A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE …

BoD 05 March 2020: Agenda (PRM)

A MEETING OF THE BOARD OF DIRECTORS

WILL TAKE PLACE ON THURSDAY 5 MARCH 2020, 9.00 am

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL AGENDA

No Item Sponsor Ref 1 Apologies and Welcome:-

Mrs K Firth – Non Executive Director Mr K Clifford – Non Executive Director

Mr T Lake Chairman

Verbal

2 To receive any Declarations of Interest. Verbal Assurance

3 To approve the minutes of the meeting of the Board of Directors held in public on Thursday 6 February 2020.

20/03/05/03 Approve

4 To approve the action log in relation to progress to date and review any outstanding actions.

20/03/05/04 Approve

5 To receive and review a patient’s story.

Mrs J Murphy Director of Nursing &

Quality

Presentation Information

ASSURANCE

6 To receive and approve the Chair’s Log for the Quality and Governance Committee (Q&G) held on Wednesday 26 February 2020.

Ms R Moore Non-Executive

Director Chair of

Quality & Governance Committee

20/03/05/06

Assurance

7 To receive and approve the Chair’s Log for the People, Finance and Performance Committee (PFP) held on 27 February 2020.

i Gender Pay Gap Report

Mr F Patton Non-Executive

Director Chair of

Finance & Performance Committee

20/03/05/07

20/03/05/07i

Assurance

8 To receive the Chair’s Log for Barnsley Facilities Services (BFS) including BFS 2019/20 Aims and Objectives Quarter 3 update.

Mr F Patton Non-

Executive Director

20/03/05/08

Assurance

9 To receive and review the Chair’s Log on any escalation issues from the Executive Team (ET).

Dr R Jenkins Chief

Executive

Verbal Assurance

10 To receive the Integrated Performance Report (IPR) Month 10.

Dr S Enright Medical Director

20/03/05/10 Assurance

11 To approve the Data Protection Annual Assurance Report.

Mr T Davidson Director of ICT

20/03/05/11

Assurance

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BoD 05 March 2020: Agenda (PRM)

12 To receive and review the annual report of the Staff Survey.

Mr S Ned Director of HR

20/03/05/12

Assurance

13 To receive the Bi-annual approval of the use of the Trust’s Seal.

Ms M Saunders Director of Corporate

Governance

20/03/05/13

Assurance

14 To approve the Managing Conflicts of Interest Policy. Ms M Saunders Director of Corporate

Governance

20/03/05/14

Approval

STRATEGY

15 To review and receive the Trust’s Aims and Objectives for 2020/21.

Mr B Kirton Chief Delivery

Officer & Deputy Chief

Executive

20/05/03/15 Assurance

16 To receive the Chair’s Log for the Barnsley Integrated Care Partnership Group.

Mr T Lake Chairman

Verbal Note

17 To receive and review the latest intelligence report. Mrs E Parkes Director of

Marketing & Comms

20/05/03/17 Note

CULTURE

18 To endorse the report on Celebrating our People. Mrs E Parkes Director of

Marketing & Comms

20/05/03/18 Note

OTHER ITEMS

19 To receive and review the monthly report from the Chairman.

Mr T Lake Chairman

20/05/03/19 Note

20 To receive and review the monthly report from the Chief Executive, including an update on the South Yorkshire and Bassetlaw Integrated Care System (ICS).

Dr R Jenkins Chief

Executive

20/05/03/20 20/05/03/20i

Note

21 To invite questions from members of the public relating to items on today’s meeting agenda. Members will be invited to raise questions relating to items on the meeting agenda at the Chair’s discretion.

Mr T Lake Chairman

Verbal

22 In accordance with the Trust’s Standing Orders and Constitution, to resolve 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. Date of next meeting: Thursday 2 April 2020, 9.00 am, Lecture Theatre

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MINUTES OF A MEETING OF THE

BOARD OF DIRECTORS HELD ON THURSDAY 6 FEBRUARY 2020 AT 9.00 AM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT

PRESENT: Mr T Lake Chairman, Chair Dr R Jenkins Chief Executive Dr S Enright Medical Director Mr R Kirton Chief Delivery Officer & Deputy Chief Executive Mr C Thickett Director of Finance Mrs J Murphy Director of Nursing & Quality Mr S Ned Director of Workforce Ms R Moore Non- Executive Director Mrs S Ellis Non-Executive Director Mrs K Firth Non-Executive Director Mr N Mapstone Non- Executive Director Mr F Patton Non- Executive Director Mr P Hudson Non-Executive Director Mr K Clifford Associate Non-Executive Director IN ATTENDANCE: Ms M Saunders Director of Corporate Governance Miss L J Watson Executive PA to CEO/Chairman Mrs R Milligan Patient Experience and Improvement Manager – item 20/05 Mr G Portier Head of Nursing Quality – item 20/05 OBSERVERS: Mr A Higgins Lead Governor, Public Mrs M Sheard Public Governor Mr T Conway Public Governor Ms E Coombe Public Observer Mr M Robertson NHS Professionals Mrs C Swanson-Hunt PwC Deals Manager Mrs L Middleton PwC Director APOLOGIES: Mr T Davidson Director of ICT Ms E Parkes Director of Marketing and Communications Action 20/01 APOLOGIES & WELCOME

Mr Lake welcomed members and attendees to the first Board of Directors meeting of 2020. A particular welcome was extended to Price Waterhouse Cooper (PwC) who was in attendance to observe the meeting as part of the Well Led Review, feedback will be provided as part of the programmed work.

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

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BoD 06 February 2020 - February Minutes PUM

20/02 TO RECEIVE ANY DECLARATIONS OF INTEREST The standing declaration of interest for Mr Patton and Mrs Firth was noted. No other declarations were received. With effect from 10 February 2020, a standing declaration of interest will be noted for Dr Jenkins upon commencement of the joint role as Chief Executive with The Rotherham NHS Foundation Trust. No declarations of interest were received in relation to the items for discussion today.

20/03 MINUTES OF THE LAST MEETING Subject to minor changes the minutes of the meeting held on Thursday 5 December 2019 were reviewed and accepted as an accurate record of events.

20/04 ACTION LOG All outstanding actions from the previous meetings were reviewed with updates noted accordingly.

20/05 PATIENT/STAFF STORY Mr Portier was in attendance to present the Mental Capacity Act in Practice. The patient had been admitted to hospital following concerns raised by neighbours who alerted the Local Authorities to the decline in the health of the patient. Following a diagnosis of bowel cancer emergency surgery was required to relieve the bowel obstruction. Due to the patient also being diagnosed with dementia and lacking the mental capacity to make decisions relating to care and treatment a Best Interest Meeting was held involving the Care Home Manager, Surgical/Anaesthetic Consultants and the neighbours of the patient as next of kin were unable to be located. All views were considered and it was agreed that the patient’s wishes prior to the diagnosis of dementia would be taken into account, which it was considered, would be to decline surgery or to be cared for at the care home. The patient was subsequently discharged back to the care home with support from the Palliative Care Team in the community. This enabled the patient’s symptoms to be well controlled and he peacefully passed away. The presentation today demonstrated the links to the Mental Health Strategy and the Dementia Strategy highlighting the importance of partnership working, individualising patient care and providing compassionate care to the patient with the end of life care having been delivered in the favoured environment. Mr Lake queried if any specific training is undertaken for staff that form the Multi-disciplinary Group within the Best Interest Meeting. Staff are required to undertake the Mental Health Capacity Training and Safe Guarding Training, a best interest assessor is also present at the meeting as the Chair. Dr Enright commented as part of medical training this element forms a large part of the junior doctor training programme within the Medical School and medical profession. Mr Mapstone sought clarity regarding the Best Interest Assessor role and if this is a statutory requirement within the Trust. Currently the role is not a requirement however with the introduction of Liberty Protection Safeguards (LPS) it is anticipated this will change. The Safe Guarding Lead and Local Authorities provide expertise within care homes.

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Mrs Murphy has recently met with the Director of Nursing at South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) where agreement has been reached to enhance partnership working with a group to deliver Child and Adolescent Health Services (CAMHS) training and sharing of training generally. Mr Portier, on behalf of the Nursing Staff, thanked Mrs Murphy for her support since her commencement at the Trust. On behalf of the Board Members Mr Lake thanked Mr Portier for the complex presentation.

20/06 CHAIRS LOG FOR THE QUALITY & GOVERNANCE COMMITTEE (Q&G) Ms Moore as Chair of the Quality and Governance Committee (Q&G) presented the report providing an update following the meetings held on 18 December 2019 and 29 January 2020, highlighting the following key points:- • The Committee received a report regarding the Medical Examiners Office

which is now well established and compliant with legal requirements. • For assurance, a presentation was received on the changes to the Acute

Stroke Service which took place following the Hyper-acute Stroke Unit (HASU). The Committee also looked at the general improvements highlighted within the Sentinel Stroke National Audit Programme (SSNAP) audit.

• For information the 50% reduction in category 2 pressure ulcers resulting in lapses of care has not been met by the Trust.

• The Trust has reported 19 cases of C-Diff. • An update on the Coronavirus had been received. • The Committee received the six monthly cancer services report. In relation to the pressure ulcer report Mrs Firth queried if sufficient preparation had taken place during the summer months and in sourcing equipment. Mrs Murphy informed members additional mattresses and falls alarms were purchased and in place prior to December 2019. There were a number of issues regarding the appropriate placement of fall alarms to ensure accessibility when required. This has been a managed process with is now complete. Mr Mapstone requested an update in relation to patients who have had a stroke and require referral to the vascular surgeons. Dr Enright confirmed the Trust has a relationship with Sheffield Teaching Hospitals (STH), as the local tertiary center, for the transfer of patients supported by outreach clinics within Barnsley. Mr Lake queried if the Trust receives the Service Level Agreements (SLAs) within the current agreement with STH. Dr Enright commented he has not aware of any issues with the service. Dr Jenkins suggested, given the perceived lack of availability of vascular surgeons, there may be benefit in confirming current arrangements with the service. Mr Kirton confirmed the Trust does receive the allocated time for the planned work which is delivering as planned. The main issue for the Trust is in relation to an urgent care need arising on site. However a review to improve pathways within the process has been completed. Further updates will be provided through the Quality & Governance Committee. The Board noted and received the report.

SE

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Policy for approval – Following approval at relevant Committees, the Board was asked to approve the Trans Equality Policy. The policy was approved by the Board noting the Marketing and Communications Team will provide support to reinforce the Trust’s values. Acknowledgement was expressed to Mr C Brotherston-Barnett for his commitment and contribution in implementing the policy.

EP

20/07 CHAIRS LOG FINANCE, PERFORMANCE AND WORKFORCE COMMITTEE (FP&W) Mr Patton presented the Chair’s Log from the Finance, Performance and Workforce Committee (F, P&W) held on 30 January 2020, noting the Chair’s log for December 2019 had previously been circulated for information. The following key points were highlighted:- • The Committee sought assurances regarding the ability to deliver the year

end capital spend, a detailed planned approach was provided providing assurance the plan could be delivered

• The Committee received an update on SLAs which evidenced good progress in terms of sign off however a number remained flagged as red rated and amber. Assurance was provided that work continues to address these issues however discussions were held to prioritise those with the highest value.

• National detailed planning guidance, at the time of F, P&W, was awaited however assurance was provided that regardless of the late receipt the Trust will still meet the time lines for providing information to Committees and Board.

• The Committee was assured, based on comparison to 2018/19 Cost Improvement Plan (CIP) plan that the team remains on track to deliver the 2019/20 programme.

• Assurance was provided that delivery of the 4 hour access target was being implemented to deliver the best care for patients. Updates were provided on the winter escalation.

• The People Strategy update was received and the team were complimented on the development of the report. Queries were raised regarding the links between the actions and the Care Quality Commission (CQC) well led domains, a better understanding of the domains is required to provide assurance that the actions being taken were delivering against those standards.

• The Draft Organisational Strategy was received for comments; a suggestion was made to link the strategy into the People Plan to support the assurance of the delivery. Feedback is to be provided to the Director of Workforce.

• The Gender Pay Gap report was received. Further work is required in terms of the action plan for 2020/21 which be discussed further at the next Committee meeting, 27 February 2020. This will also be attached to the report for presentation at the Board meeting on 5 March 2020.

• An updated on System C Medway was received. Concerns were raised regarding the pressures within the team regarding staff training, assurance was provided this is achievable.

• The Board Assurance Framework (BAF) and Corporate Risk Register (CRR) were reviewed. The risk relating to EU exit and tax implications for HMRC require reassessing following recent national announcements.

In response to a request for further information relating to Capex, Mr Thickett provided a brief update. Regular meetings are taking place to ensure the Trust is on track on a weekly basis to ensure delivery of the profile. The main reason

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pertaining to spend is due to earlier delays during year, however the team are confident all the elements with the programme will be delivered. There are a number of areas where there is an element of risk however an exercise has been undertaken to identify items from the 2020/21 programme which can be accelerated.

20/08 CHAIR’S LOG – AUDIT COMMITTEE Mr Mapstone presented the Chair’s Log from the Audit Committee held on 22 January 2020 highlighting:- • A plan is in place to prepare the 2019/20 end of year accounts. • The Committee discussed arrangements to invite tenders for the external

audit service for three years from 1 September 2020. The Governor representative on the Committee has been asked to liaise with governor colleagues regarding involvement in the process.

• The Committee noted the decision by the Director of Finance to increase the external audit fee.

• Internal audit have issued a number of reports since the last Audit Committee in October 2019. Two audits were given limited assurance of opinion by the auditors however, the committee was confident that management responses were adequate.

• The Committee reviewed and made suggestions regarding the Draft Internal Audit and Counter Fraud Plan for 2020/21.

• A Clinical audit assurance report was received. • Subject to minor amendments, the Committee approved the Conflict of

Interest Policy. • The Committee is required to undertake an annual review of the Trust’s

Governance Arrangements. • The Committee is required to undertake an annual review of the posts

eligible to dismiss staff. However it was noted that the Grievance and Disciplinary Policy is due for review. Mr Ned confirmed this policy is currently under review by the HR Team with the intention to present at the F, P&W Committee in April/May 2020.

Following discussion the Absence Management Assurance Report will be forwarded to Mr Patton for presentation at the F, P&W Committee. Dr Enright thanked Mr Mapstone and the Audit Committee for the involvement with the Clinical Audit Process. The Board noted and received the report.

NM

20/09 CHAIR’S LOG – EXECUTIVE TEAM (ET) Dr Jenkins drew the following items to the attention of Board:- • Coronavirus – Following media coverage two cases of coronavirus have

been reported within the United Kingdom, detected in York, both individuals are being managed in a Regional Centre. Daily updates are being received from Public Health England and national organisations regarding the evolving response to the virus as further understanding of the illness and risks become clear. The Trust is following all national guidance as a precautionary measure with regular update calls scheduled between all relevant agencies within Barnsley.

• The planning guidance has recently been published and the Trust is currently in the process of reviewing the plan for 2020/21.

• From January 2020, the Trust now provides an out-of-hours Gastro-internal Haemorrhage service for The Rotherham NHS Foundation Trust. In the first month, three patients were transferred out-of-hours; no issues with clinical

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care were identified. This is being reviewed on a case by case basis to ensure there are no unanticipated issues.

The Board noted and received the verbal update.

20/10 INTEGRATED PERFORMANCE REPORT (IPR) – Month 09 Mr Thickett presented the IPR for Month 9 with the following key items being highlighted:- Performance • Due to a challenging period, the 4 hour access target deteriorated in

December 2019, reported at 80.7% with a 5% increase in A&E attendances above plan and a 6% increase in non elective admissions for the same period. The site has been under extreme pressures throughout December 2019. The Winter bed escalation plan has been in place which has helped alleviate flow issues.

• 18 week access reported compliant. Referral Time to Treatment (RTT) incomplete position of 93.57%.

• Compliant access for 62 day pathways for cancer patients in November, 2 week access not compliant at 92.9% relative to a 93% standard. 38 day access was not compliant 68.8%. Challenges remain due to staff shortages in Breast Radiology with teams currently reviewing alternatives to appoint a Consultant to assist with services.

• Diagnosis wait remains compliant at 99.7%. • Two 28 day breaches were reported in month; both patients have now been

treated and seen. Quality • 14 category 2 hospital acquired pressure ulcers have been reported, 10 of

which were due to lapses in care. • Four incidents resulting in severe harm have occurred with one incident

resulting in death and four serious incidents reported in month. • 81 inpatient falls were reported Trust wide with 22 repeat falls. This figure

has increased and coincides with the additional beds being introduced to accommodate demand. Three falls resulted in moderate harm or greater. All cases have been investigated via Root Cause Analysis (RCA) and were presented to the Falls Prevention Group Meeting in January 2020.

• Ten new complaints had been received with the primary theme being clinical care and treatment, 128 concerns and 45 general enquires were received by the Patient Advice & Complaints Team (PA&C).

People • Sickness has increased for the fourth consecutive month. This is being

reviewed and monitored on a monthly basis at the People and Engagement Group and F, P&W Committee.

• A Mental Health and Well Being Fair was held in January 2020 offering awareness and support to staff.

• Mandatory training compliance reported at 91.24%, above target, this may decrease with the pressures on Medway training. This position will be actively monitored and action taken as appropriate.

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Financial Position • The Trust is ahead of plan year to date and forecasting to be on plan for the

remainder of the year. The main issue from a finance perspective is more system affordability rather than the Trust’s affordability. Work continues with commissioning colleagues to understand how Barnsley as Place can balance, this dialogue continues. Reasonable assurance has been provided that both parties will balance for year end.

• Capital allocation for the year to ensure the year forecast is achieved. Mrs Firth raised a query regarding concerns in relation to the number of admissions and readmissions. Dr Jenkins informed members Barnsley Clinical Commission Group (CCG) has raised concerns regarding readmissions which it considered are avoidable. The numbers in the board papers are validated figures. In partnership with the CCG a review of 50 admissions has been undertaken as a partnership piece of work with GPs and clinical staff. The findings identified a small number of readmissions which could have been avoidable with a larger number of patient readmissions avoidable if alternative support was available. The draft findings have been discussed by GPs who have identified an actionable piece of work to redesign how Barnsley as a Health Care System works to prevent admissions. This report will be presented via the relevant committees once the validated report is available. Dr Jenkins confirmed ‘winter’ commenced at the Trust in November 2019 unlike 2018/19 when it arrived in January 2019. Demand is now starting to diminish with the Trust having experienced almost the highest growth in activity across the region, if not the country. The wider issue from the audit is Barnsley, as a place, needs to address the growth in non elective demand on the Emergency Department (ED) and hospital. With regards to the 4 hour target, Mr Kirton confirmed activity year on year within the ED has seen a 12% growth year to date, the average nationally being 6%. Non elective year on year is 11.3% versus 1.8% within the region. Activity overall is higher in the region however the Trust has hugely exceeded targets in terms of demand. Winter pressures arrived earlier than previously and with the combination of the flu and existing pressures the Trust was unable to generate capacity to meet demand. Work is on going with the relevant teams to ensure the site is managed safely and adequate guidelines are in place. Following discussion it was apparent there were some inaccuracies within the forecast rates. This will be addressed with the relevant teams and amended accordingly. The Board noted and received the report.

20/11 MEDICAL DIRECTORS QUARTERLY REPORT Dr Enright presented the quarterly Medical Director’s report with the following key priorities highlighted:- • The Proud to Improve group has now been established. All monthly

meetings have been scheduled with the Improvement Academy for the Advanced Quality Improvement (QI) for Leaders.

• Following the restructure and reappointments of posts within Medical Education, Dr S Siddiqui was appointed as Director of Medical Education (DME) in September 2019. The Associate Director of Undergraduate

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Medical Education was the appointed in December 2019 and work is underway to reappoint the Undergraduate Leads.

• The Research Awareness Day was held on 10 October 2019 to celebrate the achievements Barnsley Hospital have made in research and also discussing future aspirations, excellent feedback of the day was received.

• As at 31 December 2019, 96.8% of doctors were in date with their appraisals. Three doctors are out of date which the Responsible Officer has deemed acceptable.

• A number of projects the Directorate is leading on are now concluding, in particular the ICE filing and Discharge 1 (D1) projects. ICE filing is expected to be completed by March 2020, the work to embed the changes and continuous monitoring will move to the Clinical Business Units (CBUs). The new e-form for D1s is has now been implemented for the majority of discharges. Further work to refine the process continues and is being taken forward by the Chief Clinical Information Officer (CCIO).

• Dr Beahan is developing processes to improve Medical and Clinical Leadership. All Senior Medical Leaders have been surveyed and the results have been reported to the Executive Team (ET). A programme has also been developed targeting different groups at different stages in the leadership journey. Initially, focus is upon Clinical Leads within services with the programme being developed to respond to individual needs. The first strand of the work is the Clinical Leeds Programme which commenced on 24 January 2020. There are 25 individuals, who are not currently in mainline leadership roles, and expressed an interest in being developed for future Clinical Leads.

Mr Patton enquired if Non-Executive Directors (NEDs) would be able to observe the Quality Improvement (QI) tester day; Dr Enright will facilitate this request. In response to a query regarding changes within the Directorate, it was agreed it would be useful for a graphic to be produced detailing the personnel within the Directorate and list the main strategic priorities. Dr Enright will circulate this to Board members for information. With regards to the D1 Task and Finish Group, Mr Lake queried what liaison with partners was undertaken to receive implementation feedback. Dr Enright informed members meetings are held with the external partners and in terms of timeliness of the D1s, currently around 90% are completed within the 24 hour timeframe. The Board noted and received the report.

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20/12 CHAIR’S LOG – BARNSLEY FACILITIES SERVICES (BFS) Mr Patton presented the Chair’s Log from the BFS Board Meeting held on 20 December 2019 highlighting the following performance data within the report:- • An update was provided on the NHS Supply Chain Savings. Work has been

carried out centrally to look at the savings which the procurement team has reviewed and identified the methodology used and the credibility of true cash releasing savings at requisition point level.

• In terms of reverse SLAs, meetings have been held with Marketing and Communications, Finance, IT, HR/Occupational Health, Legal Services & Outpatient Pharmacy. Over the counter pharmaceuticals for employees is now in place following the slight delay due to operational pressures.

• On going consultations are taking place with the porters to review the

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working arrangements and with Domestic Services to review pay. • Sickness has increased to 3.98% in December 2019; mandatory training

compliance is 93.1%. • Quarterly review of BFS aims and objectives, the full plan will be presented

to the Board meeting in March 2020 for Board approval and sign off.

Regarding the ED/Children’s Assessment Unit (CAU), Mr Patton confirmed the tenders have now been received and are within the figures discussed at the Board meeting in December 2019. In relation to the Estates Strategy, Mr Lake added following conversation with Matt Gladson, Director of Estates for the Council regarding the Travel Policy the Local Authority is receptive to working with the Trust to incorporate the needs of the site as part of Barnsley’s Travel Policy and is willing to provide support where needed as part of the review. Mr Mapston queried if there are proposals to review the attendance bonus for BFS staff. Confirmation was provided a full review has been undertaken noting this bonus is positive and well received within BFS. This will be carried on within BFS as it is working well which is evident in the sickness figures, consistently below 3%. The Board noted and received the update.

20/13 BOARD ASSURANCE FRAMEWORK (BAF) & CORPORATE RISK REGISTER (CCR) Ms Saunders presented the BAF and and CRR for Quarter 3. These have been presented and discussed within the various committees as part of the governance process with a number amendments made to identified risks. A discussion was held regarding Risk 1967 and the potential for reversion following receipt of planning guidance. Dr Jenkins commented the CCG and the Trust has agreed the next four years in relation to forecast activity with a 5% annual rise predicted in both non elective and emergency specialities. This risk is therefore no longer relevant and will be amended. In discussion it was noted updates are required to a number of risks within the report. These will be updated to ensure alignment with the Trust Strategy. The BAF strategic risks will be reviewed for 2020/21 led by Ms Saunders. The Board noted and received the report.

