all ‘Requirement Notice’ action plans focussing on the “must do” recommendations. It was noted that the Trust had taken the decision to commence work to develop an improvement plan with the target of achieving “Outstanding” ratings across all 5 domains and the Medical Director and the Director of Nursing, Midwifery & Allied Health Professionals were leading on developing a plan to achieve that; this was discussed and endorsed by Management Board.

MB/18/7/12 The report was discussed in the context of, amongst other things, the feeling amongst some staff groups who had worked hard to complete recommendations and make improvements in their areas following the 2015 inspection; some of these areas had not been inspected this time and as such the previous rating still applied and staff had found this very disappointing.

The CQC Report & Action Planning update was NOTED.

STRATEGY DEEP DIVES

MB/18/7/13 Information Management & Technology (IM&T) Strategy

MB/18/7/14 Simon Marsh delivered a presentation which provided an overview of the

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IM&T strategy and progress to achieve key milestones and deliverables. The presentation had been included in the papers and was assumed to have been read, it included the following:

Strategy Overview - the following key points were noted: o The strategy was aligned and in response to the corporate strategy o IT governance framework had been established o IT projects had clearly defined benefits o There was a good level of internal stakeholder engagement o Standardised best practice project methodology was utilised across all

IT projects

Concerns including: o Lack of financial commitment will curtail the achievement of

perceived benefits. o Ability to engage at an appropriate level within Care Groups.

A detailed update on each IT scheme including progress so far and what was expected to be delivered in 2018/19 and 2019/20.

Progress on the schemes was rag rated. Of the 19 schemes 15 schemes were rated ‘Green’, 2 were rated ‘Amber’ and 2 were rated ‘RED’; a more detailed update on these was provided on the ‘Red’ schemes.

MB/18/7/15 A standard template had been agreed for the Strategy Deep Dive presentations. After being presented to Management Board the presentations would be considered by the relevant Sub-committees of the Board, either Finance & Performance (F&P) Committee or the Quality & Effectiveness Committee (QEC), it was agreed to ensure the presentation was in the new format for F&P. With regard to funding to achieve the strategy the DoF asked several questions and Simon Marsh clarified which projects were already funded and which were not; this was discussed. .

MB/18/7/16 The Information Management & Technology Strategy was DISCUSSED and NOTED.

Estates & Facilities Strategy

MB/18/7/17 Kirsty Edmondson Jones delivered the presentation which was in the standard format and provided an update on the following:

Strategy Overview & Assurance

Strategy Milestones 18/19

Key Challenges

Key Interdependencies

Opportunities


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What’s Next - including key risks.

MB/18/7/18 She noted the key risk to the delivery of Estates and Facilities Services remained the poor condition of the infrastructure and level of risk this posed to the delivery of services to patients. It was therefore vital that investment in the Infrastructure continued to be recognised as a key Board priority going forwards. There were currently 3 high level risks relating to this on the Trusts risk registers, the Trust had recently separated out a risk relating to the lifts, for which funding had now been agreed, and there was to be further discussion by the executive team about potentially separating out other elements of the overall risk to the delivery of Estates and Facilities Services.

MB/18/7/19 There were 8 key milestones each of which had a detailed action plan. With the exception of one milestone which was on hold pending the outcome of a Business Case due to be considered by the Board later in the year. All milestones were rated ‘Green’ having either been completed or on target. An overview of each milestone was provided.

MB/18/7/20 The Estates & Facilities Strategy was DISCUSSED and NOTED.

CORPORATE ISSUES

Trust Associate Specialist

MB/18/7/21 Management Board received the report of Alasdair Strachan, Director of Education, which set out a proposal for the establishment of Trust Associate Specialist roles and relevant terms and conditions. Due to national shortages a number of Trusts were advertising Trust Associate Specialists. These roles were not on the national terms and conditions as the role had been closed but Trusts were creating their own terms and conditions, and the Trust had already lost staff to these posts in other Trusts. The roles was more aligned to consultants although some Trusts/specialties may use these doctors to fill ST3+ (registrar level) gaps. Alasdair suggested that the Trust Associate Specialist role was different to a Speciality doctor with a higher level of responsibility to provide independent senior service delivery, both clinical and non-clinical.