20/14 UPDATE ON BARNSLEY INTEGRATED CARE PARTNERSHIP GROUP - ICPG Mr Kirton provided a verbal update in relation to the Barnsley Integrated Care Partnership Group (ICPG). Agreement has been reached via the Governance Committees within the Trust to co-locate the Rightcare Barnsley Service with a new Care Co-ordination Service based at a site in Kendray. This enables co-location of the services and assurance has been provided that the quality and the productivity of the service will remain. A further update will be provided in the Private Board regarding the ICPG. Work continues with partners in the Barnsley Place to establish key success criteria and an away day has been planned for March 2020 to try and improve the health care for the greater population in Barnsley as a Barnsley Place. The Board noted and received the verbal update.

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20/15 UPDATE ON TRUSTS OBJECTIVES QUARTER 3 (Q3) Mr Kirton provided an update regarding the 2019-20 Trust Objectives for Quarter 3. Overall the Trust has progressed with the objectives outlined under the strategic aims in equal balance. There have been a number of challenges and risks with mitigation plans implemented wherever possible which have been monitored throughout the year. The key highlights in Q3 were the stroke pathway being implemented from 1 October 2019, improved patient flow and the Trust performing favourably against the year to date consolidated financial plan. The draft Trust Objectives for 2020/21 will be circulated to Board members following the meeting today for review and feedback. The final objectives will be presented for approval and sign off at the Public Board Meeting in March 2020. The Board noted and received the updates.

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20/16 UPDATE ON THE TRUST CLINICAL STRATEGY Dr Enright presented the six monthly update following the publication of the Trust’s Clinical Service Strategy in September 2019. A significant amount of progress has been made against the priorities described in the Clinical Strategy. The areas of concern are listed in detail within the paper; each action taken from the strategy has been allocated a Clinical Lead. Over 50% of actions have been completed with the majority being on target for completion within the timeframe. Discussion took place in relation to the key priorities for the outpatient modernisation programme, in particular exploring the use of video and virtual clinics. Mrs Murphy added as part of the clinical strategy work conversations are currently taking place with the Digital Clinical Team with the aim of implementing these changes as quickly as possible to endeavour to reduce the demand on the Trust. Dr Enright confirmed the Getting It Right First Time (GIRFT) Annual Report was presented the ET on Wednesday 5 February 2020, demonstrating progress to date. The overall position is the management resource for support towards GIRFT is appropriate. The report will be presented through the relevant committees for assurance and at a later date, will be presented to Board. The Board noted and received the updates.

20/17 INTELLIGENCE REPORT Dr Jenkins presented the monthly intelligence report on behalf of Mrs Parkes which provides an overview of the NHS Choices reviews and ratings for the Trust. The Board noted and received the report.

20/18 CELEBRATING OUR PEOPLE Dr Jenkins presented the report on behalf of Mrs Parkes, providing an update regarding the Brilliant Award winners as part of the reward and recognition process for celebrating the excellent work of staff within the Trust. The awards are presented by the Chief Executive and Chairman along with other Directors to personally congratulate staff.

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The Board noted and received the update.

20/19 QUARTERLY COMMUNICATIONS UPDATE Dr Jenkins presented the report on behalf of Mrs Parkes. The report highlights actions taken in the previous quarter within the marketing and communications function to build on positive perceptions of the Trust both internally and externally. One key point highlighted within the report is the achievement of the £1m target for the Tiny Hearts Appeal. As part of the closedown celebrations a celebratory event has been arranged for 11 February 2020 to recognise this fantastic achievement. The Trust is about to launch a project to review the Trust website. Mr Mapstone queried the merit of producing an integrated website with the CCG as a Barnsley Place as opposed to individual organisations. Feedback will be provided to Mrs Parkes. The Board expressed their thanks to the Marketing and Communications Team.

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20/20 REPORT OF THE CHAIRMAN The Chairman’s report was received providing a brief summary of key meetings and events recently attended on behalf of the Trust. The following key points were highlighted:- • To formally note, at the Council of Governors (CoG) meeting held on 22

January 2020, Mr Alan Higgins was appointed as the Lead Governor, for an initial period of twelve months, following recommendation by the Nominations Committee.

• A positive quartley meeting was recently held with the Local MPs despite a very busy period, discussions were held regarding progress in the future and maintaining the excellent positive relationships.

• Price Waterhouse Cooper (PwC) Well-Led review is currently on going, feedback will be provided when available.

The Board noted and received the update.

20/21 REPORT OF THE CHEF EXECUTIVE – including update on South Yorkshire & Bassetlaw Integrated Care System (SY&B ICS) Dr Jenkins provided an overview of recent meetings and events which have recently been undertaken on behalf of the Trust. The following key points were highlighted:- • The International Day for the Nurse celebrations is 12 May 2020. A series

of events will be arranged to celebrate the contributions for the Nursing and Midwifery Staff.

• Phase 1 for the Paediatric Emergency Department and CAU is now complete and the new ambulance point is now in operation.

• The CoG provided helpful feedback about how well the contactors have done with the works relating to noise and disruptions.

The South Yorkshire and Bassetlaw Integrated Care System (ICS) report was attached from Sir Andrew Cash, Chief Executive of the ICS for information. The ICS North of England Score Cards and the ICS Local Organisation scores

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were also attached for information detailing the challenges experienced throughout the NHS in meeting standards. The Board noted and received the report.

20/22 QUESTIONS FROM THE PUBLIC Mr Lake opened the meeting up for any questions relating to the agenda from observers and members of the public who were in attendance today. Mr Higgins queried if it would be possible to link the electronic prescribing software to the ordering of medicines. Due to the Director of ICT being unavailable at the meeting today, the matter will be discussed with relevant colleagues and feedback will be provided to Mr Higgins. On behalf of the Governors, Mr Higgins raised a query over delays in vascular surgery/referrals for Diabetic patients. Dr Jenkins confirmed certain diabetic foot conditions have to treated quickly and following a Serious Incident (SI) last year, a new process is now in place for the transfer of vascular patients Mr Higgins also sought views of the Board regarding Trust governance in relation to the work of the ICS. Mr Lake reported there are a number of issues pertaining to the evolving governance structures of the ICS with certain areas of concerns for the Trust. The Trust remains a sovereign organisation as whereas the ICS is an arrangement predicated on partnership awaiting further central guidance on an underpinning governance structure. Mr Lake will respond to Mr Higgins, as Lead Governor, either via letter or at the next CoG meeting scheduled for 18 March 2020. The Trust has previously requested a detailed structure of ICS governance which continues to be awaited. In accordance with the Trust’s Standing Orders and Consultation, to resolve 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.

BK TL

20/23 DATE AND TIME OF NEXT MEETING The next meeting of the Trust Board is scheduled for Thursday 5 March 2020, 9.00 am to be held in the Lecture Theatre, BHNFT.

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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/04

SUBJECT: BOARD ACTION LOG – PUBLIC

DATE: 5 MARCH 2020 Private & Confidential

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance

For review Governance For information Strategy

PREPARED BY: Margaret Saunders, Director of Corporate Governance SPONSORED BY: Trevor Lake, Chairman PRESENTED BY: Trevor Lake, Chairman STRATEGIC CONTEXT

To ensure that actions emerging from Board meetings are progressed and reported to Board in a timely manner.

EXECUTIVE SUMMARY

Current action log arising from Public Board meetings as attached.

RECOMMENDATION The Board of Directors is asked to: a) note and approve reported progress and any verbal updates and b) review any outstanding actions

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Key to RAG status Red Action overdue or no update provided Amber Update Provided but action not complete Green Update provided and action complete

Subject: Board Action Log Ref: BoD 20/03/05/04 ACTIONS ON AGENDA: Table 1 Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG status

20/06 06.02.20 Chairs log for Quality

and Governance (Q&G)

Mr Lake queried if the Trust receives the Service Level Agreements (SLAs) within the current agreement with STH. Dr Enright commented he has not aware of any issues with the service. Dr Jenkins suggested, given the perceived lack of availability of vascular surgeons, there may be benefit in confirming current arrangements with the service.

SE 05.03.20 05.03.20 Reported to be presented verbally during item 4 of the BoD agenda for 5 March 2020.

Green

Following approval at relevant Committees, Board was asked to approve the Trans Equality Policy. The policy was approved by Board noting the Communications Team will provide support to reinforce the Trust’s values.

EP 05.03.20 27.02.20 Complete. Green

20/08 06.02.20 Chairs log for Audit Committee

Absence Management Assurance Report to be forwarded to Mr Patton to be presented at People, Finance and Performance (PFP) Committee.

NM 05.03.20 27.02.20 Complete. Green

20/11 06.02.20 Medical Directors Report

Mr Patton enquired if Non-Executive Directors (NEDs) would be able to observe the Quality Improvement (QI) tester day, Dr Enright will facilitate this request.

SE 05.03.20 27.02.20 Complete. Green

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In response to a query regarding changes within the Directorate, it was agreed it would be useful for a graphic to be produced detailing the personnel within the Directorate and list the main strategic priorities. Once completed, will be circulated to Board Members.

SE 05.03.20 05.03.20 In progress – will be completed by March Board. Green

20/15 06.02.20 Update on Trusts Objectives – Quarter 4

The draft Trust Objectives for 2020/21 will be circulated to Board members following the meeting today for review and feedback.

BK 05.03.20 17.02.20

Katherine Sowden Circulated the objectives to Board Members. The item has been added onto the agenda for 05.03.20.

Green

20/19 06.02.20 Quarterly

Communications Update

The Trust is about to launch a project to review the Trust website. Mr Mapstone queried the merit of producing an integrated website with the CCG as a Barnsley place as opposed to individual organisations. Feedback will be provided to Mrs Parkes.

TL 05.03.20 28.02.20 Under discussion. Green

20/22 06.02.20 Questions from the public

Mr Higgins queried if it would be possible to link the electronic prescribing software to the ordering of medicines. Due to the Director of ICT being unavailable at the meeting today, this will be discussed with relevant colleagues and feedback will be provided to Mr Higgins.

BK 05.03.20

28.02.20 - A presentation was given to the Governors at the Finance and Performance Sub Committee held on 12 February 2020. Feedback will be provided to Alan Higgins.

Amber

Mr Higgins also sought views of the Board regarding Trust governance in relation to the work of the ICS. Mr Lake will respond to Mr Higgins, as Lead Governor, either via letter or at the next CoG meeting scheduled for 18 March 2020.

TL 05.03.20 28.02.20 - An update meeting with the lead governor and agreed to raise concerns with the ICS.

Amber

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ACTIONS COMPLETED & CLOSED SINCE LAST MEETING: Table 2 – N/A

19/210 05.12.19 Chairs Log F&P

Primary Care Streaming Project – following discussions with the GP Federation it was noted there were issues pertaining to the level of performance in relation to capacity to mitigate pressures within ED were absent from the paper. BK confirmed the project has met the original criteria however it is believed further capacity could be achieved and discussions are continuing. An update will be provided at the Board meeting in February 2020.

BK February 2020 28.01.20

The Chief Delivery Officer and Director of Finance met with the GP Federation on 13th December to discuss the contract. A number of issues were discussed, including the value of potential rebate owed for non-delivery of elements of the service, and the ability of the GP Federation to recruit substantively into roles and the impact this was having on the cost of delivery. The Trust and GP Federation are currently in dialogue to agree a way forward.

Green

19/214a 05.12.19 Quarterly Mortality Report

Presentation which was presented at the Governor’s meeting in December 2018 regarding the rebase and impact to be forwarded to Mr J Unsworth for information.

MS/SE February 2020 28.01.20 Complete - presentation forwarded

to Mr J Unsworth. Green

19/216 05.12.19

Proud to Improve Strategy, Quality Improvement (QI) Vision, Innovation

Strategy

SE to circulate what is required from the Board in terms of support to the three papers which were presented at the Board meeting today.

SE February 2020 28.01.20

Email circulated to Board Members on behalf of Dr Enright by Mr A

Wiles, Business Manager, Medical Directorate.

Green

19/150

05.09.19

Annual Health and Safety Report 2018/19

Dr Jenkins agreed to ensure that a thematic deep dive of the incidents of violence and abusive behaviour towards staff colleagues was undertaken with a view to ensuring that the Trust is taking all the necessary steps that it can. The outcome of this review would be reported to the Board in due course once completed.

RJ February 2020 06.02.20

25.-9.19 Scope of review to be determined and identification of external reviewer to be sought. 03.10.19 - Thematic deep dive in incidents of violence and aggression will be undertaken by external reviewers, it is anticipated that this work will be completed by the end of the calendar year. Upon Completion this will be presented at Q&G Committee for process Management prior to presentation to board. 07.11.19 – Paper to be presented At Board in December 19.

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(Cont. 19/150) 05.09.19 Annual Health and

Safety Report 2018/19 RJ February 2020

29.11.19 – Internal work has commenced. Update to be provided February 2020. 05.12.19 – Due by date agreed to be moved to February 2020. 06.02.20 – Discussed in the private section of Board.

Green

ROLLING TRACKER OF OUTSTANDING ACTIONS: Table 3 red = overdue Minute

ref Meeting

date Item Action Owner Due date Done Date Progress report RAG status

19/194 07.11.19 Chairs log – Audit Committee

Following discussion of the BAF/CRR it was agreed that a small working group would be arranged to discuss the next steps moving forward This group will involve Mr Mapstone and Ms Saunders.

MS/NM 31.12.19

Introductory meeting held 12 November 2019 with MS/NM. Working Group meeting to be confirmed shortly. 05.12.19 – Dates are currently being worked on, update to be provided to the Board meeting in February. 27.02.20 - this action is now superseded - the director of corporate governance is to prepare a risk management strategy that subsumes the action about the board assurance framework. The risk management strategy is to be presented to the audit committee in April 2020.

Amber

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Abbreviations/acronyms: • ACS – Accountable Care System • BAF – Board Assurance Framework • CCG – Clinical Commissioning Group • CQC – Care Quality Commissioning Group • CIP – Cost Improvement Programme • Comms – Communications • CRR – Corporate Risk Register • Dir – Director • EqIA – Equality Impact Assessment • ET – Executive Team • F&P – Finance & Performance Committee • FPSG – Finance & Performance Sub-Group (Governors) • ICT – Information & Communications Technology • IPR – Integrated Performance Report • Q&G – Quality & Governance Committee • QGSG – Quality & Governance Sub-Group (Governors) • VTE – Venous Thromboembolism

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1

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/06 SUBJECT: QUALITY AND GOVERNANCE ASSURANCE REPORT

DATE: 18 December 2019

PURPOSE: Tick as

applicable Tick as applicable

For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Rosalyn Moore, Non Executive Director/Committee Chair SPONSORED BY: Dr S Enright/Jackie Murphy, Executive Directors PRESENTED BY: Rosalyn Moore, Non Executive Director/Committee Chair STRATEGIC CONTEXT

The Quality & Governance Committee (Q&G) is one of the key committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of quality and safety across the Trust in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on quality and safety matters to the Board of Directors.

EXECUTIVE SUMMARY

This report provides information to assist the Board on obtaining assurance about the quality of care and rigour of governance. From the Q&G Committee Meeting on the 18th December, the following issues were addressed

• Outcome of the most recent National Emergency Laparotomy Audit (NELA)

• Report on Clinical Audit Process

• Regular review of Service Pressures, CBU Performance Reports and the IPR

• Most recent Chairs Logs and Minutes from the Sub Committees and PSHG Morality Report and HSG Report on Audit of Management and Information Systems in Pathology

• Medical Staffing Report

• Nursing Staffing Report

• Plan for the Quality Account

• Volunteer Strategy Implementation Plan

These items have been reviewed to provide assurance to the Trust Board. For the purpose of assurance, the Chair’s Log below sets out the range of issues reviewed and assurance provided. The Log highlights items for the attention of the Board. RECOMMENDATION(S)

The Board is asked to receive and review the attached Log.

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2

Subject: QUALITY AND GOVERNANCE ASSURANCE REPORT Ref: BoD: 20/03/05/06 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: Quality and Governance Committee (Q&G) Date:26th February 2020 Chair: Rosalyn Moore

Ref Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or

Committee

Recommendation / Assurance/ mandate to

receiving body

1. NELA

The Committee received an update from Dr Orr on work arising from the NELA . We received a mortality outlier alert in 2018-19 which had resulted from a data abnormality. However it had led to a deep dive that revealed a trend upwards. A number of issues were highlighted that are being addressed and recent unvalidated data suggest we are coming back in line.

Board of Directors For assurance

2. COVID-19

The Committee reviewed arrangements in place to ensure the safety of staff and patients in the event of any COVID-19 cases. Currently there are no cases in the Trust.


3. Mortality Report – Stoke

The Mortality Report included actions to address an outlier flag regarding stroke related mortality. A case review had taken place revealing data anomalies but no evidence of deficiencies in care. All these deaths had also been subject to a Structured Judgement Review. Further assurance has been gained by the Committee the previous month, during a presentation from Dr Iqbal on the actions that had taken place since the last SSNAP Audit and performance of the Stroke Unit.


4. Medical Nurse and Midwifery Staffing

The Committee discussed in detail the Medical Nursing and Midwifery Safe Staffing Report; whilst Medical and Midwifery staffing is satisfactory there are increasing shortages in nurse staffing. Whilst the main Nurse Sensitive Quality Indicators suggest that quality is being maintained the Red Flag system

Board of Directors For escalation

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3

Ref Agenda Item Issue and Lead Officer Receiving Body, i.e. Board or

Committee

Recommendation / Assurance/ mandate to

receiving body

indicated that some nursing tasks were being missed. There was also a simultaneous increase in sickness absence and staff turnover. The DoN is acutely aware of the risks to quality safety of patient care and the health and wellbeing of staff and outlined a range of mitigating actions.

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REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/07 SUBJECT: FINANCE, PERFORMANCE & WORKFORCE ASSURANCE REPORT

DATE: 5 March 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval x Assurance For review Governance For information Strategy

PREPARED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

SPONSORED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

PRESENTED BY: Francis Patton, Non-Executive Director, Chair Finance & Performance Committee

STRATEGIC CONTEXT

The Finance & Performance Committee (F&P) is one of the key sub committees of the Board responsible for Governance. Its purpose is to provide detailed scrutiny of financial matters, operational performance and people in order to provide assurance and raise concerns (if appropriate) to the Board of Directors and to make recommendations, as appropriate, on financial and performance matters to the Board of Directors

EXECUTIVE SUMMARY KEY: £k = thousands £m = millions

The aim of this report is to critically analyse and evaluate the financial and operational performance of the Trust in order to provide assurance to the Board. This will be accomplished by:

- critically analysing and reviewing the financial performance in order to identify any opportunities or threats

- critically analysing and reviewing the Cost Improvement Programme (CIP) in order to get assurance that it is on plan and will deliver the planned savings

- critically analysing and reviewing the corporate performance in order to ensure that the Trust is delivering the optimum performance safely and negating any penalties

- critically analysing the key people data and reviewing delivery of the People Strategy.

- reviewing business cases at the six months anniversary in order to ensure that they are delivering planned benefits

- critically analysing and reviewing the Board Assurance Framework (BAF) in order to ensure any risks to the strategic plan are identified and mitigated

In terms of the people the committee received the final version of the draft Organisational Development strategy which it recommends to Board, the latest Workforce Insight report, an overview of the staff survey results (also coming to Board) and the action plan for the Gender Pay Gap report which it signed off and recommends to Board for external publication. Key measures from the Workforce Insight report showed that in terms of People sickness is running at 5.16% (up on last month by 0.11%), training decreased from last month to 90.6% and appraisals are at 92.6%. In terms of Performance the Trust continues to do well in most areas however the 4-hour emergency access continues to be non-compliant at 86.92% (an improvement on December), in December, the Trust was non-compliant position for 2-week access at 92.9%, the 62-day access standard was compliant, the

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38 day inter provider transfer access was not compliant at 66.7% (although improved from the previous month). The incomplete position for RTT shows delivery in December at 93.57% and Diagnostic wait performance remains compliant with 99.9% of patients accessing diagnostics within 6 weeks. In terms of ICT the committee received an update and assurance about the plans for the Medway System C rollout and the Data Protection Annual Assurance Report which it signed off. In terms of finances the month ten position is a surplus position of £0.057m, against a planned deficit of £0.455m, which is £0.512m favourable to plan. In terms of the CIP programme £0.483m was delivered in month against a plan of £0.566m, £0.083m adverse to plan, year to date CIP is £5.846m against a plan of £5.623m, which gives a year to date positive variance of £0.223m. The cash position at the end of the month is £9.725m, which is £8.725m ahead of plan. The capital expenditure as at month 10 was £4.643m which is £1.387m adverse to plan. Forecast outturn is a £0.448 surplus which is ahead of the planned break-even outturn. The committee also received the GIRFT annual report, an update on the ICS financial position, the 2019 Reference Cost report, the latest Service Line Reporting. An update on Healthcare Contracts and the draft Operational Plan.

ECOMMENDATIONS

This report therefore recommends that: - The Board ratifies the draft Organisational Development Strategy. - The Board notes the latest Workforce performance metrics. - The Board ratifies sign off and publication of the Gender Pay Gap report. - The Board notes the operational performance and ongoing issues with delivering the 4-hour

target. - The Board notes and gains assurance on the ongoing delivery of Medway System C. - The Board notes and ratifies the intended sign off of the Data Protection Annual Assurance

report and delegates final sign off to the March P, F & P committee meeting. - The Board notes the month ten financial performance and the forecast outturn to deliver ahead

plan.

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Subject: Finance & Performance Committee Assurance Report Ref: BoD: 20/03/05/07

CHAIR’S LOG: Chair’s Key Issues and Assurance Model

Committee / Group Date 27th February 2020 Chair Finance and Performance Committee January 2020 Francis Patton, Non Executive Director KEY: £k = thousands / £m = millions

Log Ref Agenda Item Issue and Lead Officer

Receiving Body, i.e. Board or Committee

Recommendation/ Assurance/ mandate to receiving body

1. Organisational Development Strategy

The committee received the final draft of the Organisational Development Strategy and suggested a number of minor amendments/additions to it. Once signed off by Board a full action plan will be developed which will be linked to the People strategy and monitored by P, F & P. The committee commended the team on the development of the strategy and recommend it to Board for sign off when it comes to the April Board.

Board For information, assurance and sign off.

2. Workforce Insight Report

In terms of workforce the committee received the Workforce Insight Report which gives far more detail into issues facing the Trust from a Workforce perspective and worked through it section by section. Key issues identified were as follows: -

- Sickness Absence and Wellbeing: Sickness absence has increased this month by 0.11% to 5.16% (and is higher than in the same month in 2019 when it was at 5.03%). The shift has been due to a increase in short term sickness by 0.22% to 1.95% but there has been an decrease in long term sickness by 0.11% to 3.21% The cumulative figure is at 4.37%. The committee had a detailed discussion on the level of sickness, the internal plans in place to address it (receiving assurance from Sue Ellis on what was in place as observed by her at PEG) and whether there was now a new level of sickness in the NHS. Whilst we would always want to aspire to be in the top quartile it was acknowledged that this was a “wicked” problem linked to many of the other people indicators and that we needed a new approach to this as “doing what we always did will get what we always got”.

- Headcount & FTE: Headcount for month is 3996 (3787 excluding bank). The actual FTE is recorded as 3621.42. The figure reported this month for funded establishment FTE is 3266.99 versus a funded establishment for FTE of 3449.63

- Staff Turnover: Turnover rate is at 10.8% and therefore above the target range of between 7 – 10%. There were 47 leavers and 59 starters this month.

- Mandatory Training: is at 90.6% (an decrease of 0.64% from last month) and continues to be above the 90% compliance target. A discussion was held around training and the added pressure in ensuring that Medway training is complete by the year end. As a result, it was accepted that there was a need to extend the compliance window for nursing & midwifery to 14 months on mandatory training to accommodate this which would have a knock on affect on the overall

Board For information and Assurance

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performance. - Appraisals: The Trust is now preparing for the 2020/21 appraisal window which

will open on 1 April 2020, compliance for 19/20 is 93.20%. The committee acknowledged all of the work ongoing from a People perspective and the need now for the report to begin to discuss actions being undertaken as it is obvious in discussions at committee a lot is going on but this is not presented in the report. As a result of the discussions the committee were assured that the people agenda is a clear focus for the Trust.