MB/18/7/22 There were some specialities where there were not enough consultants available and the Trust could look at creating these posts in those areas. It was also hoped that the posts may attract senior doctors from outside the organisation as well as improve staff retention.

MB/18/7/23 Management Board considered the proposal in detail and there was a wide ranging, in depth discussion on the matter. Several concerns were raised including:

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There were staff working in the Trust in areas where there were not considered to be shortages who may already demonstrate some of the criteria for the post and the Trust needed to be careful not to create an imbalance between specialities. Examples of this were provided.

There was further concern that the creation of the role could disenfranchise some areas of the workforce.

Concern that the role could result in a significant financial impact on some divisions.

MB/18/7/24 There was further discussion about the proposal in the context of the ICS and

national staff shortages, and organisations trying to recruit to the same gaps. The Trust needed to be clear about whether the proposal was to address these recruitment issues, or create a clear career progression. After further discussion it was resolved to consider the matter further at the Divisional Directors meeting, in terms of whether to more clearly set out the framework and rules for creating these posts, or not to progress the case.

Management Board DISCUSSED and NOTED the establishment of Trust Associate Specialist roles and relevant terms and conditions and delegated authority to the Divisional Directors Meeting and Medical Director to reach an agreement on whether or not to proceed with the proposal.

Holt Proposal for Reducing Agency Rates

MB/18/7/25 Management Board received the report of the Director of People & Organisational Development (P&OD) who noted all Trusts had been tasked with reducing agency spend as a whole and agency locum rates over the coming months by NHSI. Holt Doctors have previously attempted to implement ceiling rates at their MV Trusts, but this proved difficult, with conversations taking place with doctors in the Trusts directly in terms of rates to expect to be paid. The paper set out an action plan to reduce agency spending though the implementation of a standardised approach. It included:

Aim of the plan

Stakeholders to be involved

Options to be introduced

Action plan and responsibilities

Potential saving – attached as an appendix

Risks

MB/18/7/26 Management Board considered the risks. It was felt that previous attempts to reduce agency rates had been broadly unsuccessful and, amongst some Divisional Directors, there was a lack of confidence in Holt to fill gaps. There was a risk that other Trusts in the region would not adopt the proposal and

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may then attract staff from the Trusts who chose to proceed with the approach; The Director of P&OD provided an update on the position of other Trusts, ongoing discussions with them and the likelihood of them signing up to the proposal; it was noted that no Trusts had yet made a commitment to the proposal. After further discussion it was resolved that the Trust should support the proposal but only as a collective with other Trusts.

Management Board DISCUSSED and NOTED the Holt Proposal for Reducing Agency Rates and SUPPORTED the proposal to implement a standardised approach as a collective with other Trusts.

Effective Patient Pathway – Presentation

MB/18/7/27 Due to time constraints the presentation was DEFERRED to the next meeting.

DP/EC

HSDU Market Test – Presentation

MB/18/7/28 The Director of Facilities and Estates delivered a presentation which provided an overview of market testing of Trust HSDU Services. It included the following:

Overview of Current Service

Procurement Process

List of Options

Key Features of the Preferred Option

Patient Safety Benefits of the Preferred Option

Contract Management Arrangements

Outline Implementation Resources

Outline Implementation Timeline

MB/18/7/29 5 Bids had been evaluated by in-house teams and an external consultant. The Trust was nearing the stage of recommending to Board the direction of travel and a business case was being finalised to be taken though F&P prior to Board in August. Currently the in house facility based at DRI had a 2 to 2.5 day turnaround time and 2 hospitals were already receiving a transported service from DRI; the proposal would mean a significant improvement in turnaround for those sites as well as an improvement for DRI. Management Board discussed how well informed staff were about the proposal and what their feelings were about it; there had been discussions with staff and although initially some staff had opposed the proposal staff had become more receptive to the idea and there was now good support. There was discussion about teething issues experienced at other trusts. It was noted that the Executive team had agreed to recommend the proposal to board.

MB/18/7/30 The HSDU Market Test Presentation was DISCUSSED and NOTED.

9

Finance Report

MB/18/7/31 Management Board received the Finance Report for May 2018.

MB/18/7/32 The Director of Finance (DoF) presented the report which summarised performance in month 2. Management Board noted the reported in-month income & expenditure (I&E) position of a deficit of £1.9m, which was an adverse variance against budget in month of £402k. The cumulative position to the end of month 2 was a £4.75m deficit, which was £415k adverse to budget.

MB/18/7/33 The DoF provided an update on the June 2018 (month 3) position; Unfortunately in June the Trust had overspent and the position had deteriorated in a number of areas, details of this were provided and discussed. There were several areas the Trust needed to look at including more efficient utilisation of Montagu Hospital and this was discussed. Delivery of CIP which had been back loaded in the plan and significant savings were still required to be identified and delivered. Whilst work continued the gap in the plan was not being closed quickly enough and the Chief Executive emphasised the need to look at opportunities and where the Trust could make efficiencies.

MB/18/7/34 The Finance Report was NOTED.

Corporate Risk Register

MB/18/7/35 Management Board considered a report of the Trust Board Secretary which set out for consideration the Board Assurance Framework (BAF) and Corporate Risk Register (CRR). The report set out 3 changes to the BAF and CRR; two risks had added by executives in the month, one risk relating to risk of critical lift failure was at an extreme level and was proposed to be included on the corporate risk register, the second related to the risk of failure to mitigate the impact of an ambitious effectiveness and efficiency programme on quality of care. A further risk had been escalated via Datix, the risk related to Inability to book interpreters for patients needing endoscopic procedures and details were provided on page 2 of the covering report; the risk was remitted to the Director of Nursing, Midwifery & Allied Health Professionals for investigation.

MB/18/7/36 Management Board considered the extreme risk for inclusion on the Corporate Risk Register which was APPROVED.

MB/18/7/37 The report on the Corporate Risk Register and BAF was NOTED.

10

Replacement Consultants

MB/18/7/38 The following proposals for a replacement consultants were presented for consideration: Replacement Consultant Community Paediatrician The case was APPROVED subject to approval of the job plan and person specification by the Medical Directors office. Long standing vacancy Consultant Histopathologist The case was APPROVED subject to approval of the job plan and person specification by the Medical Directors office.

MB/18/7/39 The following information items were NOTED:

Business Intelligence Report as at 31 May 2018

Chief Executive’s Report

Minutes of the CIG Meeting held on 30 May 2018

Minutes of the Children & Families Board meeting held on 11 May 2018

Minutes of the Urgent & Emergency Care Steering Group meetings held on 9 May & 12 June 2018

Any Other Business

MB/18/7/40 None.

Items for escalation from sub-committees

MB/18/7/41 None.

Date and time of next meeting

MB/18/7/42 The next meeting of Management Board would take place 13 August 2018 at 2pm in the Boardroom.

1

As at 16 August 2018

Board of Directors Agenda Calendar

STANDING ITEMS OTHER / AD HOC ITEMS

MONTHLY QUARTERLY BIANNUAL / ANNUAL

SEPTEMBER 2018

CE Report

Business Intelligence Report

MB Minutes

Finance & Performance Minutes

Finance Report

Chairs’ Assurance Logs

Bed Plan

OCTOBER 2018

CE Report ANCR minutes Charitable Funds minutes

Business Intelligence Report Executive Team’s Objectives Fred & Ann Green Legacy minutes

MB Minutes


Finance Report


NOVEMBER 2018

CE Report QEC minutes Annual Compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR)

Business Intelligence Report Board Assurance Framework & corporate risk register Q2

MB Minutes Estates Quarterly Performance


Finance Report


2


FEBRUARY 2019

CE Report QEC Minutes Budget Setting / Business Planning / Annual Plan

Finance Strategy

Business Intelligence Report Board Assurance Framework & corporate risk register Q3

MB Minutes

HWB Decision Summary


Finance Report


DECEMBER 2018

CE Report Report from the Chair of the ANCR committee (Verbal)


MB Minutes


Finance Report


JANUARY 2019

CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual Plan

Constitution

Business Intelligence Report Executive Team’s Objectives SOs, SFI, Scheme of Delegation CT/HASU (part 2)