3. Staff Survey

The committee received an update on the National Staff Survey Highlights of the survey include: • The Trust had its highest ever response rate to the survey with a 71% response rate (representing the views of 2,237 staff) • The Trust scored the same or higher than average against 10 of the 11 themes in the staff survey and was rated the highest amongst acute Trusts nationally in relation to Equality, Diversity and Inclusion. • There have been significant improvements in relation to themes from the staff survey including, ‘support from immediate managers’ (6.9 to 7.1) ‘morale’ (6.2 to 6.3) and ‘Quality of care’ (7.5 to 7.7). The report said that it was clear from the survey results that further work needs to be focussed in the area of the Quality of Staff appraisals and creating a safe environment in regard to staff experiencing violence at work. This generated discussion around the fact that, whilst the violence at work aspect was very important, perhaps there was a need to look at some other areas where scores were low despite our being ahead of the average. In particular health and wellbeing was a key area when linked to some of the workforce statistics around sickness and turnover. There was also a discussion around training for staff on appraisals not so much on how to fill it in but on how to hold a quality discussion. Finally, it was suggested that a pulse check was undertaken in July around quality of appraisals. The next steps following receipt of this year’s staff survey are to develop a corporate action plan supported by action plans from CBU’s and Corporate Divisions. The development and monitoring of performance against the action plans will be done through the People and Engagement Group with regular reports to the People, Finance and Performance Committee. The report will also come to Board in March.


4. Gender Pay Gap

At the last meeting the committee had requested that an action plan be developed to address the issues outlined in the Gender Pay Gap report for 2018/19. This was presented and accepted and as a result the committee signed off the report for publication on the government website. The report and action plan is attached for information.


5. Integrated The committee reviewed the IPR focusing on the key performance indicators around Board For information Pack page 27




Performance Report

patient access, people and finance. The Trust continues to deliver access to services in a timely manner for our patients in most areas apart from Emergency Access. In terms of key messages: - Emergency access & Patient Flow: The Trust’s 4-hour access performance remained below target in January 2020 but improved to 86.92% compared with 80.7% in December 2019. Challenges in achieving the target over the winter period remain with Emergency Department attendance and non-elective admission activity levels continuing to be significantly above plan. RTT: A compliant RTT position was maintained in December 2019 with performance of 93.57% compared with the target of 92%. The Trust was the fifth highest performing in the country for the month. Cancer: The Trust delivered compliant access for 62-day pathways for cancer patients in December 2019. Two-week access was non-compliant at 92.9% relative to a 93% standard and 38-day access was not compliant at 66.7%. 31-day access is in a compliant position. Breast symptomatic access remains a challenge due to staffing shortages in Breast Radiology, although the 93% 2-week access standard for breast symptomatic patients was achieved in December. Diagnostic Waits: Diagnostic access performance remained strong in January with 99.9% of patients accessing investigations within 6 weeks. There was also discussion on readmission figures as there is a difference in approach to reporting between the Trust and the CCG. An audit has recently been undertaken as a system and this will come through to the committee.

and Assurance

6. GIRFT

The committee received the getting it right first-time annual report. The reports conclusions were that significant resource is needed to progress a workstream before any delivery is achieved. The predelivery resource requirement amounts to circa 65 hours of input per speciality and when applied across the specialities in this report it equates to 1700 hours. This calculation does not include any of the resource required to take forward actions and this is where improved outcomes are delivered. PMO resource to facilitate/co-ordinate this programme is minimal, however the resource requirement to track and monitor progression of the programme as it stands far outweighs that currently available in PMO. When the GIRFT programme was initially supported by PMO there were 6 specialities to track with large gaps between the visits, this is in contrast to the 26 specialties currently in the programme with 5 deep dive visits taking place in September and October 2019 alone. More co-ordination support is required to maintain all of the specialities in the programme and provide the level of tracking and challenge required to facilitate improved outcomes and benefits. Outputs rather than outcomes or benefits are pulled out as it is difficult to evidence improved outcomes or benefits in high numbers with the work which has taken place so far. It is likely more outputs and evidence of improved outcomes and benefits could be achieved with more focus on the tracking and monitoring of GIRFT plans at a speciality level.


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The report generated a lot of discussion around the benefits derived from this process which pulled out more than was within the report and assured the committee that, whilst the process is resource hungry, it does deliver benefits and the teams find it a useful process to go through.

7. ICT

The main focus for the ICT section was on the System C Medway EPR project. The project is progressing to plan with a couple of exceptions around Care Plans and Maternity covered below. End User Training started on the 3rd February and runs through to the end of March. 322 sessions were attended by 290 members of staff, with the total number of sessions booked standing at 1594 for 755 members of staff. In addition to this around 80 staff have attended view only training. A total of 47 people did not attend their session – these are being reported back to service managers on a daily basis. The second phase of testing User Acceptance Testing (UAT2) started on the 10th February. It’s progressing well with only one major issue identified. Disappointingly some of the changes made during UAT1 have not been copied over. This has been escalated with System C to prevent it happening again and a UAT3 has been scheduled to gain full assurance. Cutover planning is under way with a Dress Rehearsal (DRH) running over the weekend 7th-8th March. This will time and test our cutover process, giving a clear indication of the required downtime. We’re still working to a plan of having ED up on Saturday along with AMU and Maternity, followed by Wards and Outpatients on Sunday. There is still work to do on Data Migration (DM) with a 5th test planned for the end of February. The information in Lorenzo is very poor quality in many areas which makes the migration task more complex. Some continued support will be required to fix data in Lorenzo prior to Go Live. New CNST requirements were published in December 2019 which requires an immediate update to Medway Maternity. We’ll be taking the latest release on the 2nd March after a week of testing. It’s exceptional to take a release this close to go-live but failing to do so would remove the potential CNST rebate – which was circa. £465k last time. Nursing Care Plans is brand new functionality for Medway and System C have failed to deliver to the agreed 6th Feb timeline. A corrective plan is being discussed which would deliver the majority of functionality on the 3rd March, with a final release after go live. A separate paper has been presented and being followed up with System C to understand testing and training options.


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Engagement with staff is still very high and those that use Medway can see the potential of where it will take the trust. Many comment on how intuitive it is and how much time it will save. The committee sense checked the update with CBU leads and gained assurance that training was progressing well however also got feedback from the Executive there will be a decision gateway regarding go-live on the 10th March. The Executive would need full assurance on testing and training before agreeing to proceed. Although there are issues with the solution and need to be fixed there is full expectation these will be achieved before this date. The committee also received an update on ePMA and the Electronic Document Management System.

8. Data Protection Annual Assurance Report

The committee received the Data Protection Annual Assurance Report as it stands at February 2020. The aim of the report was to give final assurance to People, Finance and Performance Committee that we can submit a compliant position on our data protection toolkit position for 31st March 2020 to NHS Digital. There is a new information data protection e-learning package that replaces the existing IG requirement for the IG Toolkit. The Data Protection e-learning for the trust is currently at 94%. We are confident we will meet the target of 95% by 31st March 2020, as there are number of exceptions such as Nurse Bank staff that we are no longer responsible for. A 360Assurance Internal Audit was started in Jan 2020 on our data protection toolkit self-assessment and will detail any recommendations to ensure we meet full compliance. We expect the report back during March 2020. Any recommendations will be completed by 31st March 2020. We completed a General Data Protection Regulation (GDPR) Audit in October 2018 which received significant assurance. A cyber security report to board provided significant assurance during August 2019 and Board members received appropriate cyber security training from National Cyber Security approved training centre. The trust Cybersecurity position is updated as part of the ICT report to PF&P monthly. The committee were happy that we are compliant as of the 27th February and are assured that we should be compliant at yearend and recommend to approve the report of a compliant position for the Data Protection Toolkit to be submitted to board with the rider that it gets final sign off at March P, F & P.


9. Finance At month ten the Trust has a consolidated year to date deficit position of £0.57m, against a plan of £0.455m deficit, which is £0.512m favourable to plan. Planned Provider Board For information

and Assurance Pack page 30




Sustainability Funding of £8.151m has been accrued in full. In addition to this £0.379m has been accrued in relation to further 2018/19 bonus monies, which NHSI have requested be reflected in the 2019/20 position. CIP is £5.846m against a plan of £5.623m, which is £0.223m favourable to plan. The cash position at the end of the month is £9.725m, which is £8.725m ahead of plan. The capital expenditure as at Month 10 is £4.643m, which is £1.387m adverse to revised plan. Use of Resources rating is 3 The main areas that the committee sought further assurance/explanation on were, as last month, the ability to deliver the yearend capital spend where assurance was received and why the Trust had more cash than planned. In terms of the cash balance the difference between the month 10 actual of £9.725m and plan of £1m was explained as being potential repayment of loan (£2.6m), capital being behind plan (£1.387m), creditor back log (£2.335m), other working capital movements (£1.873m) and SoCI variance to plan (£0.510m).

10. Reference Costs 2019

The committee received the National Cost Collection Index (NCCI) for 2018/19 which was released on 31st January 2020. The Trust’s NCCI, after adjusting for the market forces factor (MFF) is 101, against the national average 100. Work is ongoing in a number of areas to analyse why our costs are out of kilter.


11. Service Line Reporting

The committee received and noted the latest service line reporting to December and were assured that it is used by CBU’s and in performance meetings. Board For information

and Assurance

12. CIP

Month 10 saw actual savings of £0.483m against a plan of £0.566m resulting in an under achievement of £0.083m. This is largely to due to the Imaging Over Performance scheme not releasing savings in month, but this is expected to recover over the remainder of the year. Cumulative savings to date are £5.846m against a plan of £5.623m which gives a year to date positive variance of £0.223m. The forecast overall programme position against target has decreased since last month from £7.108m to £7.076m (a decrease of £0.032m) however this still gives a positive variance of £0.333m against the £6.743m target. In comparing the programme forecast value to this point last year, the value was £9.411m with a positive variance of £0.911m to the £8.500m target. Recurrency ratio has remained the same as last month, staying at 86% although this remains significantly favourable to this point last year when it was 68%. There are 58 schemes in the programme with 50 schemes at full maturity. The value of fully mature schemes has risen from £6.977m to £6.991m, an increase of £0.014m. In terms of remaining pipeline schemes, there is currently £0.085m of the programme at maturity level 1 & 2. The ratio of schemes at full maturity is 99% compared

Board

For information and Assurance

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to 95% at the same point last year. Programme Risk Achievement of the £6.743m target remains positive, but a focus on delivery of fully matured schemes will be essential to ensure the forecast savings are achieved. In terms of the2020/21 Programme work is still on-going to formulate next year’s draft programme and there has been some movement in the maturity levels of identified schemes seeing Maturity Level 4 schemes increase from £0.167m to £0.526m since January 2020. The overall forecast value sits at £5.215m, having increased by £0.480m since January 2020. Caution must be noted with regards this value due to the number of schemes at Maturity Level 1. As seen in previous years, some of the predicted values will reduce as schemes are worked up and financially validated. When comparing the Programme position to this time last year, the overall forecast position is currently higher by £1.158m compared to £4.057m, however progression of the Maturity Level 4 schemes was significantly more progressed at £1.318m. Focus is to be given to delivery of the existing schemes in the 2019/20 programme in addition to significantly progressing and adding to the long list of 2020/21 schemes for March’s meeting.

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1

Barnsley Hospital NHS Foundation Trust

Gender Pay Gap Report 2019

Executive Summary

All UK employers have a legal requirement to publish their gender pay data on an annual basis. The gender pay gap calculation is based on the average hourly rate paid to men and women. This calculation makes use of two types of averages; a mean average and a median average. In simple terms, the mean is the average hourly rate and the median is the mid-point hourly rate for men and for women in the workforce. The mean figure is the figure most commonly used. The report for Barnsley Hospital NHS Foundation Trust reviews the latest data set, which covers the 12 month period ending 31 March 2019.

Our Overall results: Overall, across our entire workforce our mean gender pay gap is 37%. This means that the average hourly pay rate for men is 37% higher than for women. This rate remains the same as the last reporting period ending 31 March 2018. Our overall median gender pay gap is 23% - this means that the mid-point hourly rate for men is 23% higher than for women. However, this overall figure represents the combined data for our Medical and Dental staff group and all other staff groups. When this is broken down, our figures show:

- For Medical and Dental staff, the mean gender pay gap is 19% - For all other staff who are not medical or dental (which is our largest

workforce group), the mean gender pay gap is 9%.

Our proportion of male and female staff should be taken into account when looking at our gender pay gap, as should the age range of our male and female workforce, as members of staff who have enjoyed long careers in the NHS can often be higher up the pay point scales than those who are just starting their careers. In Barnsley, whilst we have a higher proportion of female staff in our workforce, we also have a significant proportion of our male workforce who are now at the point in their careers where they are senior medical staff and therefore are higher up the pay grades than some more junior members of staff. This is reflected in our overall gender pay gap and, as a trust, we recognise that this is a generational and societal issue. We know that an increasing number of women are choosing medicine as a career and our figures this year show that we have the same percentage of female

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junior doctors as male. Also at a medical consultant level from 1st Jan 2019 to date, we have appointed 8 female consultant/locum consultants and 13 male. Over the last 5 years, we have seen an increase in the number of female consultants working at the Trust and as a result, our consultant profile gender gap is reducing; as at 31 March Female % Female Male % Male Total

2019 56 28.57% 140 71.43% 196 MD2018 48 28.40% 121 71.60% 169 MD2017 45 28.48% 113 71.52% 158 MD2016 41 28.28% 104 71.72% 145 MD CD2015 41 28.08% 105 71.92% 146 MD CD

*includes Medical Director and Clinical Director

For Medical and Dental staff, the mean gender pay gap since the last reporting period ending 31 March 2018 has remained the same at 19%, having reduced from 23% in the previous reporting period ending 31 March 2017. The proportion of male and female employees in the lowest pay quartile is 87% female and 13% male, compared to the proportion of male and female employees in the highest pay quartile which is 66% female and 34% male. (The quartile information is created by sorting all employees by their hourly rate of pay and then splitting the list into 4 equal parts to create 4 pay quartiles). The gender pay gap data we report also includes bonus payments. The consultants clinical excellence awards (CEAs) are included in the bonus pay calculation. Following publication of previous results, we have undertaken proactive communications, publicity and training support has been offered to female and male consultants on how to apply for CEAs. Our mean gender bonus pay gap has improved since the last reporting period ending 31 March 2018 as it has reduced from 79% to 38%. Our median gender bonus pay gap has also improved since the last reporting period ending 31 March 2018 as it has reduced from 96% to 60%. Gender Pay and Equal Pay – the difference: It is important to be clear about the difference between gender pay and equal pay. The solutions to equal pay and gender pay are different. Closing the gender pay gap is a broader societal as well as organisational issue. Equal pay is specific to men and women doing comparable roles for different pay. Though we have a gender pay gap due to our disproportionate representation of men and women within the workforce (as reflected across the NHS), we are confident that we pay equally and fairly in accordance with the nationally recognised

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Agenda for Change and Medical & Dental pay structures and our locally recognised Senior Manager and Director pay structures. Our future intentions: As a trust we are committed to supporting the career progression and ensuring equal opportunities for women and men within our workforce. Our in house talent management programme is designed to nurture our future leaders regardless of their gender. We have a range of family friendly policies, supporting childcare, flexible working, fair rostering and leave provision. We have published a number of toolkits to help managers in applying these policies for our staff and in 2019 we held a series of policy training sessions for managers. At our equality and inclusion conference in February 2019 we launched our Carers Charter. This set out the work we commenced in 2019 to raise awareness and increase recognition of staff who are carers, to identify what issues they face, leading to improved engagement and retention. We welcome this report and the findings. The data has given us the opportunity to understand what else we can do to further reduce our gender pay gap. Ultimately, our aim is to ensure there is no gap and that men and women are equally represented in the workforce at all levels.

Gender Pay Gap Detailed Results

Our gender pay gap results (based on the hourly pay rates our employees received on 31 March 2019) are as follows:

• Our mean gender pay gap is 37% • Our median gender pay gap is 23% • Our mean bonus gender pay gap is 38% • Our median bonus gender pay gap is 60% • Our proportion of males receiving a bonus payment is 9% • Our proportion of females receiving a bonus payment is 2% • Our proportion of males and females in each quartile pay band is;

Pay Quartile Female % Male % 1 87 13 2 87 13 3 87 13 4 66 34

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The reasons behind our gender pay gap -

• The mean and median gender pay gap can be explained by the observation that while men make up only 20% of the workforce, there is a disproportionate number of males, 34% in the highest paid quartile.

• The Trust’s mean gender pay gap is 37% in favour of men (women earn 37% less than men) compared to the national average of 16.2% in favour of men (source: Annual Survey of Hours and Earnings, Office for National Statistics, 2019).

• There is no significant mean gender pay gap in the Non-medical & Dental staff groups (9%). There is a mean gender pay gap of 19% in the Medical & Dental staff group.

• The table below shows Agenda for Change pay bands 2 to 7 split by gender and average hourly rate:

Band Female Male Ave Hourly Rate Female Ave Hourly Rate Male2 553 80 £10.04 £10.073 362 36 £10.61 £10.564 163 23 £11.42 £10.895 613 67 £14.63 £13.646 432 68 £17.65 £16.607 222 52 £20.24 £20.07

• The female average hourly rate is higher in all AfC pay bands except band 2, where the male average hourly rate is higher by only 0.03p.

• As at 31 March 2019 there were 15 female (48%) and 16 male (52%) employees on Local Senior Manager or Exec/Non-Exec Director pay scales, compared to 47% of very senior manager roles in the NHS held by women (NHS Employers data from NHS Digital workforce statistics 2018).

• There were 52 female (31%) and 114 male (69%) M&D consultants, compared to 63% of consultants who are men and 37% of consultants who are women in the NHS (NHS Employers data from the NHS Digital workforce statistics 2018). There were 20 female (43%) and 27 male (57%) foundation doctors.

• The gender split by age shows the majority of female doctors are young ( of those aged 21 – 40, 49% are female compared to 51% male) and the majority of male doctors are older (of those aged 41 and over, 73% are male and 27% are female).

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• In the reporting period, there were 69 medical staff (16 women and 53 men) who received Clinical Excellence Awards and Discretionary Points Awards which accounts for 64% of all bonuses awarded. There were 39 staff (33 women and 6 men) who received Long Service Awards in the form of monetary awards which accounts for 36% of all bonuses awarded. 8% of the total number of ‘relevant employees’ received bonus pay.

• In the gender split of the number of CEA Awards paid in 2018 and 2019,

there has been an increase of 9 female award recipients compared to an increase of 7 male award recipients. The improvement is also due to the fact that there were 18 consultants who received CEA Awards in 2018 who did not receive an award in 2019. Of these 18, four men and no women had received awards which were above Level 1 and up to Level 5 high value awards.

Reducing our gender pay gap: Female consultants applying for Clinical Excellence Awards (CEAs)

Following the publication of previous gender pay gap results, further analysis was undertaken on the gender split of eligible consultants who applied and were successful in receiving CEAs over the last 5 years. On average a slightly lower proportion of female consultants applied (23% compared to 27% males). Consultants that applied had equal chance of receiving the award regardless of gender and the panel’s gender split was proportionate.

Two years ago, proactive communications, publicity and training support was offered to female and male consultants on how to apply for CEAs. The data has been refreshed to include the last financial year awarded and over the last 5 years on average the gender gap of CEA applicants has slightly reduced to 23% female consultants applied compared to 25% males. Of those who applied on average, 59% female consultants were successful compared to 66% males.

However, the increase in female applicants in 2016/17 (29% compared to 26% male applicants) has not been sustained. In 2017/18 there were 24% female and 24% male applicants. Of those who applied, 67% women and 90% men were successful in their applications.

In 2020 the Trust will look to offering a mentoring and buddying scheme for female and male consultants to encourage and support them with their CEA applications.

Supporting flexible working and ensuring fair rostering

95% of part time workers are female, compared to 80% of full time workers who are female;

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Female Male % Female working % Male working Part time 1259 71 94.66% 5.34%Full Time 1196 308 79.52% 20.48%

The gender pay gap results show that men’s average hourly rate is higher for both part time and full time workers;

Female Male Ave Hourly Rate Female Ave Hourly Rate MalePart time 1259 71 £14.14 £15.91Full Time 1196 308 £14.31 £15.56

As at 31 March 2019, there were 89 women on maternity leave and 2 women on adoption leave. There were no men on adoption or maternity support (paternity leave). There were no women or men on shared parental leave.

Four changed post after returning from maternity leave, 11 are still on maternity leave 12.36%, 76 came back to the same post 83.52% and 8 have now left 8.99%.

These results tell us that the provision and fair access to part time and flexible working opportunities are important to support the needs and retention of our workforce.

In 2019 we commenced a review of flexible working arrangements and provision for staff through our nurse retention improvement programme. This includes a review of the flexible working policy and procedure to ensure fair access and enable better monitoring, reporting and recording of request numbers and outcomes.

We have also launched the rostering policy and fair rostering top tips at a series of drop in training sessions for managers.

Launch of Carers Charter

Our Carers Charter was launched at our equality and inclusion conference in February 2019. This set out the work we commenced in 2019 to raise awareness and increase recognition for staff who are carers, to identify what issues they face, leading to improved engagement and retention.

Sharing our gender pay gap with our employees It is important to share and explain our gender pay gap and our action plan to reduce the gap with our employees, trade union representatives and managers in advance of the external publication date. In particular to be clear about the difference between gender pay and equal pay. The solutions to equal pay and gender pay are different. Closing the gender pay gap is a broader societal as well as organisational issue. Though we have a gender pay gap due to our disproportionate representation of men and women within the workforce (as reflected across the NHS), we are confident that we pay fairly in accordance with the nationally recognised Agenda for

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Change and Medical & Dental pay structures and our locally recognised Senior Manager and Director pay structures. It is proposed to share the information with the Joint Partnership Form and the Joint Local Negotiating Committee and explain what the data shows. Also to agree an internal communications message for distribution and briefing all staff. The difference between gender pay and equal pay It is important to be clear about the difference between gender pay and equal pay. The solutions to equal pay and gender pay are different. Closing the gender pay gap is a broader societal as well as organisational issue. Though we have a gender pay gap due to our disproportionate representation of men and women within the workforce (as reflected across the NHS), we are confident that we pay fairly in accordance with the nationally recognised Agenda for Change and Medical & Dental pay structures and our locally recognised Senior Manager and Director pay structures. As part of the introduction of the Agenda for Change modernised NHS pay structure in 2004 was the development of the NHS Job Evaluation Scheme as a means of determining pay bands for posts. The key feature in both the design and implementation of this scheme was to ensure equal pay for work of equal value. The scheme has been tested legally and has been found to be equal pay compliant. The process involves use of job descriptions and person specifications which accurately reflect the demands of the job. Jobs are then locally matched to national benchmark profiles or locally evaluated and consistency checked by trained matching panel members and job evaluators consisting of management and staff side representatives working in partnership. The jobs are scored against a sufficiently large number of weighted factors (16) to ensure that all significant job features have been measured fairly. This includes specific factors to ensure that features of predominantly female jobs are fairly measured, for example communication and relationship skills, physical skills, responsibilities for patients and emotional effort. Scoring and weighting has been designed in accordance with a set of gender neutral principles, rather than with the aim of achieving a particular outcome, for example all responsibility factors are equally weighted to avoid one form of responsibility been viewed as more important than others. The NHS Staff Council job evaluation handbook provides guidance and advice on the NHS job evaluation scheme, which has been used to shape the Trust’s locally agreed job evaluation policy and procedure. Conclusion The Finance, Performance and Workforce Committee is asked to approve the report for external publication on the designated government website and the Trust’s website by the reporting deadline of 30 March 2020.