MB Minutes Complaints, Compliments, Concerns and Comments Report

Joint working


External reviews policy

Finance Report


3


MARCH 2019

CE Report Budget Setting / Business Planning / Draft Annual Plan


MB Minutes

HWB Decision Summary


Finance Report


APRIL 2019

CE Report ANCR minutes Draft Annual Report Mandatory training update

Business Intelligence Report Executive Team’s Objectives Draft Quality Account

MB Minutes Estates Annual Report Staff Survey

HWB Decision Summary Board Assurance Framework & corporate risk register Q4 (inc. annual assurance summary)


Finance Report


MAY 2019

CE Report QEC Minutes Annual Report

Business Intelligence Report Quality Account

MB Minutes Annual accounts

HWB Decision Summary ISA260 and quality account assurance


Charitable Funds minutes

Finance Report Mixed Sex Accommodation


4


JUNE 2019

CE Report


MB Minutes


Finance Report


JULY 2019

CE Report ANCR Minutes ANCR Annual Report

Business Intelligence Report Estates Quarterly Performance

MB Minutes Board Assurance Framework


Finance Report


AUGUST 2019

CE Report QEC minutes Health and Wellbeing

Business Intelligence Report ANCR Minutes Missed Appointments

MB Minutes Executive Team Objectives


Finance Report


Minutes of the meeting of the Board of Directors

Held on Monday 31 July 2018

In the Boardroom, Doncaster Royal Infirmary

Present: Suzy Brain England OBE Chair of the Board Karen Barnard

Alan Chan Pat Drake

Director of People and Organisational Development Non-executive Director Non-executive Director

Moira Hardy Director of Nursing, Midwifery and Allied Health Professionals

Richard Parker Chief Executive Linn Phipps Non-executive Director David Purdue

Neil Rhodes Chief Operating Officer Non-executive Director

Jon Sargeant Director of Finance Kath Smart Non-executive Director In attendance: Nick Mallaband

Kirsty Edmondson-Jones Marie Purdue

Divisional Director – Medical Services (representing the Medical Director) Director of Estates and Facilities Director of Strategy and Transformation

Matthew Kane Trust Board Secretary Adam Tingle

George Webb Clive Tattley Mark Bright Phil Beavers Mike Addenbrooke Rick Dickinson Karl George

Acting Head of Communications and Engagement Governor Governor Governor Governor Governor Deputy Director of Nursing, Midwifery and AHPs The Governance Forum

ACTION Welcome and apologies for absence

18/7/1 The Chair welcomed Alan Chan, Non-executive Director, to his first Board meeting together with Karl George, of The Governance Forum, who was observing as part of a Board development exercise. Apologies were presented on behalf of Sheena McDonnell, Non-executive Director, and Sewa Singh, Medical Director.

Declarations of Interest

18/7/2 The Board noted the updated Register of Interests. The Chair requested that board members be re-sent the guidance on what was necessary to declare to ensure consistency amongst declarations.

18/7/3 No interests were declared in the business of the public session of the meeting.

Actions from the previous minutes

18/7/4 The list of actions from previous meetings was noted and updated.

18/6/4 – This action was complete and could now be signed off.

Presentation slot – Formal relationship of Doncaster & Bassetlaw Teaching Hospitals (DBTH) and Hall Cross Academy School in the context of the widening participation agenda

18/7/5 The Board considered a presentation from Alasdair Strachan, Director of Education, and Kelly Turkhud, Education Manager, which set out information relating to the key priorities, challenges and future developments across the widening participation agenda including the connections with local schools, colleges and Universities and the development of new roles to support the current workforce.

18/7/6 The presentation and accompanying paper proposed a formal relationship between Hall Cross Academy and DBTH. This proposal had been agreed by the governors of Hall Cross Academy and was now before the Board of Directors for consideration.

18/7/7 The work was based around five key principles:

Having the right people with the right skills, values and behaviours whilst promoting equal access for all

Local demographics – ensuring that the healthcare workforce was representative of the communities it served

Ensuring a workforce fit for the future

NHS Core values – equality, diversity and inclusion

Talent for Care - Get in, Get on, Go further

18/7/8 The project had a number of benefits including engaging existing staff, growing apprenticeships, increased partnership working and talent development allowing the Trust to grow its own workforce. Details of the increased activity were provided.

18/7/9 The Board positively welcomed the proposal. Linn Phipps sought assurance that the team had capacity to take on another project and asked how non-executive directors could support. The Board was advised that the work was not a project as such but a way of working that complemented some of the Trust’s work on continuous improvement. Non-executives would play a key role in providing challenge and championing the proposals.

18/7/10 The Board APPROVED the establishment of a formal relationship between the Trust and Hall Cross Academy and supported the widening participation agenda for DBTH.

Management Board Structure

18/7/11 The Board considered a report of the Deputy Chief Executive and Trust Board Secretary which sought approval of a refreshed Management Board from August 2018 along with the establishment of a new Senior Leadership Forum.

18/7/12 The Board APPROVED:

(1) the revised terms of reference for Management Board.

(2) the establishment of, and terms of reference for, the new Senior

Leadership Forum.

Annual Members’ Meeting arrangements

18/7/13 The Board considered a report of the Trust Board Secretary which set out a proposal for the 2018 Annual Members’ Meeting which was scheduled to take place Wednesday 19 September 2018 from 4pm at the Keepmoat Stadium, Doncaster.

18/7/14 The proposal built on lessons learned last year and proposed changes to the meeting format and meeting room layout in addition to being signed by a British Sign Language interpreter. Details of the ‘market stalls’ showcasing the work of the Trust were set out in the paper.

18/7/15 Board APPROVED the arrangements for the upcoming Annual Members’ Meeting.

Amendment to Constitution

18/7/16 Further to the meeting of the Council of Governors on 26 July 2018, the Board APPROVED the following deletion to paragraph 2.1.19 to Annex 5 of the Trust’s constitution: “A governor is not eligible to become or continue in office as a governor if he/she had, within the preceding 2 years, been a chair or non-executive director of another health service body.”

Chairs Assurance Logs for Board Committees held 23 and 24 July 2018

18/7/17 The Board considered a report of the chairs of Finance and Performance Committee and Audit and Non-clinical Risk Committee following their meetings on 23 and 24 July 2018.

18/7/18 The Finance and Performance Committee reported that the Trust had met its financial targets to earn its full Provider Sustainability Fund (PSF) monies in the quarter but this had required support from non-recurrent expenditure. The outstanding effectiveness and efficiency target was £2.65m. The meeting had received positive assurance on finance, performance and workforce issues.

18/7/19 The Chair of Audit and Non-clinical Risk Committee escalated two matters. These related to the progress of outstanding medium/high-risk recommendations from 2016/17 audits and the return rate from some areas for the Trust-wide Register of Interests. Actions had been put in place to move these issues forwards.

18/7/20 Board NOTED the updates. Strategy and Transformation Update

18/7/21 The Board considered a report of the Director of Strategy and Transformation that set out exceptions against delivery of enabling strategy milestones in Quarter 1. Milestones were currently on track and deep dives into each strategy had commenced at board committees.

18/7/22 In response to a question from Kath Smart, the Board was advised that further work was being done to develop strategic key performance indicators (KPIs) to measure progress against delivery of the milestones.

18/7/23 The Director of Strategy and Transformation then gave a presentation on

the Trust’s work with the NHSI programme, Vital Signs – an improvement practice for the NHS, which had started in advance of the planned start date of July 2018.

18/7/24 The NHSI programme was developing an improvement practice based on lean principles. It complemented the Trust’s Qii work that sought to make improvement part of everyday practice.

18/7/25 The NHSI team facilitated a “visioning” session with the Executive team in June 2018 in order to: define the aim, scope, boundaries and targets for the programme; start the personal training of the executive team; and help the Executive Team start to understand their governance responsibilities and the different styles of leadership required to deliver a successful lean principles based transformation.

18/7/26 A product of this session was a purpose pyramid that identified the vision, mission and goals of the improvement work ensuring it was aligned to the DBTH Strategic Direction and tied down to one year and five-year goals. In the short to medium term, the Trust expected to deliver benefits in quality of care, staff engagement, finance and delivery. In five years’ time, the Trust had the aspiration to be the safest trust in England, outstanding in all it did.