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Appendix 1

Gender Pay Gap Data

Data from ESR as at 31 March 2019

Data based on 3154 Full Pay Relevant Employees.

A “ Full Pay Relevant Employee” is any employee who is employed on the snapshot date (31 March 2019) and who is paid their usual full basic pay during the relevant pay period (1 – 31 March 2019).

Proportions of male and female employees in each pay quartile based on Ordinary Pay

Quartile Female Male Female

% Male

% 1 682 106 86.55 13.45 2 686 102 87.06 12.94 3 685 104 86.82 13.18 4 518 271 65.65 34.35

682.00

686.00

685.00

518.00

106.00

102.00

104.00

271.00

0 200 400 600 800 1000

1

2

3

4

Female and Male in each Quartile

Female

Male

Key Points:

• Ordinary pay includes basic pay, allowances, pay for leave, shift premium pay and on call pay.

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• In order to create the quartile information all staff are sorted by their hourly

rate of pay, this list is then split into 4 equal parts (where possible).

• To calculate the hourly pay, the employee’s bonus payments (this includes clinical excellence awards, discretionary points awards and long service awards) are added to their ordinary pay and this is divided by the employee’s number of working hours.

• To calculate the number of working hours the on call units worked and basic

hours are added together. This inflates the units worked which then lowers the hourly pay. For example 162.95 basic hours plus 48.00 on call weekend plus 121.00 on call weekday equals 331.95 units worked divided by the pay value £4301.41 equals an hourly pay of £12.96

• Elements of salary sacrifice have been removed

Mean and Median Gender Pay Gap Results

Gender Mean Hourly Rate Median Hourly Rate

Male £ 23.78 £ 17.59 Female £ 15.01 £ 13.50 Difference £ 8.77 £ 4.09 Pay Gap % 36.88% 23.25%

£23.78

£17.59

£15.01£13.50

£0.00

£5.00

£10.00

£15.00

£20.00

£25.00

Avg. Hourly Rate Median Hourly Rate

Male

Female

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Key Points: • The mean hourly and the median hourly rate of pay is calculated from a specific pay period, in this case it is 1st of March to 31st March 2019. The hourly rate is calculated for each employee based on 'ordinary pay' which includes basic pay, allowances and shift premium pay. The median rate is calculated by selecting the average hourly rate at the mid-point for each gender group. • The percentage variance for the mean hourly rate of pay is 36.88%. This calculation is based on the mean hourly rate of 2571 female staff compared to 583 male staff; because the average is calculated over different numbers of staff (there are over 4 times more female staff), some variance is to be expected. •The data includes both staff on Agenda for Change and staff on non-Agenda for Change terms and conditions (see sections below for a breakdown of Medical & Dental Staff and Non-Medical & Dental Staff gender pay gap results). Within each Quartile by Gender working Part time or Full time :

Quartile 1Female Male % Female working % Male working

Part time 288 15 95.05% 4.95%Full Time 316 89 78.02% 21.98%







Key Points: Proportion of part time workers who are female is consistent throughout all pay quartiles (94 – 95%). There are less full time workers who are female in quartile 4 (74%) compared to the lower pay quartiles.

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Mean and Median Gender Bonus Pay Gap Results

Data based on 3459 Relevant Employees.

“Relevant Employees” are all employees who are employed on the snapshot date (31 March 2019) and this term includes full-pay relevant employees and also other employees employed on the snapshot date but on less than full pay because of leave (which has reduced pay).

The bonus period is a twelve month period that ends on the snapshot date. And will always be the preceding twelve months.

Gender Mean bonus Pay Median Bonus Pay Male £ 17,354.65 £ 15,049.93 Female £ 10,793.33 £ 6,031.94 Difference £ 6,561.32 £ 9,017.99 Pay Gap % 37.81% 59.92%

£17,354.65

£15,049.93

£10,793.33

£6,031.94

£0.00

£2,000.00

£4,000.00

£6,000.00

£8,000.00

£10,000.00

£12,000.00

£14,000.00

£16,000.00

£18,000.00

£20,000.00

Avg. Pay Median Pay

Male

Female

Proportion of male and female employees who received bonus pay

Gender Employees Paid Bonus

Total Relevant Employees %

Female 48 2788 1.72 Male 59 671 8.79

Key Points:

• The gender pay gap calculations make use of two types of averages; a mean average and a median average.

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• Mean averages give a good overall indication of the gender pay gap, but very

large or small pay rates or bonuses can ‘dominate’ and distort the answer. For example, mean averages can be useful where most employees in an organisation receive a bonus but could be less useful in an organisation where the vast majority of bonus pay is received by a small number of employees (as is the case here).

• Median averages are useful to indicate what the ‘typical’ situation is i.e. in the

middle of an organisation and are not distorted by very large or small pay rates or bonuses. However, this means that not all gender pay gap issues will be picked up.

• The bonus pay criteria includes Clinical Excellence Awards (CEAs) and Discretionary Points Awards paid to 16 female and 53 male medical staff during 1st April 2018 and 31st March 2019. It also includes Long Service Awards (monetary awards in the form of shopping vouchers) given in 2018 for service gained in 2017. 33 Females and 6 Males received a Long Service Award (LSA). Therefore the number of employees who received a bonus payment is small, the value and type of bonus payments received is varied with more men receiving the higher value CEAs and more women receiving the lower value LSAs and this has distorted the figure.

• The Clinical Excellence Awards payments have been included in the bonus pay calculation (and the average hourly rate calculation) because the payments are subject to eligible applicants demonstrating that they are performing ‘over and above’ the standards expected in their role. Also in accordance with the Trust’s Local Employer Based Awards (Clinical Excellence Awards) Policy the awards are subject to application for renewal every 5 years.

• This calculation expresses the number of staff receiving bonus pay as a percentage of the total number of staff in each gender group.

Mean and Median Gender Bonus Pay Gap Results excluding Long Service Awards The Trust formally recognises and rewards long serving employees’ commitment and loyalty to the national health service by way of its Long Service Awards scheme. The awards take the form of certificates and badges from 10 years service and then at every 5 years service intervals until 40 years service. In addition a monetary award (in the form of shopping vouchers) to the value of £250 is made at 25 years service and £150 at 40 years service and this is presented to the recipient at an annual long service awards ceremony.

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The award is therefore designed so as not to be anything that relates to productivity, performance or incentive, but more recognition for long service. If long service monetary awards are excluded, the mean bonus pay gap increases from 37.81% to 37.90% and the median bonus pay gap reduces from 59.92% to 54.71%.

Gender Mean bonus Pay

excl LSA Median Bonus Pay

excl LSA Male £ 17,354.65 £ 15,049.93 Female £ 10,777.71 £ 6,815.77 Difference £ 6,576.94 £ 8,234.17 Pay Gap % 37.90% 54.71%

£17,354.65

£15,049.93

£10,777.71

£6,815.77

£0.00

£2,000.00

£4,000.00

£6,000.00

£8,000.00

£10,000.00

£12,000.00

£14,000.00

£16,000.00

£18,000.00

£20,000.00

Avg. Pay Median Pay

Male

Female

Gender Employees Paid Bonus excl LSA

Total Relevant Employees %

Female 16 2788 0.57 Male 53 671 7.90

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Appendix 2

Non - Medical and Dental Gender Pay Gap Results





Quartile Female Male

Female %

Male %

1 604 104 85.31 14.69 2 628 80 88.70 11.30 3 632 77 89.14 10.86 4 591 118 83.36 16.64

604

628

632

591

104

80

77

118

500 550 600 650 700 750

1

2

3

4

Female

Male


Gender Mean Hourly Rate Median Hourly Rate Male £ 15.63 £ 13.53 Female £ 14.22 £ 13.12 Difference £ 1.41 £ 0.41 Pay Gap % 9.02% 3.03%

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£15.63

£13.53

£14.22

£13.12

£11.50

£12.00

£12.50

£13.00

£13.50

£14.00

£14.50

£15.00

£15.50

£16.00


Male

Female

Key Points: • The percentage variance for the mean hourly rate of pay is 9.02%. This calculation is based on the average hourly rate of 2455 female staff compared to 379 male staff; because the average is calculated over different numbers of staff, some variance is to be expected.

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Appendix 3

Medical and Dental Gender Pay Gap Results





Quartile Female Male

Female %

Male %

1 40 40 50.00 50.00 2 31 49 38.75 61.25 3 27 53 33.75 66.25 4 18 62 22.50 77.50

40

31

27

18

40

49

53

62

0 20 40 60 80 100

1

2

3

4

Female

Male

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Gender Mean Hourly Rate Median Hourly Rate Male £ 38.92 £ 41.12 Female £ 31.61 £ 27.23 Difference £ 7.31 £ 13.894 Pay Gap % 18.78% 33.78%

£38.92£41.12

£31.61

£27.23

£0.00

£5.00

£10.00

£15.00

£20.00

£25.00

£30.00

£35.00

£40.00

£45.00


Male

Female

Key Points: • The percentage variance for the mean hourly rate of pay is 19%. This calculation is based on the average hourly rate of 116 female staff compared to 204 male staff; because the average is calculated over different numbers of staff, some variance is to be expected.

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Gender Pay Gap Report Action Plan 2020-2021

Aims/ Targets/ Objectives

How this will be achieved

What expected outcome will be

What evidence will support this

Who will lead this

Timescales this will be achieved within

Where this will be reported/ monitored to - ie Committee/ Group Timescale

RAG rating

To reduce the Trust’s gender pay gap

Proportionate number of men and women in the upper pay quartile

Representation of men & women, and the gender split by age (seniority) of medical & dental consultant workforce has improved in line with the NHS consultant profile

Latest available NHS Employers data from the NHS Digital workforce statistics

Workforce Planning & Information Manager

Before next GPG reporting period

Workforce, Finance & Performance Committee

January 2021

Proportionate number of men and women in the upper pay

Equal representation of men & women on Local Senior Manager or

Latest available NHS Employers data from the NHS Digital workforce

Workforce Planning & Information Manager



January 2021

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quartile Exec/Non-Exec Director pay has been sustained

statistics

Review access and provision of flexible working opportunities at all pay grades

Equal and fair access to part time and flexible working arrangements

Numbers of flexible working requests and outcomes.

Staff Survey 2019 results

Assoc Director of HR & OD



January 2021

Identify and increase recognition of staff who are carers to identify what issues they face

Analysis of staff Carers and their needs & support in work

Profile and analysis of staff who are Carers

Equality, Diversity & Inclusion Lead



January 2021

Analyse Staff Survey 2019 results, and Exit Interview results by gender and seniority level

Identification of any differences in staff survey results and exit interview results by gender and

Staff Survey 2019 results

Exit Interview and Leavers Data results

Equality, Diversity & Inclusion Lead



January 2021

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to identify any differences in engagement, motivation, aspirations and experience

seniority level

To reduce the Trust’s gender bonus pay gap

Trust to offer a mentoring and buddying scheme for female and male consultants to encourage and support them with their Clinical Excellence Award applications.

Reduction in the gender gap of Clinical Excellence Award (CEA) applicants and recipients

Number and gender split of CEA applicants and recipients

Medical Staffing Team



January 2021

KEY RAG Rating

Complete

On track for delivery

Behind plan and action needed to bring back on target

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REPORT TO THE BOARD OF DIRECTORS (BHNFT) REF: BoD: 20/03/05/08

SUBJECT: BARNSLEY FACILITIES SERVICES LIMITED (BFS).

DATE: 5 MARCH 2020 PRIVATE AND CONFIDENTIAL

PURPOSE:


applicable For decision/approval Assurance


PREPARED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

SPONSORED BY: Francis Patton, Chair, BFS & Non-Executive Director BHNFT

PRESENTED BY: Francis Patton, Chair BFS & Non-Executive Director BHNFT

STRATEGIC CONTEXT

Barnsley Facilities Services Ltd (BFS), (formerly Barnsley Hospital Support Services Limited BHSS), was established in 2012 as a wholly owned subsidiary of BHNFT and became operational from January 2013. It is intended as a vehicle for the Trust to explore and expand commercial opportunities and enhance income streams for the benefit of patient services.

EXECUTIVE SUMMARY

The aim of this report is to provide the Trust’s Board of Directors with a regular update on the activities of BFS and to flag any risks or concerns. The enclosed Log reflects discussions from the BFS Board’s meeting in February 2020. In terms of performance updates are provided on space utilisation, electrical shutdowns, a site asset review, O-Block refurbishment, ED/CAU Development and LED lighting. Productive meetings were held with Communications, Marketing & Design, Financial Services, Legal and HR. From an HR perspective sickness is at 3.02% and training is at 92.5%.

RECOMMENDATION

BFS Board recommends that: • The Board of BHNFT notes the attached report and take assurance that the wholly

owned Operated Healthcare Facility is performing to plan and budget.

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REPORT TO THE BOARD OF DIRECTORS AND P,F&P - BFS (BHSS) Chair’s Log

REF: BoD: 20/05/03/08 CHAIR’S LOG: Chair’s Key Issues and Assurance Model Committee / Group: BFS Board Meeting Date: 17th February 2020 Chair: Francis Patton

Item Issue Receiving Body, i.e. Board or Committee


1. Performance Report

Key highlights from the performance report include: 1. Space Utilisation – A paper was presented to the Executive Team on the 14/01/2020 discussing the availability of space for further growth and expansion along with current space pressures. Works are on-going in the development of short, medium and long-term strategies in relation to space and the Estates Strategy. 2. Waste Management - To assist with both waste management and to reduce fire load on lift lobbies and the basement metal bins 770 litre bins have been procured and will be rolled out for general (household) and cardboard waste. 3. Electrical Shutdowns – BFS successfully completed the first phase of the planned essential replacement of obsolete LV air circuit breakers/switchgear and conduct essential high voltage maintenance. The second phase of the works are to be completed in January 2020 with the third phase anticipated to be undertaken in late Summer 2020. Detailed planning continues so that all stakeholders are aware of the impact on their services. 4. Site Asset Review - Reviews have been undertaken into site-wide furniture condition and usage of electrical goods such as fridges and kettles. 5. O-Block – A number of decants into newly refurbished office accommodation has taken place on Level 4. Jarvale Construction has been appointed as the main contractor

Trust Board For Information and Assurance

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BoD October 2019 BFS_Chairs Log



for the Paediatric Ward refurbishment, commencing on the 27/01/2020 with the establishment of the site compound and external scaffold access now in place. Works are also due to commence on the 24/02/2020 for the planned lift upgrade within O Block by ANSA lifts; a pre-start meeting with all stakeholders is planned. 6. ED/CAU – Phase 1 (road works and ambulance entrance) completed on 24/01/2020. This was a complex but well managed and co-ordinated piece of work. Phases 2 and 3 have now been awarded to Illingworth and Gregory Ltd who are due to establish site setup from the 17/02/2020. Works are scheduled to complete end November 2020 for Phase 2 and Phase 3 by March 2021. 7. Theatres – the theatre Air Handling Unit (AHU) upgrade works are due to be completed by 05/02/2020. This has been a complex undertaking to minimise disruption to neighbouring theatres along with related works. 8. LED Lighting – Phase 1 of the LED lighting installation is progressing well, with an anticipated completion date of mid-March 2020. Phase 2 is in planning and will include some clinical areas.

2. Reverse SLA’s Meetings were held with Communications, Marketing & Design, Financial Services, HR/Occupational Health, Legal Services. Good support was received from all areas.


3. HR

From an HR perspective the cumulative turnover rate was 8.5%. There were 3 leavers and 10 new starters during January. Sickness decreased by 0.96% from 3.98% in December to 3.02% in January. Training compliance is 92.5%. There are a number of new starters yet to complete induction training. Domestic staff have requested a return to paper pay-slips,


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BoD October 2019 BFS_Chairs Log



due to IT reasons.

4. Picker Survey

The 2019 Picker Survey results show a response rate of 93.6% for BFS compared to a rate of 49.1% in 2018. The Trust response rate was 73% for 2019. Overall the BFS results show a positive improvement on 2018, with the following results being achieved:

• 69 questions (78%) have improved, compared to 51% 46 questions in 2018.

• 7 questions (8%) have shown no significant change (>2%).

• 12 questions (13%) have deteriorated < 2%, compared to 19 questions (21%) in 2018.

• 2 questions had no data from 2017/18 to make a comparison.

We have identified the main areas of improvement and will address these through the Leadership Training Programme and Appraisal Training. Further diagnostic is still to take place on each department / cluster for their individual results to identify action plans across lower scoring areas.

5. Gender Pay Gap

The BFS mean gender pay gap is 10.77%. This means that the average hourly pay rate for men is 10.77% higher than for women. Our overall median gender pay gap is 7.08% - this means that the mid-point hourly rate for men is 7.08% higher than for women. We have a relatively small gender pay gap due to our high representation of women within the workforce. We are confident that we pay equally and fairly in accordance with the nationally recognised Agenda for Change structures and our local pay structures.

Pack page 57

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/10 SUBJECT: Integrated Performance Report: January 2020 DATE: 5 March 2020

PURPOSE:

Tick as applicable Tick as applicable


PREPARED BY: Andrew Potts – Associate Director of Operations SPONSORED BY: Bob Kirton – Chief Delivery Officer PRESENTED BY: Simon Enright – Medical Director STRATEGIC CONTEXT Strategic Objective 1 – Patients will experience safe care Strategic Objective 3 – People will be proud to work for us Strategic Objective 4 – Performance Matters EXECUTIVE SUMMARY 1. Patient Access:

Emergency access & Patient Flow: The Trust’s 4 hour access performance remained below target in January 2020, but improved to 86.92% compared with 80.7% in December 2019. Challenges in achieving the target over the winter period remain with Emergency Department attendance and non-elective admission activity levels continuing to be significantly above plan. RTT: A compliant RTT position was maintained in December 2019 with performance of 92.66% compared with the target of 92%. The Trust was the fifth highest performing in the country for the month. Cancer: The Trust delivered compliant access for 62 day pathways for cancer patients in December 2019. Two week access was non compliant at 92.9% relative to a 93% standard and 38 day access was not compliant at 66.7%. 31 day access is in a compliant position. Breast symptomatic access remains a challenge due to staffing shortages in Breast Radiology, although the 93% 2 week access standard for breast symptomatic patients was achieved in December. Diagnostic Waits:

Diagnostic access performance remained strong in January with 99.9% of patients accessing investigations within 6 weeks. 2. Quality of Care:

2.1 Patient Safety: Pressure Ulcers

There were 17 category 2 hospital acquired pressure ulcers reported in January. Of these, 13 resulted from lapses in care. This represents an increase in the numbers of category 2 pressure ulcers with lapses in care also increasing from last month. A process for spot checks to be undertaken by the lead nurses and tissue viability teams to ensure correct techniques are being utilised and documentation is being completed.

There was 1 hospital acquired medical device related pressure ulcer, which was found to have lapses in care. This is a category 2 pressure ulcer caused by a brace. The RCA process found lapse in care Pack page 58

resulting from the brace not being removed and the device checklist not being completed. Incidents:

• One incident resulting in severe harm; • One incident resulting in death; and • Two serious incidents reported in the month

Falls: For the month there were 88 inpatient falls reported Trust wide, 22 of which were repeat falls. This is similar to the position in December 2019. There was 1 fall which resulted in moderate or greater harm. The moderate harm was suffered by a patient who fell on Ward 19 causing a fractured arm. The root cause analysis report will be presented at February’s Falls Prevention Group meeting.

2.2 Patient Experience: During January 2020, the Trust received 31 new complaints. The primary theme was clinical care and treatment. The percentage of cases closed within agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 52 days. 76% of complaints closed within January were upheld or partly upheld. The PA&C Team dealt with 174 concerns and 79 general enquiries (total 253) during the month.

3. People: Sickness: • Sickness absence for the month of January 2020 is at 5.16%, an increase from the previous month

figure of 5.05%. The main reason remains stress, anxiety, depression and other psychiatric illness, with 1600.93 FTE days lost in January. The reason for the anomaly is because different measures have been referred to in the two reports – One is episodes 1142 for Gastro, one is FTE days lost due to stress 1600.93. The People and Engagement Group has identified Trusts nationally where sickness absence rates are sustainably low. Visits have been arranged to these Trusts to identify areas where the Trust can improve performance in this area.

Mandatory Training: • Mandatory training for the month of January 2020 is at 90.57%, a slight decrease from the previous

month (91.24%). The Executive team has approved an extension to Mandatory compliance periods for Nursing and Midwifery staff in order to reflect the requirements of Medway training.

Staff Appraisal Rate: • The appraisal rate for the Trust remains high at 92.6%, consistent with the previous month (92.9%).

In preparation for the appraisal season commencing in April 2020, amendments have been made to the appraisal form to reflect feedback from the National Staff Survey results.

Staff Turnover: • Staff turnover for the year to January 2020 is 10.8%. The staff group with the highest turnover is

Allied Health Professionals at 15.29%. Work is underway with the CBU to look at changes to terms and conditions to try to address the perceived cause of turnover within this staff group.

Finance: • The Trust has a consolidated year to date surplus of £0.057m against a deficit plan of £0.455m

giving a favourable variance of £0.510m. • Total income is £7.730m favourable to plan year to date. Clinical income variances total

£5.448m. Other income is £1.903m above plan mainly due to education and training along with drugs and pathology recharges.

• CIP achievement is favourable to plan by £0.223m year to date. • Cash is £8.725m favourable to plan. • Capital expenditure is £2.816m less than original plan.

RECOMMENDATIONS Finance & Performance Committee is asked to receive and endorse the latest IPR

Pack page 59

Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Bob Kirton

`

January 2020

Pack page 60

Exe

cuti

ve S

um

mar

y

1. Purpose of the Report:

The purpose of this report is to inform the Trust Board and sub-committees of the latest position against key performance indicators, including operational and

quality requirements mandated nationally, metrics detailed in the NHSi oversight model and those identified within the BHNFT Operational Plan for 2019/20. In

addition, it provides Trust Board with information relating to activity delivered and finance, which are key drivers for sustainability.

This report details the latest validated information available.

A high level view of the Trust’s performance is available in the at a glance summary. Further details on the domains of quality, people, patient access and finance

are available in more depth as part of the wider document.

2. Background and Introduction:

The well-led framework used by NHSi identifies effective oversight by Trust Boards as essential to ensuring Trusts consistently deliver safe, sustainable and high

quality care for patients.

BHNFT provides an integrated performance report to Trust Board each month for assurance. The report outlines key performance against a number of quality,

operational, financial and activity based indicators. The purpose of the report is to ensure Trust Board has timely and robust oversight of performance in key

areas along with actions being taken to address required improvements.

Executive Summary January 2020

Pack page 61

1 2 3 9 10 16 17 18 19 20 21

Planned Financial Position

Income

Cost Improvement Programme

Cancer

Diagnostic Waits

Sickness Absence

Mandatory Training

Staff Turnover

Staff Appraisal Rates

Performance against the 4 hour target increased in January to 86.92% from 80.72% in December. Although below target, the Trust’s performance in January was the

12th best in the country. Non-elective admissions and Emergency Department attendances continued at levels significantly above plan. A number of actions are being

implemented to increase capacity and improve patient flow. A review of winter 2019/20 is being undertaken to identify areas for improvement for the 2020/21 winter

plan.

A compliant RTT position of 92.66% was achieved in December 2019.

The Trust were compliant in December for all Cancer reportable standards with the exception of two week wait referrals. This was 0.1% away from achieving the

national target of 93.0%.

Diagnostics waiting time performance remained strong with 99.9% of patients accessing investigations within six weeks.

Capital Plan

The Trust has a consolidated year to date surplus of £0.057m against a deficit plan of £0.455m giving a favourable variance of £0.510m. This is distorted by £0.379m

bonus PSF relating to 2018/19 and £0.052m donated income relating to charitable donations for assets, leaving a net favourable variance of £0.079m.

Total income is £7.730m favourable to plan year to date. Clinical income variances total £5.448m above plan as a consequence of the increased activity being seen.

Other income is £1.903m above plan mainly due to education and training (higher training numbers and one-off receipts); along with drug and pathology recharges

(offset by expenditure).

CIP has under achieved by £0.083m in-month but remains favourable to plan by £0.223m for the year to date. The year-end forecast continues to be the achievement

of the £6.743m target.

Cash is £8.725m favourable to plan due to creditor repayments, receipt of PSF bonus, slippage on capital expenditure and receipt of NHS Barnsley CCG overtrade

monies.

Capital expenditure is £2.816m less than the original plan as a result of the Trust agreeing to slip two externally funded schemes earlier in the year following a request

by NHSI. The year end forecast is to spend to a revised plan of £10.741m following the recent success of several externally funded IT bids.

Sickness absence for the month of January 2020 is at 5.16%, an increase from the previous month figure of 5.05%. The main reason remains stress, anxiety, depression

and other psychiatric illness, with 1600.93 FTE days lost in January. The reason for the anomaly is because different measures have been referred to in the two reports

– One is episodes 1142 for Gastro -One is FTE days lost stress 1600.93 The People and Engagement Group has identified Trusts nationally where sickness absence rates

are sustainably low. Visits have been arranged to these Trusts to identify areas where the Trust can improve performance in this area.

Mandatory training for the month of January 2020 is at 90.57%, a slight decrease from the previous month (91.24%). The Executive team has approved an extension to

Mandatory compliance periods for Nursing and Midwifery staff in order to reflect the requirements of Medway training.

The appraisal rate for the Trust remains high at 92.6%, consistent with the previous month (92.9%). In preparation for the appraisal season commencing in April 2020,

amendments have been made to the appraisal form to reflect feedback from the National Staff Survey results.

Staff turnover for the year to January 2020 is 10.8%. The staff group with the highest turnover is Allied Health Professionals at 15.29%. Work is underway with the

CBU to look at changes to terms and conditions to try to address the perceived cause of turnover within this staff group.

Referral To Treatment (18 weeks)

Pat

ien

t A

cces

sP

eop

leFi

na

nce

Emergency Access

Planned Cash Position

Patients Partnerships People Performance

BHNFT At-a-Glance January 2020

Pack page 62

1 2 9 10 16 17 18 19 20 21

Qu

alit

y

Patient

Experience

Clinical

Effectiveness

SHMI - Latest data - 99.40

HSMR Rolling 12 month - 98.82

Patient

Safety

Complaints

During January the Trust received 31 new complaints. The complaints were allocated as follows: CBU 1 – 9, CBU 2 – 16, CBU 3 – 6 and Corporate Services - 0. The primary theme was clinical care and

treatment. The percentage of cases closed within agreed timeframe or agreed extension for the month was 100%. The average number of working days to investigate complaints was 52 days. 76% of

complaints closed within January were upheld or partly upheld. The PA&C Team dealt with 174 concerns and 79 general enquiries (total 253) during the month.

Incidents

One incident resulting in severe harm

• Delayed cancer diagnosis (incident still under review by clinical governance)

One incident resulting in death

• Cardiac arrest (incident still under review by clinical governance)

Two serious incidents reported in the month

• 2020/862 – Treatment delay for a fracture (incident occurred in July 2018)

• 2020/1227 – Avoidable inpatient fall resulting in a fractured neck of femur (incident occurred in December 2019)

Patient Safety

Pressure Ulcers

There have been 17 category 2 hospital acquired pressure ulcers reported this month. Of these, 13 so far have resulted from lapses in care. A process for spot checks to be undertaken by the lead nurses and

tissue viability teams to ensure correct techniques are being utilised and documentation is being completed. We have designed a perfect ward pressure ulcer prevention audit that is being trialled across the

Trust.

There has been 1 hospital acquired medical device related pressure ulcers, which was found to have lapses in care. This is now a category 2 pressure ulcer that was caused by a brace. The RCA process found

lapse in care resulting from the brace not being removed and the device checklist not being completed.

Falls

For this month there were 88 inpatient falls reported Trust wide, 21 were repeat falls. This is a continuation of December’s performance with the additional beds being introduced to accommodate demand. For

this month, there were 1 fall that resulted moderate harm or greater.

The moderate harm was a patient who fell on ward 19 and suffered a fractured arm. The RCA will be presented at February’s Falls Prevention Group meeting.


BHNFT At-a-Glance January 2020

Pack page 63

2 3 4 6 7

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateEnd of Month

Forecast

Year-End

Forecast Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

Falls 785 (<) 65 BHNFT 88 713 784 856 70 66 72 76 71 55 70 47 75 73 77 81 88

Repeat Falls n/a BHNFT 21 145 160 174 14 11 19 17 17 5 13 5 16 14 15 22 21

Falls resulting in moderate harm or above 20 (<) 1 BHNFT 1 12 13 14 1 1 0 2 0 2 1 2 0 1 0 3 1

Hand washing 95% (>) National 96% 96% - 96.9% - - - 94% 97% 97% 96% 99% 99% 97% 97% 96% 96%

Pressure Ulcers category 2 (Lapses in care) G < 30, R >30 0 BHNFT 17 29 32 35 2 5 5 4 7 6 3 4 10 13

To eliminate pressure ulcers resulting from medical devices resulting in lapses of care. 2 9 10 11 4 3 0 2 0 0 1 3 1 1

Safety thermometer harm free care - - National 96.6% 96.6% - - 96.6%

Q - Hospital Acquired Clostridium Difficile 19 (<) 1 NHSE 2 19 21 23 0 2 2 1 1 2 2 4 3 2 1 1 2

Q - Serious Incidents - NHSE 2 23 - - 2 2 5 2 0 2 2 3 3 1 4 4 2

Q- Total Number of Incidents Resulting in Death 0 0 National 1 3 - - 0 0 0 0 0 0 0 1 0 0 0 1 1

Q-Total Number of Incidents Resulting in Severe Harm 0 0 National 1 13 - - 1 1 0 1 0 2 3 0 0 1 1 4 1

Q- FFT Response Rate ED G >= 10%, R < 10% BHNFT 5.9% 2.5% - - 1.3% 1.5% 6.2% 3.1% 0.4% 0.4% 0.9% 1.5% 3.5% 5.9%

Q - FFT Response Rate IP G >= 10%, R < 10% BHNFT 39% 32% - - 32% 35% 38% 44% 31% 31% 32% 31% 18% 39%

Q- FFT Response Rate MAT G >= 10%, R < 10% BHNFT 40.0% 43.9% - - 32.6% 39.9% 61.6% 45.2% 50.2% 37.0% 57.6% 34.4% 40.5% 40.0%

Q- FFT Positivity Rates - EDG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 87% 83% - 90% 79% 61% 84% 86% 94% 95% 88% 81% 96% 84% 63% 53% 87%

Q- FFT Positivity Rates - IPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 96% 97.5% - 97% 97% 99% 98% 98% 98% 99% 98% 98% 92% 98% 98% 99% 96%

Q- FFT Positivity Rates - OPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 95.7% 95.8% - 95% 96% 94% 96% 94% 96% 95% 96% 96% 96% 97% 97% 95% 96%

Q- FFT Positivity Rates -StaffG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT - 72.1% 82.0%

Complaints closed within target or agreed extension % G >90%, A >=70%-90%, R <70% (>) BHNFT 100% 100% - 100.0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q- Single Sex Breaches 0 0 National 0 0 - - 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - Duty of Candour Breaches 0 0 National 0 0 - - 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - VTE Screening Compliance G>= 95%, R < 95% NHSE 98.0% 98.0% - 98.2% 98.1% 98% 97.8% 98.1% 98.2% 98.5% 98.2% 98.5% 98.2% 97.4% 96.6% 98.4% 98.0%

Q - Sepsis-Antibiotics given within Hour of diagnosis G >= 90%, R < 90% National 92.9% 87.8% 85.5% 83.2%

Q - HSMR (Rolling 12 months) Latest Data is November 2019 - - - 102.8 100.5 99.2 96.9 96.9 97.9 95.4 94.2 94.8 97.3 98.8

Crude Mortality (Number of Deaths) - - - 114 96 92 100 88 79 65 69 80 81 104 104 95

SHMI (Rolling 12 months) Latest Data is September 2019 - - - 99.3 101.0 99.4

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets which will be RED if the target is not

achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule for 2019/20 to be defined and included in IPR from May 2019

Quality Performance Scorecard

Patient Safety

Patient Experience

Clinical

Effectiveness

Patients will experience safe care


5Pack page 64

People and Patient Access Scorecard

Domain KPI StandardStandard(Month)

Set By Current Qtr. Year to DateEnd of Month

Forecast

Year-End

Forecast Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

People will be proud to work for us

Staff Turnover (Rolling 12 months) G <=10%, A >10%-11%, R >11% (<) BHNFT 10.8% 10.8% - 10.2% 9.3% 9.2% 9.3% 9.3% 9.7% 10.1% 10% 10.4% 10.5% 10.8% 10.6% 10.5% 10.8%

Staff Appraisal Rate G >90%, A >=70%-90%, R <70% (>) BHNFT 92.6% 77% - 91% 90.7% 90.2% 89.9% 7.6% 31.4% 86.5% 91.2% 92.8% 93.0% 93.0% 93.2% 92.9% 92.6%

Mandatory Training G >90%, A >=85%-90%, R <85% (>) BHNFT 90.6% 90.7% - 90% 88% 89% 90.3% 90.9% 91.3% 91.2% 90.7% 90.3% 89.8% 90.4% 90.6% 91.2% 90.6%

Sickness Absence (In Month) G <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 5.16% 4.12% - 4.40% 5.03% 4.85% 4.63% 4.12% 4.10% 4.02% 4.31% 3.85% 3.97% 4.29% 4.50% 5.05% 5.16%

Performance matters - Key Performance Indicators

RTT Incomplete Pathways (December 19) 92% (>) National 93.3% 93.8% - 93% 95.7% 95.6% 95.2% 95.0% 94.7% 94.3% 93.5% 93.3% 93.8% 93.6% 93.7% 92.7%

Q - Cancer 2 Week Waits 93% (>) National 92.5% 91.8% - 92% 96.4% 95.6% 95.6% 93.4% 94.8% 85.8% 87.8% 93.3% 93.7% 91.9% 92.9% 92.9%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 93.8% 83.1% - 88% 94.4% 95.3% 94.6% 92.1% 94.9% 48.4% 57.9% 82.8% 98.1% 94.6% 92.6% 94.1%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 100% 98% - 98.5% 99% 94% 99% 95% 92% 97% 100% 97% 100% 100% 100% 100%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National 100% 99% - 98.5% 91% 100% 83% 91% 100% 100% 100% 100% 100% 100% 100% 100%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100% 100% - 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 63.6% 63.1% - 65% 66.7% 50.0% 58.6% 61.9% 63.6% 70% 55.9% 70.6% 65.2% 59.4% 68.8% 66.7%

Q - 62 Day - GP Referral to Treatment 85% (>) National 87.2% 85.0% - 85% 85.4% 94% 89.2% 93.2% 78.0% 73.3% 88.8% 78.5% 93.5% 85.1% 87.0% 91.1%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 90.9% 92.8% - 90% 89.5% 93.8% 100% 100% 79% 100% 100% 94% 100% 88% 94% 90%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) BHNFT 71.4% 84% - 86% 91% 100% 100% 100% 100% 75% 94% 100% 83% 80% 38% 89%

Emergency % Patients Waiting <4 Hours 95% (>) National 86.9% 91.6% - 92% 91.1% 92.9% 96% 96% 95.6% 95.6% 93.5% 91.3% 96.3% 95.2% 85.7% 80.7% 86.9%

Average Length of Stay - Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 2.04 2.44 - - 2.88 2.32 2.72 2.65 2.20 2.94 3.00 2.67 2.56 2.41 1.79 2.13 2.04

Average Length of Stay - Non-Elective (Spell) G <=3.45, A >3.45-3.91, R >3.91 (<) BHNFT 3.67 3.20 - - 3.48 3.37 3.38 3.07 3.16 3.06 3.04 3.07 3.09 3.18 3.18 3.48 3.67

Re-admissions % (Validated) 8% BHNFT - - 7.5% 8.4% 7.2% 8.4% 8.4% 8.2% 8.3% 8.1% 8.1% 8.2% 8.1% 7.9% 7.2%

Cancelled Operations - Breaches of the 28 day rule 0 0 National 0 3 - - 0 0 0 0 0 0 0 0 0 1 0 2 0

Cancelled Operations - Sitrep Reportable 0.8% BHNFT 0.8% 0.6% - 0.6% 0.8% 0.2% 1.1% 0.5% 0.7% 0.4% 0.7% 0.5% 0.6% 0.4% 0.4% 1.0% 0.5%

DNA Outpatient DNA RatesG <=7.2%, A >7.3%-8.5%, R >8.6%

(<)7.2% BHNFT 7.5% 6.9% - 7% 6.4% 6% 6.5% 6.8% 6.9% 6.7% 6.6% 6.7% 7.1% 6.8% 6.5% 7.5% 7.5%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & ED targets which will be RED if the target is not

achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators such as Cancer, RTT, Cancelled Ops, etc. are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

All other indicators are classed as Achieved or Failed with the exception of all Workforce KPIs, Average Length of Stay & DNA rates which detail the tolerances applied in the Target column.

Operational

Efficiency

Workforce

Elective Access

Cancer


6Pack page 65

Patients will experience safe care (Quality & Experience)

Nursing Staffing Fill Rate (Quality Strategy - Goal 4: Building on Capacity and Capability)

Ward 1787.80% 100.80% - 100.00% 100.80% 145.60% - - 2.7 2.2 0.0 0.0 5.2

Ward 1875.60% 103.70% 100.00% 100.00% 104.20% 111.90% 100.00% 100.00% 2.6 3.3 0.6 0.1 6.6

Ward 19 Elderly 76.00% 85.90% - 100.00% 103.20% 102.80% - - 2.4 4.0 0.0 0.1 6.5

Ward 20 ASU 62.80% 105.90% - 100.00% 93.50% 130.70% - 100.00% 2.1 1.2 0.0 0.1 6.5

Ward 21 78.20% 103.30% - 100.00% 101.20% 129.40% - 100.00% 2.5 2.8 0.0 0.2 5.4

Ward 22 Diabetes/E

ndo71.10% 125.60% - 100.00% 100.10% 166.80% - 100.00% 2.5 3.2 0.0 0.2 5.8

Ward 23 Frailty Unit 92.00% 146.60% - 100.00% 101.90% 134.20% - - 2.3 3.8 0.0 0.0 6.1

Ward 2488.10% 112.60% - 100.00% 82.30% 111.40% - - 4.0 3.4 0.0 0.1 7.5

Ward 29 SSU 100.00% 100.00% - - 99.90% 100.00% - - 2.0 1.4 0.0 0.0 3.4

Ward 30 General Medical

100.00% 100.00% - - 93.90% 100.00% - - 1.9 1.4 0.0 0.0 3.2

AMU81.20% 102.10% - 100.00% 80.20% 115.80% - - 3.8 2.7 0.0 0.3 6.8

CCU80.40% 89.50% - 100.00% 94.20% - - - 10.5 1.6 0.0 0.1 12.1

Ward 31 SA 87.70% 128.80% - 100.00% 99.90% 100.00% - 100.00% 2.9 2.7 0.0 0.1 5.7

Ward 3282.40% 99.00% - 100.00% 98.40% 118.40% - - 3.3 3.5 0.0 0.2 7.0

Ward 3395.70% 111.30% 100.00% - 101.70% 114.20% - - 2.6 3.6 0.1 0.0 6.3

Ward 3466.50% 72.20% 100.00% 100.00% 92.10% 141.80% - - 3.8 3.3 0.5 0.2 7.8

ITU106.30% 123.30% - - 110.70% - - - 28.7 2.9 0.0 0.0 31.5

SHDU110.20% 59.40% - - 103.20% - - - 17.0 2.8 0.0 0.0 19.8

AN/PN 100.00% 97.00% - - 100.00% 100.00% - - 7.5 2.6 0.0 0.0 10.1

Birthing Centre 98.60% 97.60% - - 98.10% 100.00% - - 32.0 6.5 0.0 0.0 38.6

Gynae Inpatient

Ward

100.00% 100.00% - 100.00% 100.00% 100.00% - 100.00% 3.3 3.3 0.0 1.8 8.4

Ward 15 NNU 98.10% 119.60% - 100.00% 100.80% 118.80% - 100.00% 9.1 1.3 0.0 0.4 10.8

Ward 37 99.20% 137.50% - 100.00% 92.10% 112.50% - 100.00% 7.1 2.4 0.0 0.7 10.2

0.0% 0.0 0.0

Care StaffAve fill rate

Registered

Avg fill

rateRegistered

Nursing

Associates %

Registered

Nurses/Midw

ives

OverallAve fill rate

Care staff (%)

Registered

Nurses/Midwive

s Nursing

Associates

340 - RESPIRATORY MEDICINE

Ave fill rate

Care staff (%)

430 - GERIATRIC MEDICINE

501 - OBSTETRICS

110 - TRAUMA & ORTHOPAEDICS

300 - GENERAL MEDICINE


110 - TRAUMA & ORTHOPAEDICS

100 - GENERAL SURGERY

307 - DIABETIC MEDICINE

192 - CRITICAL CARE MEDICINE

192 - CRITICAL CARE MEDICINE

Avg fill rate

care staff

Nursing

Associates %

Avg fill

rateRegistered

Nursing

Associates %

Avg fill rate

care staff

Nursing

Associates %

320 - CARDIOLOGY

430 - GERIATRIC MEDICINE

303 - CLINICAL HAEMATOLOGY


320 - CARDIOLOGY


502 - GYNAECOLOGY

422 - NEONATOLOGY

501 - OBSTETRICS

Care Hours Per Patient

SpecialtyAve fill rate

Registered

Nu

rsin

g St

affi

ng

Fill

Ra

te

301 - GASTROENTEROLOGY

100 - GENERAL SURGERY

420 - PAEDIATRICS

Care Staff

Nursing

Associates

Ward

name

Day Night


7Pack page 66

Performance Matters (KPIs)Operational Efficiency

The Trust failed to deliver the Emergency access standard in the month of January at 91.1%. Activity is now 14% above plan for emergency department attendances and 6% above plan for non-elective admissions. Year to date, delivery is at 94.7% with a organisational effort focusing on the delivery of the 95% standard at year end

Comments:

DN

A R

ate

s

Re

-ad

mis

sio

ns

The Trust continues to validate readmissions via a daily process which feeds in to quarterly reconciled position

with Barnsley CCG. Clinical audit of readmissions in key areas have demonstrated that there are no clinical

concerns and that activity around ADT processes are in place and accurate, supported by the daily validation

process.

Bre

ast

Sym

pto

mat

ic

Diagnostic access remains strong with 99.9% of patients accessing diagnostic services within 6 weeks. Cancelled operations returned to normal levels after the spike in

December 2019, caused by insufficient Intensive Care Unit capacity.


7.8% 7.1%

7.8%

6.8% 7.1% 7.6%

7.2% 7.3% 7.0% 6.9% 7.0% 7.3% 6.4%

6.0% 6.5% 6.8% 6.9% 6.7% 6.6% 6.7%

7.1% 6.8% 6.5%

7.5% 7.5%

0%

2%

4%

6%

8%

10%

% o

f D

NA

Rat

es

DNA Rates

New Follow Up Total Standard 2017/18

Cancelled Operations target is '0'

0.4%

0.8%

1.1%

0.6%

0.4%

0.6%

0.8% 0.8%

0.6%

0.3%

0.4% 0.3%

0.8%

0.2%

1.1%

0.5%

0.7%

0.4%

0.7%

0.5% 0.6%

0.4% 0.4%

1.0%

0.5%

-0.1%

0.1%

0.3%

0.5%

0.7%

0.9%

1.1%

1.3%

1.5%

% o

f C

ance

lled

Op

era

tio

ns

Cancelled Operations

28 Day Breaches % Cancelled Ops Standard

Cancelled Operations Target '0'

7.5% 7.1% 8.0% 7.6% 8.1%

7.1% 7.2% 7.8%

7.1% 6.8% 6.2%

7.7% 7.5% 8.4%

7.2% 8.4% 8.4% 8.2% 8.3% 8.1% 8.1% 8.2% 8.1% 7.9%

7.2%

0.00%

5.00%

10.00%

Cumulative Validated Re-admissions

0.7% 0.8%

1.0%

0.1% 0.2%

0.5%

0.0% 0.0%

0.5%

0.1%

0.5%

0.3% 0.2%

0.0% 0.0% 0.1%

0.0% 0.1%

0.3%

0.1% 0.1% 0.0% 0.0%

0.3%

0.1%

0.0%

0.5%

1.0%

1.5%

2.0%

Pe

rce

nta

ge o

ver

6 w

ee

ks

Diagnostic Tests over 6 Weeks

Standard Actual % 1920

8 Pack page 67

Performance Matters (KPIs)


Emergency Access and Patient Flow (1)ED

4 H

ou

r W

ait

Emergency Access and Patient Flow

Performance against the 4 hour target increased in January to 86.92% from 80.72% in December. Although below target, the Trust’s performance in January was the 12th best in the

country. Non-elective admissions and Emergency Department attendances continued at levels significantly above plan.

Additional winter bed capacity continued to be provided in January including the use of Ward 36, additional beds on Ward 23, and the temporary conversion of the elective orthopaedics

ward into a medical ward. Additional actions undertaken to enable patient flow included:

• Strengthened paediatric support including extended CAU opening hours and additional medical and nursing staff

• Bringing forward the plans to manage 300 plus ED attendances per day

• Extending the scope of “long stay Wednesday” to include all patients with a length of stay in excess of 7 days

• Designating a Deputy Director or Associate Director of the day to manage site and patient flow

• Weekly weekend plan review sessions to evaluate plans taking into account workload and staffing pressures

The roll out of the first phase of ProWard, incorporating SAFER and Red2Green processes, has been completed with all medical wards now covered. The second phase, encompassing other

wards, will be instituted after Medway has been implemented. A review of winter 2019/20 is being undertaken to identify areas for improvement for the 2020/21 winter plan.

Co

mm

en

tary

85.5%

89.9% 91.1%

90.3%

93.0%

95.4%

92.1%

97.2%

98.6%

95.4%

97.44% 96.70%

91.09%

92.85%

96.04% 95.97% 95.64% 95.56%

93.45%

91.26%

96.32% 95.20%

85.67%

80.72%

86.92%

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

0

2000

4000

6000

8000

10000

12000

Within 4Hrs Total Activity Target 4h Emergency Access PerformanceStandard

9 Pack page 68



Emergency Access and Patient Flow (2)

A&E benchmarking

Am

bu

lan

ce H

and

ove

rsIn

pat

ien

t A

cuit

y -

Am

ber

(EW

S sc

ore

5-6

)

Acuity analysis shows an expected increase as measured by EWS scores above. This is reflected in increased bed occupancy and mitigated by the flexible use of inpatient capacity

Inp

atie

nt

Acu

ity

- R

ed

A&

E 4

Ho

ur

Wai

t -

Be

nch

mar

kin

g

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0% No. Ambulance Handover Times (Pre-validated YAS)

No. between 15 & 30 mins No. between 30 & 60 mins No. between 60 & 120 mins No. over 120 mins Not recorded

EWS = Amber only

10 Pack page 69



Emergency Access and Patient Flow (3)

ED Delivery Dashboard V4

Len

gth

of

Stay

(Sp

ell)

GP

Str

eam

ing

Tru

st B

ed

Occ

up

ancy

(M

ed

ical

)

11 Pack page 70



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - December 2019Validated Position

CommentsSpecialty <18 >18 Total %

CARDIOLOGY 583 2 585 99.66%DERMATOLOGY 757 74 831 91.10%E N T 1012 76 1088 93.01%GASTROENTEROLOGY 1039 10 1049 99.05%GENERAL MEDICINE 187 1 188 99.47%GENERAL SURGERY 1665 262 1927 86.40%GERIATRIC MEDICINE 137 1 138 99.28%GYNAECOLOGY 839 50 889 94.38%OPHTHALMOLOGY 988 24 1012 97.63%ORAL SURGERY 1161 173 1334 87.03%OTHERS 721 57 778 92.67%RESPIRATORY MEDICINE 281 1 282 99.65%RHEUMATOLOGY 258 7 265 97.36%TRAUMA AND ORTHOPAEDICS 1086 91 1177 92.27%UROLOGY 617 69 686 89.94%Total 11331 898 12229 92.66%

Co

nsu

ltan

t 1

8 W

ee

k R

efe

rral

to

Tre

atm

en

t

Incompletes - Standard 92%

During December 2019 treatment commenced within eighteen weeks of referral

for 92.66% of elective pathways compared with the target of 92%. The Trust was

the fifth highest performing in the country for the month.