18/7/27 Further to a question from Pat Drake it was agreed that further work would

be required to scope how the programme would contribute to solving problems. A workshop style forum may be the most appropriate method through which to highlight the programme’s value. Linn Phipps emphasised the importance of staff and patient engagement in the programme while Kath Smart praised the strapline developed during the Executive Team visioning session.

KB

18/7/28 The Strategy and Transformation Update was NOTED.

Finance Report – June 2018

18/7/29 The Board considered a report of the Director of Finance that set out the Trust’s financial position at month 3, which was a deficit of £1.5m, favourable against plan in month by £445k. The cumulative position to the end of month 3 was a £6.2m deficit, which was £30k favourable to budget.

18/7/30 The position was achieved after the release of non-recurrent monies of £1.4m in month following the review of prior year accruals being held. This mainly related to accruals for agency doctors (through Holt) which were no longer required following review.

18/7/31 Key risks against delivery of the financial plan were set out in the report. It was noted that the Trust needed to achieve a £6.6m deficit to deliver the year end control total, and therefore needed to achieve a break even or better position for the rest of the year.

18/7/32 Board were also asked to approve the reference costing process ahead of the collection to enable the Director of Finance, on behalf of the Board, to approve the final national costs collection return before the final submission date.

18/7/33 In response to a question from Linn Phipps over whether the CIP gap was

being closed quickly enough, the Board was advised that there was still much work to do on maximising the benefits of the Getting It Right First Time (GIRFT) and Model Hospital processes. The Trust was already facilitating this through the appointment of a lead clinician for GIRFT.

18/7/34 The Board:

(1) NOTED the Trust’s deficit for month 3 (June 2018) was £1.5m, which was a favourable variance against plan in month of £445k. The cumulative position to the end of month 3 was a £6.2m deficit, which was £30k favourable to budget.

(2) NOTED that a release of prior year accruals of £1.4m had been required in month to ensure delivery of the Q1 control total.

(3) NOTED the progress in closing the gap on the Cost Improvement Programme.

(4) NOTED the risks set out in the paper.

(5) APPROVED the costing process ahead of the collection to enable the Finance Director, on behalf of the board, to approve the final national costs collection return before the final submission date.

18/7/35 The meeting adjourned at 10.25am and reconvened at 10.35am.

Performance Report as at 30 June 2018

18/7/36 The Board considered a report of the Chief Operating Officer, Medical Director, Director of Nursing, Midwifery and Allied Health Professionals and Director of People and Organisational Development that set out operational and workforce performance in month 3, 2017/18.

18/7/37 Performance against key metrics included:

Four hour access - In June, the Trust achieved 95.35% (including

alternative pathways) against the target of 95%.

RTT – In June, the Trust performed below the standard of 92%,

achieving 89.6%. However, this was almost in line with the funded

contractual performance of 90%.

Cancer targets – The 62 day performance achieved the 85%

standard, coming in at 85.6%.

HSMR – The Trust's rolling 12 month HSMR remained better than

expected at 88.7.

C.Diff – Three cases were recorded in month.

Nursing Workforce - The Trust’s overall planned hours versus actual

hours worked in June was 100%.

Appraisal rate – The Trust’s appraisal completion rate saw an

increase to 75.64%.

SET training – There had been an increase in compliance with

Statutory and Essential Training (SET) and at the end of May the rate

was 80.82%.

Sickness Absence – The Trust’s sickness absence rate had decreased

to 3.91%.

18/7/38 The month had seen a significant increase in the number of people attending Accident and Emergency and the Trust was working with local businesses to try and understand why that was the case. This additional work had been anticipated by the Trust but not by the CCG. The Trust had again asked the question of the centre as to whether alternative pathways could be counted within monthly reported figures.

18/7/39 In response to a question from Pat Drake, the Board was advised that the

Trust was currently contracted to deliver 89% for Referral to Treatment and that delivering 92% would require work for which the Trust was not paid.

18/7/40 Further to a question from the Chair, the Board was advised that 20% of the prison population in Doncaster and Bassetlaw were on the Trust’s patient treatment list. The Chair requested additional information in terms of the age range of these patients.