January is expected to be a challenging month with performance in Orthopaedics

declining as a result of the loss of the elective ward to provide additional winter

bed capacity. Dermatology and Urology are, however, expected to regain

compliance.

Following the recent report from the North of England Commissioning Support

Unit on waiting list data quality, internal sampling of data in various specialities is

being undertaken, to identify areas requiring improvement.

90% 92.21% 93.16% 93.37% 93.57% 94.35% 94.70% 95.08% 95.86% 95.32% 95.06% 95.71% 95.59% 95.20% 95.00% 94.8% 94.27% 93.53% 93.35% 93.83% 93.57% 93.70%

92.66%

80%82%84%86%88%90%92%94%96%98%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Incomplete Pathways

Actual Standard

12 Pack page 71



Regulatory Performance - Cancer

Inte

r p

rovi

de

r Tr

ansf

er

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

eek

Wai

ts

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Standard

75%

80%

85%

90%

95%

100%P

erc

en

tage

Po

siti

vity

Actual Standard

38 Day Inter-Provider Transfers December’s position of 66.7% against a target of 85% shows a similar trend to the previous month. 6 breaches in total due to varying reasons. Head & Neck (x1) – Medical reasons caused a delay to diagnostic investigations (4 weeks) which were further delayed by Trust initiated cancelations (x2) due to no HDU beds available (20 days). Transferred day 61. Lung (x1) – Capacity issues, medical reasons and patient DNA (18 days) contributed to a delay to diagnostic testing. Pathway originally referred to Head & Neck and not referred to Lung until day 31. Transferred day 74 Gynaecology (x1) – Patient initiated delay to diagnostics and clinic capacity issues (14 days to appt/6 days to report) lead to this pathway being transferred at day 49. Lower GI (x1) – delay to investigations by both Trust and patient. Transfer of care from Upper GI at day 62. IPT day 75. Urology (x2) – both due to unexceptional pathways. Transferred day 41 and 45. This position is subject to change dependant on discussions with other Trusts as shared treatments are completed. Cancer Services continue to implement various IPT data quality checks to aid the timeliness of submission/transfer in an attempt to increase the overall position.

13 Pack page 72



Regulatory Performance - Cancer

Graph to follow from Cancer services

Graph to follow from Cancer services

62

Day

Can

cer

Targ

ets

62

Day

Can

cer

Targ

ets

60%

65%

70%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Standard

0%

20%

40%

60%

80%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Standard

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Standard

14 Pack page 73



Further InformationTwo Week Wait

The validated position for December was non-compliant with the Trust performing at 92.9% for the second month in a row, marginally under the national target of 93%. 57 breaches in total due to either admin error (x1 1%), patient choice (x23 42%) or

capacity issues (x33 57%). Of the capacity breaches x9 were due to no available appointment within two weeks and x24 where the Trust were unable to offer a further appointment within target.

Breast Symptomatic

December’s validated position was compliant at 94.1% against the national target of 93.0%. 5 breaches in total with the majority due to the trust not being able to offer a further appointment within target after the patient was unable to attend the

original allocated slot (x3). Patient choice and clinic capacity were the reasons for the others.

62 Day GP Referral to Treatment

December performance for 62 day GP referral to treatment was compliant for a fourth successive month with 91.1% against a target of 85%. Performance has been aided by a focus on four services (Lower GI, Head & Neck, Lung and Urology) in areas such

as front end diagnostics and the option of Straight to Test in Lower GI. Lung, Breast, Lower GI and Gynaecology all achieved 100% performance. Breaches locally within Skin due to patients mental capacity requiring decisions by power of attorney. 7x

shared breaches of which x3 were transferred within target meaning the full allocation falls to the treating provider.

62 Day Screening Referral to Treatment

The December validated position for 62 day screening was compliant at 90.0% against a target of 90%. Breast achieved 100% with the only breach (shared pathway) occurring within Lower GI due to a provider initiated delay to diagnostic testing.

62 Day Consultant Upgrade to Treatment

Performance for December Consultant Upgrades was compliant with 89.5% against a target of 85%. All tumour group, with a treatment in December, performed at 100% with the exception of Lower GI having a single breached pathway. Despite this

pathway being transferred in target at day 34, inadequate outpatient capacity at Sheffield meant the pathway wasn’t completed until day 67.

15 Pack page 74

High Level Summary Sickness: Sickness absence for the month of January 2020 is at 5.16%, an increase from the previous month figure of 5.05%. The main reason for sickness absence is Gastrointestinal problems followed by Cold, Cough and Flu. The People and Engagement Group has identified Trusts nationally where sickness absence rates are sustainably low. Visits have been arranged to these Trusts to identify areas where the Trust can improve performance in this area. Mandatory Training: Mandatory training for the month of January 2020 is at 90.57%, a slight decrease from the previous month (91.24%). The Executive team has approved an extension to Mandatory compliance periods for Nursing and Midwifery staff in order to reflect the requirements of Medway training. Staff Appraisal Rate: The appraisal rate for the Trust remains high at 92.6%, consistent with the previous month (92.9%). In preparation for the appraisal season commencing in April 2020, amendments have been made to the appraisal form to reflect feedback from the National Staff Survey results. Staff Turnover: Staff turnover for the year to January 2020 is 10.8%. The staff group with the highest turnover is Allied Health Professionals at 15.29%. Work is underway with the CBU to look at changes to terms and conditions to try to address the perceived cause of turnover within this staff group.

16 Pack page 75

People - Trend Analysis Si

ckn

ess

(Tru

st w

ide

)St

aff

Turn

ove

r (1

2 M

on

ths)


Please the latest Sickness absence benchmarking data is only available up to December 2018

17 Pack page 76

Performance MattersActivity

18/19 19/20 19/20

Actual Plan Actual Variance %

Elective Daycases 23,069 22,917 24,802 1885 8%

Elective Inpatients 2,757 2,757 3,195 438 16%

Elective Total 25,826 25,674 27,997 2323 9%

Non Elective Total 33,613 34,311 36,261 1950 6%

Maternity Pathway Total 5,340 5,297 5,420 123 2%

A&E Total 80,640 83,547 87,904 4357 5%

Outpatients Total 281,813 275,057 297,082 22025 8%

* Please note excess bed days are not included in these figures. 2019/20 Activity Plan

2019/20 Activity Actual

2019/20 Activity Plan 2019/20 Activity Plan

2019/20 Activity Actual 2019/20 Activity Actual

Act

ivit

y

Day

Cas

es

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

Ele

ctiv

e In

pat

ien

ts

No

n-E

lect

ive

Inp

atie

nts


18 Pack page 77

Performance MattersActivity

2019/20 Activity Plan 2019/20 Activity Plan

2019/20 Activity Actual 2019/20 Activity Actual

Comments:

2019/20 Activity Plan

2019/20 Activity Actual

Ou

tpat

ien

ts

The main area of over performance is outpatient activity:

New attendances are over performing by 5,162 mainly in General Surgery +900, Ophthalmology +985,

T&O +916, Gynaecology +801 and Dermatology +841.

Follow up attendances are over performing by 16,776 mainly in Dermatology +3,626, Anticoagulant

+3,948, general Medicine +1,421 and Ophthalmology 6,139.

Day case over performance is Urology +362, Gastroenterology +607 and Dermatology +508. The main

areas of under peformance are Clinical Haematology -226 and T&O -243.

Elective The main areas of over performance are Gynaecology +99, Clinical Haematology +114 and

General Surgery +118. T&O is under performing by -61 and Colorectal Surgery by -40.

Non-elective main over performance is in CDU +236 and Endocrinology +673, Diabetes +201,

Cardiology +197, Elderly +168, Obstetrics +215 and Gynaecology +161. The main area of under

achievement is Paediatrics -248 and General Medicine -230.

Mat

ern

ity

Pat

hw

ay

ED A

tte

nd

ance

s


19 Pack page 78

SUMMARY

Trust Ove

rall

dat

aset

sco

re

Eth

nic

cat

ego

ry

Gen

eral

Med

ical

Pra

ctic

e C

od

e

NH

S N

um

ber

Po

stco

de

of

Uu

sual

Ad

dre

ss

Sou

rce

of

Ref

erra

l fo

r A

& E

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Ad

mis

sio

n M

eth

od

Dis

char

ge D

ate

Pri

mar

y D

iagn

osi

s (I

CD

)

Sou

rce

Of

Ad

mis

sio

n C

od

e

Ove

rall

dat

aset

sco

re

Trea

tmen

t Fu

nct

ion

Co

de

Mai

n S

pec

ialit

y C

od

e

Co

nsu

ltan

t C

od

e

Gen

der

Sou

rce

of

Ref

erra

l

National data item average - - 79.5 90.5 87.7 90.9 72.6 - 96.7 97.5 97.8 89.6 96.7 - 96.7 95.6 92.2 94.4 92.5

Barnsley NHS FT 97.6 99.4 96.5 98.4 99.3 100 100 96 100 100 100 98.3 100 98.9 100 100 93.5 100 95.3

The Rotherham NHS FT 92.1 88.8 99.8 100 99.5 100 0 97 100 100 100 94.8 100 99.8 100 100 100 100 99.8

Chesterfield Royal NHS FT 91.7 99.8 99.4 100 99.5 99.7 100 96.9 100 100 100 98.2 100 100 100 100 100 100 100

Sheffield Teaching NHS FT 96.6 99.6 97.3 100 99.1 99.9 100 99.8 100 100 100 99.1 100 99.5 100 100 97.5 100 100

Doncaster & Bassetlaw FT 99.6 99.2 96.1 99.5 97.1 99.9 100 99.7 100 100 100 98.2 100 99.6 100 100 99.7 100 100

Mid Yorks Hospital 94.3 99.6 100 99.8 99.2 100 97.6 96.8 100 100 100 98.7 100 98 100 100 82 100 100

Definitions

Ethnic category - as stated by the patient

General Medicine Practice code - the organisation code of the GP Practice that the patient is registered with

NHS number - unique patient identifier

Source of referral for A&E - the source of referral of each A & E episode

Treatment Function Code - recorded to report the specialised service within which the patient is treated.

Admission Method - The method of admission to a hospital provider spell. For example, elective, emergency, maternity.

Discharge Date - The date a patient was discharged from a hospital provider spell.

Primary Diagnosis (ICD) - the International Classification of Diseases (ICD) code used to identify the primary diagnosis.

Source Of Admission Code - to a Hospital Provider Spell or a Nursing Episode when the patient is in a Hospital Site or a Care Home.

Consultant Code - code uniquely identifying a consultant

Gender - patient's current gender.

Source of Referral for Outpatients - source of referral of each Consultant Out-Patient Episode

The Trust now has a well-established Data Quality Group that aims to ensure the Trust’s core electronic patient record system is up-to-date and accurate. This group comprises operational and ICT staff and

reports directly into senior operational groups on progress and ensures delivery of action plans associated with emergent and pre-existing data quality issues.

The Data Quality Maturity Index (DQMI) is a quarterly NHS Digital publication intended to highlight the importance of data quality in the NHS. The most recent data is August 2019.

Postcode of usual address - the postcode of the address nominated by the patient where the address association type is 'Main Permanent Residence' or 'Other Permanent Residence'

Main Speciality Code - the specialty in which the consultant is contracted or recognised. Main speciality classifies clinical work divisions more precisely for a limited number of specialties.

Comments - Barnsley is better than the national average across all areas of mandated data. Outpatient consultant codes will improve when we implement

Medway as Lorenzo allows none standardised consultant codes (J Codes).

DQ

MI

ED Admitted Patient Care Outpatients


20 Pack page 79

Performance - "At a glance"

Month

Plan

Month

ActualVariance % Variance Plan YTD Actual YTD

Variance

%Variance

Month

Plan

Month

ActualVariance % Variance Plan YTD

Actual

YTD

Variance

%Variance

ACTIVITY LEVELS (PROVISIONAL) Cost Improvement Plan (CIP) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 160 220 37.50% 60 2,757 3,195 15.89% 438 Income 254 271 6.69% 17 1,526 2,915 91.02% 1,389

Day Cases 2,375 2,624 10.48% 249 22,917 24,802 8.23% 1,885 Pay 115 115 0.00% 0 2,129 1,584 -25.60% (545)

Outpatients 28,818 31,020 7.64% 2,202 272,648 294,586 8.05% 21,938 Non-Pay 197 97 -50.76% (100) 1,968 1,347 -31.55% (621)

Non-elective inpatients 3,539 3,674 3.81% 135 34,476 36,400 5.58% 1,924 Total CIP 566 483 -14.66% (83) 5,623 5,846 3.97% 223

A&E 8,449 8,750 3.56% 301 83,547 87,904 5.22% 4,357

Other (excludes direct access tests) 9,165 9,432 2.91% 267 87,498 89,259 2.01% 1,761 Statement of Financial Position (SOFP) £'000 £'000 £'000 £'000 £'000 £'000

Total activity 52,506 55,720 6.12% 3,214 503,843 536,146 6.41% 32,303 Capital Spend (630) (894) -41.90% (264) (7,459) (4,643) 37.75% 2,816

Inventory 2,721 3,385 24.40% (664)

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Receivables 13,595 12,965 -4.63% 630

Elective inpatients 319 409 28.26% 90 8,269 9,279 2.96% 1,010 Payables (inc. Accruals) (15,652) (22,125) -41.36% 6,473

Day Cases 1,471 1,504 2.25% 33 14,176 15,531 9.56% 1,355 Other Net Liabilities (348) (1,813) -420.98% 1,465

Outpatients 2,878 3,226 12.11% 348 28,023 30,054 7.25% 2,031

Non-elective inpatients 6,660 7,415 11.34% 755 63,227 66,773 5.61% 3,546 Cash & Loan Funding £'000 £'000 £'000

A&E 1,207 1,245 3.17% 38 11,935 12,423 4.09% 488 Cash 1,000 9,725 872.50% 8,725

Other Clinical 4,857 4,977 2.47% 120 46,916 43,933 -6.36% (2,983) Loan Funding (70,336) (67,466) 4.08% 2,870

PSF Funding 1,143 1,143 0.03% 0 8,151 8,530 4.65% 379

Other 1,406 1,525 8.45% 119 14,062 15,965 13.53% 1,903 KPIs

Total income 19,941 21,445 7.54% 1,504 194,759 202,489 3.97% 7,730 EBITDA % 3.99% 3.86% -3.23% -0.13% 2.74% 2.88% 5.33% 0.15%

Surplus / (Deficit) % 1.03% 1.19% 16.20% 0.17% -0.23% 0.03% -112.03% 0.26%

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000 Receivable Days 20.9 19.2 -8.27% 1.7

Pay (13,772) (14,544) -5.61% (772) (135,691) (139,511) -2.82% (3,820) Payable (excluding accruals) Days 66.7 33.7 -49.49% -33.0

Drugs (1,340) (1,383) -3.19% (43) (13,400) (13,474) -0.55% (74) Payable (including accruals) Days 66.7 59.9 -10.21% -7

Non-Pay (4,033) (4,690) -16.29% (657) (40,339) (43,668) -8.25% (3,329) Use of Resources rating (after overrides) 2 3 1

Total Costs (19,145) (20,617) -7.69% (1,472) (189,430) (196,653) -3.81% (7,222) Use of Resources rating (before overrides) 2 3 1

Capital service cover rating 1 4 3

EBITDA 796 828 4.07% 32 5,329 5,836 9.51% 506 Liquidity rating 2 4 2

Depreciation (492) (480) 2.35% 12 (4,812) (4,786) 0.53% 26 I&E margin rating 3 3 0

Non Operating Expenditure (99) (92) 7.20% 7 (972) (992) -2.09% (20) I&E margin: distance from financial plan 1 1

Surplus / (Deficit) 205 256 24.97% 51 (455) 57 112.51% 510 Agency rating 1 2 1

Performance - Financial Overview Performance - Financial Overview


Page 21 of 22 Pack page 80

Performance Matters - Finance

January 20 Summary

Summary Performance:


Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • The Trust has a consolidated year to date surplus of £0.057m against a deficit plan of £0.455m giving a favourable variance of £0.510m. This is distorted by £0.379m bonus PSF relating to

2018/19 and £0.052m donated income relating to charitable donations for assets, leaving a net favourable variance of £0.079m.

• Total activity continues to be above plan in-month and year to date across all points of delivery. This reflects the increased demand seen on services across the Trust.

• Total income is £7.730m favourable to plan year to date. Clinical income variances total £5.448m above plan as a consequence of the increased activity being seen. Other income is £1.903m above plan mainly due to education and training (higher training numbers and one-off receipts); along with drug and pathology recharges (offset by expenditure).

• Operating costs are £7.222m adverse to plan in total. Pay is £3.820m adverse mainly due to activity pressures , agency spend and unachieved CIP. Non-pay costs are £3.403m adverse mainly due activity pressures, outsourcing and unachieved CIP.

• CIP has under achieved by £0.083m in-month but remains favourable to plan by £0.223m for the year to date. The year-end forecast continues to be the achievement of the £6.743m target.

• Capital expenditure is £2.816m less than the original plan as a result of the Trust agreeing to slip two externally funded schemes earlier in the year following a request by NHSI. The year end forecast is to spend to a revised plan of £10.741m following the recent success of several externally funded IT bids.

• Total payables including accruals are £6.473m higher than plan which is £0.493m lower than last month. The main variances are output vat payable to HMRC, trade creditors & accruals (timing of payments) and pay provisions.

• Cash is £8.725m favourable to plan due to creditor repayments, receipt of PSF bonus, slippage on capital expenditure and receipt of NHS Barnsley CCG overtrade monies.

• Loans remain at £2.870m below plan due to an unplanned loan repayment to the Department of Health in May.

• Debtor days are 19.2 which is 1.7 days favourable to plan, mainly due to the receipt of CCG overtrade monies.

• Payable days (excluding accruals) are 33.7 which is 33.0 days favourable to plan and continue to show the steady reduction seen throughout the year in line with the managed reduction in the creditors position. Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain. Expenditure has been calculated as operating costs, less pay, add back lead units and agency, and capex.

Page 22 of 22 Pack page 81


SUBJECT: Annual Data Protection Toolkit Compliance Report DATE: 5 March 2020

PURPOSE:


applicable For decision/approval

Assurance


PREPARED BY: TOM DAVIDSON, ICT DIRECTOR SPONSORED BY: DR RICHARD JENKINS, CHIEF EXECUTIVE PRESENTED BY: TOM DAVIDSON, ICT DIRECTOR

STRATEGIC CONTEXT

• The National Data Guardian (NDG) advises and challenges the health and care system to help ensure that citizens’ confidential information is safeguarded securely and used properly.

• The Data Security and Protection Toolkit is an online self-assessment tool that allows organisations to measure their performance against the National Data Guardian’s 10 data security standards.

• All organisations that have access to NHS patient data and systems must use this toolkit to provide assurance that they are practising good data security and that personal information is handled correctly.

EXECUTIVE SUMMARY This paper is presented to give assurance final assurance to People, Finance and Performance Committee that we can submit a compliant position on our data protection toolkit position for 31st March 2020 to NHS Digital. Appendix 1 is a status report of all the standards against the compliant requirement. There is a new information data protection e-learning package that replaces the existing IG requirement for the IG Toolkit. The Data Protection e-learning for the trust is currently at 94%. We are confident we will meet the target of 95% by 31st March 2020, as there are number of exceptions such as Nurse Bank staff we are no longer responsible for. A 360Assurance Internal Audit was started in Jan 2020 on our data protection toolkit self assessment and will detail any recommendations to ensure we meet full compliance. We expect the report back during March 2020. Any recommendations will be completed by 31st March 2020. We completed a General Data Protection Regulation (GDPR) Audit in October 2018 which received significant assurance. A cyber security report to board provided significant assurance during August 2019 and Board members received appropriate cyber security training from National Cyber Security approved training centre. The trust Cyber security position is updated as part of the ICT report to PF&P monthly.

RECOMMENDATIONS PF&P are asked to approve the report of a compliant position for the Data Protection Toolkit to be submitted to board.

Pack page 82

Appendix 1: Status report of all National Data Guardian Standards as at 19/03/2019

Pack page 83

Mtg MM YR – report title (brief)

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/12 SUBJECT: NATIONAL STAFF SURVEY RESULTS - 2019 DATE: 5TH MARCH 2020 PRIVATE & CONFIDENTIAL

PURPOSE:


applicable For decision/approval Assurance For review Governance For information √ Strategy

PREPARED BY: Steven Ned – Director of Workforce SPONSORED BY: Steven Ned – Director of Workforce PRESENTED BY: Steven Ned – Director of Workforce STRATEGIC CONTEXT

The Staff Survey results for 2019 were published nationally on 18th February, 2020. The staff survey links to our Strategic Aim that: People will be proud to work for us.

EXECUTIVE SUMMARY The Staff Survey results for 2019 provide invaluable feedback from staff about their experience of working at the Trust. Highlights of the survey include:

• The Trust had its highest ever response rate to the survey with a 71% response rate (representing the views of 2,237 staff)

• The Trust scored the same or higher than average against 10 of the 11 themes in the staff survey and was rated the highest amongst acute Trusts nationally in relation to Equality, Diversity and Inclusion.

• There have been significant improvements in relation to themes from the staff survey including, ‘support from immediate managers’ (6.9 to 7.1) ‘morale’ (6.2 to 6.3) and ‘Quality of care’ (7.5 to 7.7).

It is also clear from the survey results that further work needs to be focussed in the following areas:

• Quality of Staff appraisals

• Health and Wellbeing

• Safe environment – violence. The Director of Nursing and Quality is creating a task and finish group to address the recently published NHS England and Improvement guidance ‘Violence Prevention and Reduction standards’.

The next steps following receipt of this year’s staff survey are to develop a corporate action plan supported by action plans from CBU’s and Corporate Divisions. The development and monitoring of performance against the action plans will be done through the People and Engagement Group with regular reports to the People, Finance and Performance Committee. It is proposed that an

Pack page 84

Mtg MM YR – report title (brief)

update report is provided to the Board of Directors at the end of Quarter 1.

RECOMMENDATION(S)

The Board of Directors is asked to note the results of the 2019 National Staff Survey.

Pack page 85


2019 NHS Staff Survey

Summary Benchmark Report

Pack page 86

Organisation details

Organisation details

Completed questionnaires 2,237

2019 response rate 71%

Survey details

Survey mode Paper

Sample type Census

2019 NHS Staff Survey

This organisation is benchmarked against:

2019 benchmarking group details

Organisations in group:

Median response rate:

No. of completed questionnaires:

Barnsley Hospital NHS FoundationTrust

See response rate trend for the last 5 years

Acute Trusts

85

47%

259,296

2Pack page 87

Using the report

Key features

Question number and text(or the theme) specifiedat the top of each slide

Question-level results are alwaysreported as percentages; the meaningof the value is outlined along the axis.

Themes are always on a 0-10pt scalewhere 10 is the best score attainable

Colour coding highlights best / worstresults, making it easy to spot questions

where a lower percentage is better – in suchinstances ‘Best’ is the bottom line in the table

Number of responsesfor the organisation

for the given question

Full details on how the scores are calculated are provided in the TechnicalDocument, under the Supporting Documents section of our results page

‘Best’, ‘Average’, and ‘Worst’ refer to thebenchmarking group’s best, average and worst results

Keep an eye out!