DP

18/7/41 In response to a question from Pat Drake, the Board was advised of a trend upwards in respect of Hyper Acute Pressure Ulcers with five in June as opposed to two in May. Such cases were immediately reported as a serious incident and best practice was followed. It was agreed to give some consideration to showing those cases which had been deescalated.

18/7/42 Further to a question from Kath Smart, the Board was advised that further work was being undertaken to smooth out stroke pathways. Finally, the Board were advised that Statutory and Essential Training was known as Mandatory and Statutory Training in the rest of the South Yorkshire and Bassetlaw area and this may necessitate a further look at how this was branded at the Trust.

18/7/43 The Board NOTED the Performance Report. Q1 Estates & Facilities Performance Report

18/7/44 The Board considered a report of the Director of Estates and Facilities that provided Board with the first quarterly review of performance of estates for 2018/19. The report also included the results of the annual Patient Led Assessment of the Care Environment (PLACE), ahead of benchmarked data due in August/September.

18/7/45 Highlights from the report included:

Appraisal remained Green and increased to 94%

Sickness reduced by 1.1%

PLACE scores increased by between 6.4% - 10.3%

The Trust’s PLACE cleaning score was 99.99%

18/7/46 Areas for improvement were also highlighted. In response to a question from Alan Chan, the Board was advised that cleanliness was independently checked via the PLACE survey.

18/7/47 The Board NOTED the report. CQC Inspection Outcome

18/7/48 The Board considered a report of the Director of Nursing, Midwifery and Allied Health Professionals that formally presented the outcomes of the recent inspection of the Trust from the Care Quality Commission (CQC).

18/7/49 The Core Services that were inspected at Doncaster Royal Infirmary (DRI)

and Bassetlaw District Hospital (BDGH) and their rating outcomes were:

Urgent and Emergency Care – Requires Improvement at DRI and BDGH

Medical Care – Good at DRI and BDGH

Maternity – Requires Improvement at DRI and Good at BDGH

Children and Young People – Good at DRI and BDGH

18/7/50 The Well Led inspection in January was rated as Good. The effect of these rating outcomes improved Maternity at BDGH and the overall rating for the Responsiveness domain. The Trust and Hospital overall rating had not changed, so remained at Requires Improvement.

18/7/51 The Trust was completing the required action plan following the CQC recommendations and developing a plan to improve each core service with an aspiration of achieving Outstanding. Further to questions from the Chair, Board was advised that their aspiration was to achieve ‘Good’ by 2019 and ‘Outstanding’ by 2020. An action plan would be brought to Quality and Effectiveness Committee (QEC) in August.

18/7/52 The Board NOTED the content of the report and:

(1) The development of improvement plans in addition to the action planning against the recommendations.

(2) Monitoring of CQC compliance through QEC. Board Assurance Framework & Corporate Risk Register

18/7/53 The Board considered a report of the Trust Board Secretary which presented the Board Assurance Framework and Corporate Risk Register for Quarter 1.

18/7/54 In summary:

One risk had been removed from the Board Assurance Framework.

Two risks had been added to the Corporate Risk Register and five to the Board Assurance Framework.

Five risks had seen their ratings change.

18/7/55 The Board NOTED the Corporate Risk Register and Board Assurance Framework for Q1 2018/19. Update on Agenda for Change pay deal

18/7/56 The Board considered a report of the Director of People and Organisational Development regarding the three year pay deal for staff employed on Agenda for Change.

18/7/57 Board was advised that the deal ended the 1% pay restraint and would

result in pay of 6.5% over 3 years for those at the top of their scale (not 8d/9). Existing pay-scales would be shortened and there would be a removal of overlap between bands as well as increases in starting salaries. Minimum pay in the NHS would be £17,460.

18/7/58 The changes would also mean that Band 1 would be closed to new starters from 1 December 2018. There was a process to include upskilling Band 1 jobs to Band 2 roles during the three years of the pay deal. Additional provisions would allow for enhanced shared parental leave, child bereavement leave and a national framework on buying and selling leave.