3Pack page 88

https://www.nhsstaffsurveyresults.com/

Theme results


2019 NHS Staff Survey ResultsPack page 89

2019 NHS Staff Survey Results > Theme results > Overview

Equality,diversity &inclusion

Health &wellbeing

Immediatemanagers

Morale Quality ofappraisals

Qualityof care

Safeenvironment- Bullying &harassment

Safeenvironment

- Violence

Safety culture Staffengagement

Teamworking

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 9.4 6.7 7.4 6.7 6.6 8.1 8.5 9.6 7.2 7.5 7.2

Your org 9.4 6.1 7.1 6.3 5.6 7.7 8.2 9.3 6.8 7.1 6.8

Average 9.0 5.9 6.8 6.1 5.6 7.5 7.9 9.4 6.7 7.0 6.6

Worst 8.3 5.3 6.0 5.5 4.8 6.7 7.3 9.2 5.7 6.1 5.9

Responses 2,216 2,229 2,231 2,218 2,071 2,004 2,207 2,210 2,225 2,233 2,215

5Pack page 90

Theme results – Trends



2019 NHS Staff Survey Results > Theme results > Trends > Equality, diversity & inclusion

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 9.5 9.4 9.4 9.6 9.4

Your org 9.3 9.3 9.3 9.2 9.4

Average 9.2 9.2 9.1 9.1 9.0

Worst 8.3 8.2 8.1 8.1 8.3

Responses 1,226 1,443 1,281 1,440 2,216

7Pack page 92

2019 NHS Staff Survey Results > Theme results > Trends > Health & wellbeing

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 6.8 6.8 6.6 6.7 6.7

Your org 5.9 6.0 6.0 6.1 6.1

Average 6.0 6.1 6.0 5.9 5.9

Worst 5.3 5.3 5.4 5.2 5.3

Responses 1,245 1,462 1,297 1,446 2,229

8Pack page 93

2019 NHS Staff Survey Results > Theme results > Trends > Immediate managers

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 7.1 7.2 7.2 7.3 7.4

Your org 6.7 6.7 6.8 6.9 7.1

Average 6.6 6.7 6.7 6.7 6.8

Worst 6.1 6.2 6.3 6.2 6.0

Responses 1,246 1,458 1,297 1,453 2,231

9Pack page 94

2019 NHS Staff Survey Results > Theme results > Trends > Morale

2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 6.7 6.7

Your org 6.2 6.3

Average 6.0 6.1

Worst 5.4 5.5

Responses 1,418 2,218

10Pack page 95

2019 NHS Staff Survey Results > Theme results > Trends > Quality of appraisals

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 6.1 6.3 6.4 6.5 6.6

Your org 5.2 5.3 5.3 5.6 5.6

Average 5.1 5.3 5.3 5.4 5.6

Worst 4.2 4.4 4.7 4.6 4.8

Responses 1,107 1,342 1,161 1,323 2,071

11Pack page 96

2019 NHS Staff Survey Results > Theme results > Trends > Quality of care

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 8.1 8.2 7.9 8.1 8.1

Your org 7.4 7.4 7.3 7.5 7.7

Average 7.5 7.6 7.4 7.4 7.5

Worst 6.9 7.0 7.0 7.0 6.7

Responses 1,082 1,282 1,125 1,293 2,004

12Pack page 97

2019 NHS Staff Survey Results > Theme results > Trends > Safe environment - Bullying & harassment

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 8.4 8.5 8.4 8.5 8.5

Your org 8.2 8.2 8.2 8.3 8.2

Average 7.9 8.0 8.0 7.9 7.9

Worst 7.0 7.1 7.2 7.1 7.3

Responses 1,232 1,440 1,272 1,426 2,207

13Pack page 98

2019 NHS Staff Survey Results > Theme results > Trends > Safe environment - Violence

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 9.6 9.7 9.6 9.6 9.6

Your org 9.4 9.3 9.4 9.4 9.3

Average 9.4 9.4 9.4 9.4 9.4

Worst 9.1 9.2 9.1 9.2 9.2

Responses 1,232 1,440 1,270 1,421 2,210

14Pack page 99

2019 NHS Staff Survey Results > Theme results > Trends > Safety culture

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 7.1 7.0 7.1 7.2 7.2

Your org 6.6 6.5 6.6 6.8 6.8

Average 6.5 6.6 6.6 6.7 6.7

Worst 5.9 6.0 5.9 6.0 5.7

Responses 1,239 1,454 1,290 1,434 2,225

15Pack page 100

2019 NHS Staff Survey Results > Theme results > Trends > Staff engagement

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 7.6 7.4 7.4 7.6 7.5

Your org 6.8 6.7 6.8 7.0 7.1

Average 7.0 7.0 7.0 7.0 7.0

Worst 6.4 6.5 6.4 6.4 6.1

Responses 1,273 1,473 1,313 1,471 2,233

16Pack page 101

2019 NHS Staff Survey Results > Theme results > Trends > Team working

2015 2016 2017 2018 2019

Scor

e (0

-10)

0

1

2

3

4

5

6

7

8

9

10

Best 6.9 7.0 7.0 7.1 7.2

Your org 6.5 6.6 6.8 6.8 6.8

Average 6.5 6.5 6.5 6.5 6.6

Worst 6.1 6.1 6.0 5.9 5.9

Responses 1,244 1,449 1,299 1,455 2,215

17Pack page 102

Theme results – Detailed information



2019 NHS Staff Survey Results > Theme results > Detailed information > Equality, diversity & inclusion 1/2

Q14Does your organisation act fairly

with regard to career progression /promotion, regardless of ethnicbackground, gender, religion,

sexual orientation, disability or age?

Q15aIn the last 12 months have you personally

experienced discrimination at workfrom patients / service users, their

relatives or other members of the public?

Q15bIn the last 12 months have you

personally experienced discriminationat work from manager / teamleader or other colleagues?

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

65

70

75

80

85

90

95

Best 93.3% 91.7% 93.6% 94.3% 91.9%

Your org 87.9% 85.0% 85.0% 85.1% 89.8%

Average 86.9% 86.5% 84.8% 84.0% 84.4%

Worst 69.6% 67.1% 68.7% 69.3% 70.7%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

0

5

10

15

20

Worst 13.9% 13.8% 16.1% 16.5% 14.8%

Your org 3.4% 2.7% 3.6% 2.7% 3.8%

Average 5.4% 5.9% 6.2% 6.3% 6.8%

Best 1.8% 2.7% 3.3% 2.7% 3.3%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

0

5

10

15

20

Worst 14.7% 15.8% 15.7% 15.0% 13.8%

Your org 7.2% 5.6% 5.9% 6.9% 5.5%

Average 7.3% 7.4% 8.2% 7.8% 7.5%

Best 3.2% 4.4% 5.0% 3.7% 4.5%19Pack page 104

2019 NHS Staff Survey Results > Theme results > Detailed information > Equality, diversity & inclusion 2/2

Q28bHas your employer made adequate adjustment(s)

to enable you to carry out your work?

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

40

50

60

70

80

90

100

Best 94.8% 87.1% 83.6% 85.0% 85.8%

Your org 66.8% 66.8% 68.4% 65.0% 76.9%

Average 73.0% 74.3% 73.9% 71.9% 73.4%

Worst 42.9% 60.5% 60.3% 50.6% 58.0%

20Pack page 105

2019 NHS Staff Survey Results > Theme results > Detailed information > Health & wellbeing 1/2

Q5hThe opportunities for

flexible working patterns

Q11aDoes your organisation take positive

action on health and well-being?

Q11bIn the last 12 months have you

experienced musculoskeletal problems(MSK) as a result of work activities?

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'S

atis

fied'

/'Ver

y Sa

tisfie

d'

40

45

50

55

60

65

Best 58.2% 58.3% 60.3% 60.3% 62.0%

Your org 52.7% 54.6% 54.9% 55.9% 56.1%

Average 48.7% 50.1% 50.3% 51.9% 52.6%

Worst 40.3% 42.8% 40.0% 42.4% 41.9%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

10

15

20

25

30

35

40

45

50

55

Best 49.5% 52.1% 46.9% 46.7% 45.4%

Your org 28.1% 31.1% 32.0% 28.8% 32.4%

Average 30.3% 31.7% 31.2% 27.7% 28.2%

Worst 14.7% 18.1% 19.0% 15.3% 16.0%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

15

20

25

30

35

40

Worst 33.6% 34.4% 34.6% 37.9% 36.2%

Your org 25.6% 23.6% 24.1% 23.5% 25.2%

Average 25.5% 25.7% 26.0% 28.7% 29.7%

Best 19.2% 18.6% 19.7% 20.3% 21.5%

21Pack page 106

2019 NHS Staff Survey Results > Theme results > Detailed information > Health & wellbeing 2/2

Q11cDuring the last 12 months have you feltunwell as a result of work related stress?

Q11dIn the last three months have you ever come to work

despite not feeling well enough to perform your duties?

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

20

25

30

35

40

45

50

Worst 44.9% 44.3% 45.9% 46.7% 46.3%

Your org 41.1% 38.8% 40.2% 38.6% 39.3%

Average 36.2% 35.3% 36.8% 39.0% 39.8%

Best 24.9% 25.4% 27.8% 29.1% 31.3%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es'

40

45

50

55

60

65

70

Worst 65.0% 62.9% 62.9% 64.3% 62.3%

Your org 59.6% 58.7% 56.8% 55.3% 56.8%

Average 57.0% 55.2% 56.3% 56.9% 56.8%

Best 44.8% 48.4% 47.7% 47.7% 48.0%

22Pack page 107

2019 NHS Staff Survey Results > Theme results > Detailed information > Immediate managers 1/2

Q5bThe support I get frommy immediate manager

Q8cMy immediate manager gives

me clear feedback on my work

Q8dMy immediate manager asksfor my opinion before makingdecisions that affect my work

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'S

atis

fied'

/'Ver

y Sa

tisfie

d'

55

60

65

70

75

80

Best 74.0% 75.6% 76.0% 77.4% 79.5%

Your org 67.7% 66.6% 69.2% 69.5% 74.5%

Average 65.8% 66.9% 67.5% 68.6% 69.4%

Worst 57.3% 58.9% 58.4% 58.2% 55.2%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

45

50

55

60

65

70

Best 66.9% 66.9% 69.0% 69.2% 69.9%

Your org 61.5% 62.7% 65.2% 64.1% 64.7%

Average 58.0% 60.2% 60.5% 60.1% 61.4%

Worst 50.9% 51.5% 52.2% 50.7% 48.0%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

40

45

50

55

60

65

Best 61.8% 60.5% 61.2% 61.4% 62.4%

Your org 55.5% 55.1% 56.5% 55.7% 56.8%

Average 51.7% 53.7% 54.8% 54.1% 55.4%

Worst 40.0% 45.8% 45.5% 44.5% 44.2%

23Pack page 108

2019 NHS Staff Survey Results > Theme results > Detailed information > Immediate managers 2/2

Q8fMy immediate manager takes a positive

interest in my health and well-being

Q8gMy immediate manager values my work

Q19gMy manager supported me to receivethis training, learning or development

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

55

60

65

70

75

80

Best 70.4% 73.3% 72.4% 74.1% 77.8%

Your org 68.2% 65.6% 68.9% 69.3% 71.4%

Average 64.2% 65.6% 66.8% 66.9% 68.1%

Worst 58.3% 57.2% 59.1% 57.6% 55.5%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

60

65

70

75

80

85

Best 77.0% 77.2% 77.1% 78.6% 80.2%

Your org 70.6% 68.7% 71.7% 71.1% 74.4%

Average 69.2% 70.2% 71.2% 71.1% 72.3%

Worst 63.3% 64.7% 62.7% 63.9% 60.2%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

40

45

50

55

60

65

70

Best 61.3% 61.0% 64.5% 66.0% 63.3%

Your org 50.5% 49.8% 52.4% 56.8% 58.5%

Average 50.9% 51.0% 51.0% 53.9% 55.0%

Worst 42.7% 42.5% 42.3% 46.9% 46.3%

24Pack page 109

2019 NHS Staff Survey Results > Theme results > Detailed information > Morale 1/3

Q4cI am involved in deciding on

changes introduced that affect mywork area / team / department

Q4jI receive the respect I deservefrom my colleagues at work

Q6aI have unrealistic time pressures

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

40

45

50

55

60

65

Best 63.9% 61.1% 61.8% 62.4% 62.1%

Your org 53.1% 51.4% 52.4% 53.9% 53.1%

Average 52.1% 52.7% 52.4% 52.7% 52.2%

Worst 42.7% 45.0% 41.8% 42.7% 42.4%

2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

60

65

70

75

80

85

Best 79.0% 81.9%

Your org 69.8% 73.3%

Average 70.8% 71.4%

Worst 62.6% 62.4%

2018 2019

% o

f st

aff

sele

ctin

g 'N

ever

'/'Ra

rely

'

10

15

20

25

30

35

Best 28.3% 31.2%

Your org 25.4% 24.6%

Average 20.9% 21.9%

Worst 14.6% 17.6%

25Pack page 110


Q6bI have a choice in deciding

how to do my work

Q6cRelationships at work are strained

Q8aMy immediate managerencourages me at work

2018 2019

% o

f st

aff

sele

ctin

g 'O

ften

'/'A

lway

s'

45

50

55

60

65

Best 61.0% 60.9%

Your org 57.2% 55.4%

Average 53.8% 53.9%

Worst 47.0% 48.6%

2018 2019

% o

f st

aff

sele

ctin

g 'N

ever

'/'Ra

rely

'

30

35

40

45

50

55

60

Best 55.4% 57.4%

Your org 39.2% 42.4%

Average 42.8% 44.1%

Worst 32.2% 36.8%

2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

55

60

65

70

75

80

Best 76.8% 79.4%

Your org 68.4% 73.0%

Average 67.9% 69.9%

Worst 60.0% 56.7%

26Pack page 111


Q23aI often think about

leaving this organisation

Q23bI will probably look for a job at a neworganisation in the next 12 months

Q23cAs soon as I can find another

job, I will leave this organisation

2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

15

20

25

30

35

40

45

Worst 40.7% 41.8%

Your org 26.3% 26.1%

Average 30.0% 28.3%

Best 19.1% 19.6%

2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

10

15

20

25

30

35

Worst 31.7% 30.3%

Your org 17.4% 17.7%

Average 21.0% 19.9%

Best 14.4% 14.5%

2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

5

10

15

20

25

Worst 24.9% 22.8%

Your org 13.1% 12.2%

Average 15.3% 14.3%

Best 9.5% 8.7%

27Pack page 112

2019 NHS Staff Survey Results > Theme results > Detailed information > Quality of appraisals 1/2

Q19bIt helped me to improve how I do my job

Q19cIt helped me agree clearobjectives for my work

Q19dIt left me feeling that my workis valued by my organisation

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

10

15

20

25

30

35

40

Best 31.8% 32.1% 34.7% 35.0% 35.1%

Your org 18.7% 22.0% 20.3% 23.9% 22.5%

Average 19.6% 22.0% 22.2% 23.0% 23.3%

Worst 12.9% 13.2% 15.1% 14.1% 14.6%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

20

25

30

35

40

45

50

Best 43.1% 45.5% 46.7% 46.4% 46.6%

Your org 29.7% 33.0% 31.4% 33.5% 35.5%

Average 32.8% 34.1% 34.5% 34.8% 35.9%

Worst 22.6% 24.8% 25.7% 22.8% 24.4%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

15

20

25

30

35

40

45

Best 39.4% 42.0% 42.0% 42.4% 43.3%

Your org 25.1% 27.3% 27.0% 31.6% 34.1%

Average 28.1% 29.6% 30.0% 32.3% 33.6%

Worst 19.9% 20.9% 21.8% 22.7% 18.9%

28Pack page 113

2019 NHS Staff Survey Results > Theme results > Detailed information > Quality of appraisals 2/2

Q19eThe values of my organisation were

discussed as part of the appraisal process

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'Y

es, d

efini

tely

'

15

20

25

30

35

40

45

50

55

Best 48.7% 50.7% 52.7% 52.4% 53.3%

Your org 36.3% 37.0% 36.3% 40.3% 43.0%

Average 29.6% 32.3% 32.2% 34.8% 37.8%

Worst 16.5% 17.1% 20.0% 21.9% 23.7%

29Pack page 114

2019 NHS Staff Survey Results > Theme results > Detailed information > Quality of care

Q7aI am satisfied with the quality of

care I give to patients / service users

Q7bI feel that my role makes a

difference to patients / service users

Q7cI am able to deliver the care I aspire to

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

65

70

75

80

85

90

95

Best 90.7% 88.6% 88.1% 89.5% 87.3%

Your org 80.2% 80.3% 78.5% 81.6% 85.7%

Average 82.3% 83.0% 80.6% 79.9% 80.7%

Worst 72.9% 74.0% 72.9% 72.2% 68.0%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

80

85

90

95

Best 93.9% 93.8% 93.0% 92.9% 93.4%

Your org 88.8% 89.6% 87.3% 89.0% 91.2%

Average 90.4% 90.5% 90.2% 89.5% 89.7%

Worst 86.0% 88.1% 86.2% 84.2% 81.4%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

50

55

60

65

70

75

80

85

Best 79.6% 80.5% 76.8% 81.0% 80.3%

Your org 66.4% 65.3% 63.7% 70.1% 73.8%

Average 67.6% 69.6% 66.7% 66.8% 68.3%

Worst 54.3% 56.1% 57.9% 58.0% 55.5%

30Pack page 115

2019 NHS Staff Survey Results > Theme results > Detailedinformation > Safe environment - Bullying & harassment

Q13aIn the last 12 months how many

times have you personally experiencedharassment, bullying or abuse at work

from patients / service users, theirrelatives or other members of the public?

Q13bIn the last 12 months how

many times have you personallyexperienced harassment, bullyingor abuse at work from managers?

Q13cIn the last 12 months how many

times have you personally experiencedharassment, bullying or abuse

at work from other colleagues?

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

bully

ing,

har

assm

ent

or a

buse

20

25

30

35

40

Worst 38.9% 38.2% 36.0% 37.7% 36.0%

Your org 23.9% 24.9% 25.0% 23.4% 26.2%

Average 29.1% 28.7% 28.4% 28.7% 28.7%

Best 22.9% 22.9% 22.9% 22.3% 23.4%

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

bully

ing,

har

assm

ent

or a

buse

5

10

15

20

25

30

Worst 27.4% 22.6% 23.8% 24.3% 23.5%

Your org 14.5% 13.1% 12.4% 11.0% 9.7%

Average 14.0% 12.9% 13.2% 13.8% 13.1%

Best 8.0% 7.8% 7.2% 8.0% 6.4%

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

bully

ing,

har

assm

ent

or a

buse

10

15

20

25

30

35

Worst 30.2% 27.5% 27.4% 28.4% 26.5%

Your org 16.9% 15.8% 15.8% 17.7% 18.0%

Average 19.3% 18.6% 19.1% 20.4% 20.3%

Best 14.7% 12.8% 14.0% 11.8% 12.9%31Pack page 116

2019 NHS Staff Survey Results > Theme results > Detailed information > Safe environment - Violence

Q12aIn the last 12 months how many

times have you personally experiencedphysical violence at work from

patients / service users, their relativesor other members of the public?

Q12bIn the last 12 months how many times

have you personally experienced physicalviolence at work from managers?

Q12cIn the last 12 months how many times

have you personally experienced physicalviolence at work from other colleagues?

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

viol

ence

5

10

15

20

25

Worst 22.4% 21.2% 22.4% 21.3% 21.8%

Your org 16.0% 18.1% 17.2% 14.4% 18.4%

Average 14.9% 15.8% 15.2% 14.5% 15.1%

Best 9.9% 8.2% 11.0% 10.1% 11.3%

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

viol

ence

0

1

2

3

Worst 2.4% 1.9% 2.3% 1.5% 2.0%

Your org 0.5% 0.7% 0.5% 0.7% 0.7%

Average 0.6% 0.7% 0.7% 0.7% 0.6%

Best 0.0% 0.0% 0.0% 0.0% 0.1%

2015 2016 2017 2018 2019

% o

f st

aff

sayi

ng t

hey

expe

rienc

ed a

t le

ast

one

inci

dent

of

viol

ence

0

1

2

3

4

5

6

7

Worst 4.7% 3.5% 4.3% 6.5% 3.8%

Your org 1.2% 2.7% 1.2% 1.9% 1.6%

Average 1.8% 1.9% 1.9% 1.6% 1.6%

Best 0.0% 0.2% 0.8% 0.6% 0.6%32Pack page 117

2019 NHS Staff Survey Results > Theme results > Detailed information > Safety culture 1/2

Q17aMy organisation treats staffwho are involved in an error,near miss or incident fairly

Q17cWhen errors, near misses or incidents arereported, my organisation takes action

to ensure that they do not happen again

Q17dWe are given feedback about changes

made in response to reportederrors, near misses and incidents

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

35

40

45

50

55

60

65

70

75

Best 64.3% 64.5% 65.1% 69.6% 71.1%

Your org 49.7% 46.7% 52.4% 55.6% 56.5%

Average 52.1% 53.8% 54.3% 58.3% 59.6%

Worst 39.4% 37.7% 39.6% 42.8% 41.3%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

50

55

60

65

70

75

80

85

Best 75.8% 76.7% 76.2% 82.3% 80.7%

Your org 72.1% 68.4% 67.7% 72.2% 70.5%

Average 67.1% 68.2% 68.6% 69.9% 70.2%

Worst 52.1% 54.8% 52.4% 55.8% 53.9%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

35

40

45

50

55

60

65

70

75

Best 62.6% 73.2% 71.6% 72.2% 72.2%

Your org 62.6% 61.9% 64.5% 66.7% 65.8%

Average 53.0% 54.3% 56.4% 58.8% 60.1%

Worst 39.7% 41.0% 41.1% 43.3% 43.7%

33Pack page 118

2019 NHS Staff Survey Results > Theme results > Detailed information > Safety culture 2/2

Q18bI would feel secure raising concerns

about unsafe clinical practice

Q18cI am confident that my organisation

would address my concern

Q21bMy organisation acts on concernsraised by patients / service users

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

55

60

65

70

75

80

Best 77.0% 75.5% 76.1% 76.9% 77.0%

Your org 69.2% 67.5% 69.6% 73.0% 70.7%

Average 67.2% 69.1% 68.8% 69.3% 70.4%

Worst 57.9% 59.2% 58.9% 60.8% 58.6%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

35

40

45

50

55

60

65

70

Best 69.9% 69.5% 67.9% 69.2% 69.6%

Your org 56.2% 54.1% 54.7% 59.5% 59.4%

Average 55.2% 56.3% 56.9% 56.7% 57.7%

Worst 40.6% 42.3% 42.6% 42.4% 37.6%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

40

45

50

55

60

65

70

75

80

85

Best 83.7% 83.5% 83.1% 84.8% 84.5%

Your org 72.1% 67.7% 69.9% 74.4% 76.0%

Average 73.0% 73.2% 72.8% 72.7% 72.9%

Worst 55.0% 56.4% 56.9% 56.6% 44.7%

34Pack page 119

2019 NHS Staff Survey Results > Theme results > Detailed information > Staff engagement – Motivation

Q2aI look forward to going to work

Q2bI am enthusiastic about my job

Q2cTime passes quickly when I am working

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'O

ften

'/'A

lway

s'

45

50

55

60

65

70

75

Best 70.3% 66.1% 66.7% 67.6% 68.8%

Your org 53.0% 51.5% 53.4% 57.2% 57.2%

Average 59.2% 59.8% 58.4% 59.2% 60.2%

Worst 49.9% 51.5% 50.2% 50.6% 47.1%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'O

ften

'/'A

lway

s'