18/7/59 Changes from April 2019 would also see an end to automatic pay progression. Instead, it would be dependent on a completed individual appraisal process that was in line with the organisation’s standards, no live formal disciplinary action being on the staff members’ record, all statutory and/or mandatory training being fully complete and any local standards, as agreed through partnership working, being met. For line managers only, all appraisals for their staff must be complete.

18/7/60 Board was advised that the changes meant a significant funding gap for the Trust. The Trust was also assessing the impact on staff who worked for companies contracted by the NHS. It was understood that the Department of Health would fund such increases where staff were subject to “dynamic use” of NHS Agenda for Change.

18/7/61 The Board NOTED the update. Recruitment and Retention – development of a workforce strategy

18/7/62 The Board considered a report of the Director of People and Organisational Development which provided the current position on key vacancies.

18/7/63 There was an overall vacancy rate of 7% across the Trust with nursing and midwifery at 4.9%, allied health professions/scientific & professions at 3.9% and medical staff at 16%. Sixty-six newly qualified nurses and midwives were due to join the Trust in September which would reduce the nursing vacancy rate to below 2%.

18/7/64 There was a brief discussion on values based recruitment which had been employed for the recent recruitment of the Deputy Chief Operating Officer and Deputy Director of Nursing. A future workshop was proposed on values based recruitment to understand it in more detail.

KB

18/7/65 Further to a question from the Chair, the Board recognised the challenges in respect of retaining staff in professions such as coding which provided the Trust with a route to ensuring it was properly paid for the work it carried out.

18/7/66 The Board:

(1) CONFIRMED that the Board was assured by the work being undertaken by the Trust to reduce vacancy levels, reduce agency expenditure and improve turnover and retention rates.

(2) AUTHORISED the Workforce and Education Committee, reporting through to the Finance and Performance Committee, to monitor progress to reduce vacancies and temporary staffing expenditure and through to QEC for work around improving retention rates and developing a longer term workforce strategy.

Board Development Programme

18/7/67 The Board considered a report of the Director of People and Organisational Development that presented an update on the schedule for the Board Development programme.

18/7/68 The Board NOTED the update.

Reports for Information

18/7/69 The following items were NOTED:

Chair and NEDS’ report

Chief Executive’s report

Audit and Non-clinical Risk Committee Annual Report

Minutes of Finance and Performance Committee, 21 June 2018

Minutes of Management Board, 11 June 2018

Board of Directors Agenda Calendar

18/7/70 Further to a question from Linn Phipps on whether the new Secretary of State had signalled any changes in direction, the Board was advised that the Trust had written to Rt. Hon. Matt Hancock MP to congratulate him on his appointment. It was understood that he remained interested in IT and digital but that this may change as a harsh Winter was expected with increased demand on the NHS as a sector. There was then a brief discussion around Brexit and the implications for medicines supply and overseas nurses. It was agreed that the direct impact of Brexit be assessed as a risk.

MK

Items escalated from Sub-Committees

18/7/71 None.

Minutes

18/7/72 The minutes of the meeting of the Board of Directors on 26 June 2018 were APPROVED as a correct record. Any other business

18/7/73 The Chair took the opportunity to promote the Trust’s new publication, Good Health, which was priced at £6.99 if bought at the Trust.

Governors questions regarding business of the meeting

18/7/74 Referencing the arrangements for the Annual Members Meeting, George Webb asked whether that meeting would be ratifying changes to governor terms of office. In response, Board was advised that the Board Secretary had assessed whether the rule change should be a matter for the AMM. As the matter of terms and tenure was not a matter relating to the powers, duties or role of governors the issue of governor terms was not a matter for the AMM.

18/7/75 George Webb also reminded the Board of the need to keep governors abreast of developments, in view of the recent issues with the lifts at Doncaster Royal Infirmary.

18/7/76 A question from Mark Bright relating to a change in expenditure on page 129 of the board pack was clarified as relating to agency pay. In response to a supplementary question from Mark Bright, the Board advised that performance graphs would be changing shortly to reflect the changes in divisional structures.

Date and time of next meeting

18/7/77 10.00am on Tuesday 21 August 2018 in the Boardroom, Montagu Hospital. Exclusion of Press and Public

18/7/78 It was AGREED that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Suzy Brain England Date Chair of the Board

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