65

70

75

80

85

Best 81.9% 80.3% 79.2% 81.8% 81.7%

Your org 72.3% 70.2% 71.5% 76.6% 76.5%

Average 75.1% 75.1% 74.3% 74.9% 75.3%

Worst 67.2% 69.8% 68.1% 69.3% 67.9%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'O

ften

'/'A

lway

s'

70

75

80

85

Best 83.9% 81.4% 80.8% 83.3% 81.9%

Your org 76.4% 72.8% 73.7% 74.6% 75.9%

Average 78.1% 78.0% 77.2% 76.7% 76.9%

Worst 73.5% 71.8% 72.2% 72.6% 71.5%

35Pack page 120

2019 NHS Staff Survey Results > Theme results > Detailedinformation > Staff engagement – Ability to contribute to improvements

Q4aThere are frequent opportunities

for me to show initiative in my role

Q4bI am able to make suggestions

to improve the work ofmy team / department

Q4dI am able to make improvements

happen in my area of work

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

60

65

70

75

80

85

Best 80.5% 79.8% 79.5% 79.3% 79.4%

Your org 72.6% 72.4% 74.0% 74.9% 75.4%

Average 72.9% 73.6% 73.2% 72.7% 72.8%

Worst 65.1% 67.3% 62.9% 62.8% 60.4%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

65

70

75

80

85

Best 83.7% 81.4% 83.0% 83.2% 81.9%

Your org 74.4% 74.1% 73.4% 73.0% 75.0%

Average 74.6% 75.0% 74.5% 74.5% 73.6%

Worst 67.1% 69.4% 65.5% 67.7% 65.2%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

40

45

50

55

60

65

70

Best 66.1% 63.8% 64.6% 66.0% 67.6%

Your org 54.3% 51.0% 54.1% 55.6% 53.3%

Average 55.2% 56.1% 56.1% 56.1% 56.0%

Worst 45.9% 46.9% 43.7% 45.7% 44.6%

36Pack page 121

2019 NHS Staff Survey Results > Theme results > Detailed information > Staffengagement – Recommendation of the organisation as a place to work/receive treatment

Q21aCare of patients / service usersis my organisation's top priority

Q21cI would recommend my

organisation as a place to work

Q21dIf a friend or relative needed treatment

I would be happy with the standardof care provided by this organisation

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

45

50

55

60

65

70

75

80

85

90

Best 86.1% 87.8% 87.2% 88.4% 88.0%

Your org 68.4% 67.6% 68.9% 74.7% 76.6%

Average 74.9% 76.2% 75.3% 76.7% 77.4%

Worst 55.5% 56.9% 59.6% 60.2% 46.9%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

35

40

45

50

55

60

65

70

75

80

85

Best 76.8% 76.0% 77.2% 81.1% 78.9%

Your org 56.2% 57.9% 59.6% 63.7% 69.1%

Average 60.3% 60.9% 60.7% 62.3% 62.5%

Worst 41.6% 41.4% 42.7% 39.3% 36.0%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

35

40

45

50

55

60

65

70

75

80

85

90

Best 85.3% 84.8% 85.3% 87.3% 87.4%

Your org 60.2% 61.9% 63.0% 68.0% 70.7%

Average 69.3% 69.1% 70.6% 71.2% 70.5%

Worst 45.8% 48.4% 46.4% 39.7% 39.7%

37Pack page 122

2019 NHS Staff Survey Results > Theme results > Detailed information > Team working

Q4hThe team I work in has a set of shared objectives

Q4iThe team I work in often meets to discuss the team's effectiveness

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

60

65

70

75

80

85

Best 80.1% 79.3% 79.7% 80.8% 83.4%

Your org 71.6% 71.5% 74.9% 73.6% 77.1%

Average 71.6% 72.6% 72.6% 72.0% 72.0%

Worst 66.0% 65.8% 66.5% 63.4% 63.2%

2015 2016 2017 2018 2019

% o

f st

aff

sele

ctin

g 'A

gree

'/'St

rong

ly A

gree

'

45

50

55

60

65

70

Best 66.3% 66.0% 66.7% 68.6% 68.6%

Your org 60.1% 59.3% 63.7% 64.6% 63.6%

Average 57.2% 58.0% 58.5% 58.6% 60.3%

Worst 48.2% 48.2% 49.1% 46.8% 47.6%

38Pack page 123

Workforce Equality Standards



Workforce Equality Standards

Workforce Race Equality Standard (WRES)

Workforce Disability Equality Standard (WDES)

This section contains data required for the NHS Staff Survey indicators used in the Workforce Race Equality Standard (WRES) and Workforce DisabilityEquality Standard (WDES). Data presented in this section are unweighted.

Full details of how the data are calculated are included in the Technical Document, available to download from our results website.

This contains data for each organisation required for the NHS Staff Survey indicators used in the Workforce Race Equality Standard (WRES).It includes the 2017, 2018 and 2019 trust/CCG and benchmarking group median results for q13a, q13b&c combined, q14, and q15b splitby ethnicity (by white / BME staff).

This contains data for each organisation required for the NHS Staff Survey indicators used in the Workforce Disability Equality Standard(WDES). It includes the 2018 and 2019 trust/CCG and benchmarking group median results for q5f, q11e, q13, and q14 split by disabledstaff compared to non-disabled staff. It also shows results for q28b (for disabled staff only), and the staff engagement score for disabledstaff, compared to non-disabled staff and the overall engagement score for the organisation.

40Pack page 125

http://www.nhsstaffsurveyresults.com/

Workforce Race Equality Standard (WRES)



2019 NHS Staff Survey Results > WRES > Percentage of staff experiencingharassment, bullying or abuse from patients, relatives or the public in last 12 months

2017 2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ing

hara

ssm

ent,

bully

ing

or a

buse

fro

m p

atie

nts,

rel

ativ

es o

r th

epu

blic

in la

st 1

2 m

onth

s

0

10

20

30

40

50

60

70

80

90

100

White: Your org 25.5% 23.3% 26.9%

BME: Your org 21.9% 20.5% 29.5%

White: Average 27.7% 28.4% 28.2%

BME: Average 27.7% 29.8% 29.9%

White: Responses 1,182 1,320 2,051BME: Responses 73 78 122

Average calculated as the median for the benchmark group

42Pack page 127

2019 NHS Staff Survey Results > WRES > Percentage of staffexperiencing harassment, bullying or abuse from staff in last 12 months

2017 2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ing

hara

ssm

ent,

bully

ing

or a

buse

fro

m s

taff

in la

st 1

2 m

onth

s

0

10

20

30

40

50

60

70

80

90

100

White: Your org 22.7% 21.3% 22.4%

BME: Your org 15.1% 30.8% 28.0%

White: Average 24.8% 26.4% 25.8%

BME: Average 27.1% 28.6% 28.8%



43Pack page 128

2019 NHS Staff Survey Results > WRES > Percentage of staff believing thatthe organisation provides equal opportunities for career progression or promotion

2017 2018 2019

Perc

enta

ge o

f st

aff

belie

ving

tha

t th

eor

gani

satio

n pr

ovid

es e

qual

opp

ortu

nitie

s fo

rca

reer

pro

gres

sion

or

prom

otio

n

0

10

20

30

40

50

60

70

80

90

100

White: Your org 84.4% 86.3% 90.8%

BME: Your org 84.0% 73.3% 78.0%

White: Average 86.8% 86.5% 86.7%

BME: Average 75.1% 72.3% 74.4%

White: Responses 840 893 1,515BME: Responses 50 45 82


44Pack page 129

2019 NHS Staff Survey Results > WRES > Percentage of staff experienceddiscrimination at work from manager / team leader or other colleagues in last 12 months

2017 2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ed d

iscr

imin

atio

nat

wor

k fr

om m

anag

er /

team

lead

er o

r ot

her

colle

ague

s in

last

12

mon

ths

0

10

20

30

40

50

60

70

80

90

100

White: Your org 6.1% 6.0% 4.5%

BME: Your org 5.3% 12.7% 16.7%

White: Average 6.7% 6.6% 6.0%

BME: Average 15.0% 14.6% 13.8%



45Pack page 130

Workforce Disability Equality Standard(WDES)



2019 NHS Staff Survey Results > WDES > Percentage of staff experiencingharassment, bullying or abuse from patients, relatives or the public in last 12 months

2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ing

hara

ssm

ent,

bul

lyin

g or

abu

sefr

om p

atie

nts,

rel

ativ

es o

r th

epu

blic

in la

st 1

2 m

onth

s

0

10

20

30

40

50

60

70

80

90

100

Disabled staff: Your org 25.6% 33.3%

Non-disabled staff: Your org 22.8% 25.4%

Disabled staff: Average 34.4% 33.9%

Non-disabled staff: Average 26.9% 27.3%

Disabled staff: Responses 246 484Non-disabled staff: Responses 1,126 1,683


47Pack page 132

2019 NHS Staff Survey Results > WDES > Percentage of staffexperiencing harassment, bullying or abuse from manager in last 12 months

2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ing

hara

ssm

ent,

bul

lyin

g or

abu

sefr

om m

anag

er in

last

12

mon

ths

0

10

20

30

40

50

60

70

80

90

100







48Pack page 133

2019 NHS Staff Survey Results > WDES > Percentage of staff experiencingharassment, bullying or abuse from other colleagues in last 12 months

2018 2019

Perc

enta

ge o

f st

aff

expe

rienc

ing

hara

ssm

ent,

bul

lyin

g or

abu

sefr

om o

ther

col

leag

ues

in la

st 1

2m

onth

s

0

10

20

30

40

50

60

70

80

90

100







49Pack page 134

2019 NHS Staff Survey Results > WDES > Percentage of staff saying that the last timethey experienced harassment, bullying or abuse at work, they or a colleague reported it

2018 2019

Perc

enta

ge o

f st

aff

sayi

ng t

hat

the

last

tim

e th

ey e

xper

ienc

edha

rass

men

t, b

ully

ing

or a

buse

at

wor

k, t

hey

or a

col

leag

ue r

epor

ted

it

0

10

20

30

40

50

60

70

80

90

100





Disabled staff: Responses 101 207Non-disabled staff: Responses 321 512


50Pack page 135

2019 NHS Staff Survey Results > WDES > Percentage of staff who believe thattheir organisation provides equal opportunities for career progression or promotion

2018 2019

Perc

enta

ge o

f st

aff

who

bel

ieve

that

the

ir or

gani

satio

n pr

ovid

eseq

ual o

ppor

tuni

ties

for

care

erpr

ogre

ssio

n or

pro

mot

ion

0

10

20

30

40

50

60

70

80

90

100





Disabled staff: Responses 169 355Non-disabled staff: Responses 754 1,235


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2019 NHS Staff Survey Results > WDES > Percentage of staff who have felt pressure fromtheir manager to come to work, despite not feeling well enough to perform their duties

2018 2019

Perc

enta

ge o

f st

aff

who

hav

e fe

ltpr

essu

re f

rom

the

ir m

anag

er t

oco

me

to w

ork,

des

pite

not

fee

ling

wel

l eno

ugh

to p

erfo

rm t

heir

dutie

s

0

10

20

30

40

50

60

70

80

90

100





Disabled staff: Responses 189 365Non-disabled staff: Responses 565 866


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2019 NHS Staff Survey Results > WDES > Percentage of staffsatisfied with the extent to which their organisation values their work

2018 2019

Perc

enta

ge o

f st

aff

satis

fied

with

the

exte

nt t

o w

hich

the

iror

gani

satio

n va

lues

the

ir w

ork

0

10

20

30

40

50

60

70

80

90

100







53Pack page 138

2019 NHS Staff Survey Results > WDES > Percentage of disabled staff saying theiremployer has made adequate adjustment(s) to enable them to carry out their work

2018 2019

Perc

enta

ge o

f di

sabl

ed s

taff

say

ing

thei

rem

ploy

er h

as m

ade

adeq

uate

adju

stm

ent(

s) t

o en

able

the

m t

o ca

rry

out

thei

r w

ork

0

10

20

30

40

50

60

70

80

90

100



Disabled staff: Responses 126 293Average calculated as the median for the benchmark group

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2019 NHS Staff Survey Results > WDES > Staff engagement score (0-10)

2018 2019

Staf

f en

gage

men

t sc

ore

(0-1

0)

0

1

2

3

4

5

6

7

8

9

10

Organisation average 7.0 7.1

Disabled staff: Your org 6.7 6.7

Non-disabled staff: Your org 7.1 7.2

Disabled staff: Average 6.6 6.6

Non-disabled staff: Average 7.1 7.1

Organisation Responses 1,471 2,233Disabled staff: Responses 248 488Non-disabled staff: Responses 1,129 1,705


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Appendices



Appendix A: Response rate



2019 NHS Staff Survey Results > Appendices > Response rate

2015 2016 2017 2018 2019

% o

f st

aff

resp

ondi

ng

25

30

35

40

45

50

55

60

65

70

75

Best 62.2% 66.0% 66.6% 71.3% 71.9%

Your org 45.7% 51.8% 44.3% 50.3% 70.5%

Median 40.5% 42.8% 44.5% 44.2% 47.5%

Worst 25.4% 31.3% 28.9% 33.2% 29.7%

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Appendix B: Signicance testing- 2018 v 2019 theme results



2019 NHS Staff Survey Results > Appendices > Significance testing – 2018 v 2019 theme results

The table below presents the results of significance testing conducted on this year’s theme scores and those from last year*. It details the organisation’s theme scores forboth years and the number of responses each of these are based on.

The final column contains the outcome of the significance testing: indicates that the 2019 score is significantly higher than last year’s, whereas indicates that the2019 score is significantly lower. If there is no statistically significant difference, you will see ‘Not significant’. When there is no comparable data from the past survey year,you will see ‘N/A’.

Theme 2018 score2018

respondents2019 score

2019respondents

Statisticallysignicant change?

Equality, diversity & inclusion 9.2 1440 9.4 2216 Not significant

Health & wellbeing 6.1 1446 6.1 2229 Not significant

Immediate managers 6.9 1453 7.1 2231

Morale 6.2 1418 6.3 2218

Quality of appraisals 5.6 1323 5.6 2071 Not significant

Quality of care 7.5 1293 7.7 2004

Safe environment - Bullying & harassment 8.3 1426 8.2 2207 Not significant

Safe environment - Violence 9.4 1421 9.3 2210

Safety culture 6.8 1434 6.8 2225 Not significant

Staff engagement 7.0 1471 7.1 2233 Not significant

Team working 6.8 1455 6.8 2215 Not significant

* Statistical significance is tested using a two-tailed t-test with a 95% level of confidence.

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SUBJECT: REGISTER OF SEALINGS

DATE: 5 MARCH 2020 PRIVATE & CONFIDENTIAL

PURPOSE:


applicable For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: Ms M Saunders, Director of Corporate Governance SPONSORED BY: Dr R Jenkins, Chief Executive Officer PRESENTED BY: Ms M Saunders, Director of Corporate Governance STRATEGIC CONTEXT

It is a requirement of the Trust’s Constitution that the Trust’s seal shall not be affixed except with the authority of the Board of Directors and reported including a nil report on a six monthly basis.

EXECUTIVE SUMMARY Since the last submission to the Board in March 2019 the Trust Seal has not been used during the period March 2019 to February 2020.

RECOMMENDATION(S)

It is recommended the Board note the above and for the Chair to sign off.

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Register of Sealings

Register Entry No.

Date Signed / Sealed

Item Signed by

The Trust Seal has not been used during this period

Noted by the Board of Directors 5 March 2020 Signed by Chair: ......................................................

Trevor Lake

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SUBJECT: CONFLICTS OF INTERESTS POLICY

DATE: 5 MARCH 2020 PUBLIC

PURPOSE:

Tick as

applicable

Tick as applica

ble


PREPARED BY: Margaret Saunders, Director of Corporate Governance SPONSORED BY: Margaret Saunders, Director of Corporate Governance PRESENTED BY: Margaret Saunders, Director of Corporate Governance STRATEGIC CONTEXT

The Audit Committee, on behalf of the Board, has a principal role in ensuring that the internal controls of the Trust for the management of risk operate effectively. The Trust Managing Conflicts of Interest Policy is an example of one of those controls and is aimed at ensuring that as a public body the Trust operates openly and transparently in all its decision making.

EXECUTIVE SUMMARY

1. NHS England issued guidance in February 2017 which required implementation from June 2017 for Managing Conflicts of Interest in the NHS. The guidance emphasised that NHS Foundation Trusts must have regard to the guidance through its incorporation into the NHS Standard Contract (General Condition 27).

2. The Trust Managing Conflicts of Interests policy has been updated in line with the above guidance and a draft revised policy presented to the Audit Committee in October 2019 and January 2020 where subject to minor amendments it was agreed to present to March 2020 Board for approval.

RECOMMENDATION(S)

Following due consideration the Audit Committee recommends the Managing Conflicts of Interest Policy to the Board for approval.

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DOCUMENT CONTROL: Version: Draft version 3.0 Approved by: Date approved: Name of originator/author: Margaret Saunders, Director of Corporate

Governance Name of responsible committee/individual:

Audit Committee

Date issued: Review date: Target Audience All Staff, prospective employees, Contractors, sub-

contractors, Agency staff, Volunteers, Committee, sub-committee and advisory group members engaged by the Trust.

Managing Conflicts of

Interest Policy

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Contents Policy Summary

1. Introduction

1

2. Purpose

1

3. Key Terms and Definitions

1

4. Interests

3

5. Staff

3

6. Decision Making Staff

3

7. Identification, Declaration and Review of Interests 7.1 Identification and Declaration of Interests (including hospitality and gifts) 7.2 Proactive Review of Conflicts

4 4 5

8. Records and Publication 8.1 Maintenance 8.2 Publication 8.3 Wider Transparency Initiatives

5 5 6 6

9. Management of Interests – General

6

10. Management of Interests – Common Situations 10.1 Introduction 10.2 Gifts 10.3 Hospitality 10.4 Personal Conduct 10.4.1 Lending or Borrowing 10.4.2 Gambling 10.4.3 Trading on Official Premises 10.4.4 Bankrupt or Insolvent Staff

7 7 7 8 9 9 9 9 10

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10.5 Outside Employment 10.6 Shareholdings and other ownership issues 10.7 Patents 10.8 Loyalty interests 10.9 Donations 10.10 Sponsored events 10.11 Sponsored research 10.12 Sponsored posts 10.13 Clinical private practice 10.14 Criminal Investigation

10 10 11 11 12 13 13 14 14 15

11. Management of Interests – Advice in Specific Contexts 11.1 Strategic Decision making Groups 11.2 Procurement

15 15 17

12. Dealing with breaches 12.1 Identifying and reporting breaches 12.2 Taking action in response to breaches 12.3 Learning and transparency concerning breaches 12.4 Working whilst absent due to sickness 12.5 Working whilst absent due to study leave

17 17 18 18 19 19

13. Review

19

14. Associated Documentation

19

15. References

20

16. Appendices Appendix A – Declaration of Interest Form

21

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Policy Summary

Adhering to this policy will help to ensure that we use NHS money wisely, providing best value for taxpayers and accountability to our patients for the decisions we take.

As a member of staff you should… As a Trust we will…

• Familiarise yourself with this policy

and follow it. Refer to the guidance for the rationale behind this policy h tt p s:// www.e n glan d .nh s.u k/wp - co n ten t/u p load s/20 17 /0 2 /gu idan ce - m a na ging-co nf licts-of-int e rest-n h s.pdf

• Use your common sense and

judgement to consider whether the interests you have could affect the way taxpayers’ money is spent

• Regularly consider what interests you

have and declare these as they arise. If in doubt, declare.

• NOT misuse your position to further

your own interests or those close to you

• NOT be influenced, or give the

impression that you have been influenced by outside interests

• NOT allow outside interests you have

to inappropriately affect the decisions you make when using taxpayers’ money

• Ensure that this policy and supporting

processes are clear and help staff understand what they need to do.

• Identify a team or individual(which is

the Director of Corporate Governance) with responsibility for:

o Keeping this policy under review

to ensure the policy is in line with the guidance.

o Providing advice, training and support for staff on how interests should be managed.

o Maintaining register(s) of interests.

o Auditing this policy and its associated processes and procedures at least once every three years.

• NOT avoid managing conflicts of

interest. • NOT interpret this policy in a way

which stifles collaboration and innovation with our partners

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https://www.england.nhs.uk/wp-content/uploads/2017/02/guidance-managing-conflicts-of-interest-nhs.pdf



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1 INTRODUCTION

Barnsley Hospital NHS Foundation Trust (the ‘Trust’), and the people who work with and for us, collaborate closely with other organisations, delivering high quality care for our patients.

These partnerships have many benefits and should help ensure that public money is spent efficiently and wisely. But there is a risk that conflicts of interest may arise.

Providing best value for taxpayers and ensuring that decisions are taken transparently and clearly, are both key principles in the NHS Constitution. We are committed to maximising our resources for the benefit of the whole community. As a Trust and as individuals, we have a duty to ensure that all our dealings are conducted to the highest standards of integrity and that NHS monies are used wisely so that we are using our finite resources in the best interests of patients.

2. PURPOSE

This policy will help our staff manage conflicts of interest risks effectively. It:

• Introduces consistent principles and rules • Provides simple advice about what to do in common situations. • Supports good judgement about how to approach and

manage interests

This policy should be considered alongside these other Trust policies:

• Requisitioning, Ordering and Receipt of Goods Procedure • Standing Financial Instructions • Receipt of Donations to Charitable Funds Policy • Counter Fraud Bribery and Corruption Policy

3. KEY TERMS AND DEFINITIONS

A ‘conflict of interest’ is:

“A set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.”

A conflict of interest may be:

• Actual - there is a material conflict between one or more interests • Potential – there is the possibility of a material conflict between one

or more interests in the future

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Staff may hold interests for which they cannot see potential conflict. However, caution is always advisable because others may see it differently and perceived conflicts of interest can be damaging. All interests should be declared where there is a risk of perceived improper conduct.

The Bribery Act 2010 introduced a number of offences:

• Offering, promising, or giving a bribe to another person to perform

a relevant ‘function or activity’ improperly, or to reward a person for the improper performance of such a function or activity;

• Requesting, agreeing to receive, or accepting a bribe to perform a function or activity improperly irrespective of whether the recipient of the bribe requests or receives it directly or through a third party, and irrespective of whether it is for the recipient’s benefit.

A new corporate offence was also introduced:

• Failure of a commercial organisation to prevent bribery.

This means that the Trust can be held responsible if it fails to enact adequate procedures to prevent bribery. Other relevant definitions:

Bribery Bribery may be summarised as dishonestly persuading someone to act in one’s favour by a gift of money or other inducement.

Donations Donations are charitable financial payments, which can be in the form of direct cash payment or through the application of a will or similar directive.

Gifts Gift means any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less that its commercial value.

Hospitality Hospitality means offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education and training events and the like.

Sponsorship Sponsorship means the receipt of ex gratia funding from an external source to underwrite (whether in full or part) the Trust’s corporate costs in relation to trust led activities, events, publications and the like. Sponsored posts are positions within the Trust that are funded, in whole or in part, by organisations external to the NHS.

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4. INTERESTS

Interests fall into the following categories:

Financial interests Non-financial professional interests

Where an individual may get direct* financial benefit from the consequences of a decision they are involved in making.

Where an individual may obtain a non- financial professional benefit from the consequences of a decision they are involved in making, such as increasing their professional reputation or promoting their professional career.

Non-financial personal interests Indirect interests

Where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit, because of decisions they are involved in making in their professional career.

Where an individual has a close association † with another individual who

P1F P

has a financial interest, a non-financial professional interest or a non-financial personal interest and could stand to benefit from a decision they are involved in making.

5. STAFF

At the Trust we use the skills of many different people, all of whom are vital to our work. This includes people on differing employment terms and for the purposes of this policy references to ‘staff’ will include:

• All salaried employees • All prospective employees – who are part-way through recruitment • Contractors and sub-contractors • Agency staff • Committee, sub-committee and advisory group members (who

may not be directly employed or engaged by the Trust)

The general principles of the policy are that all staff working for the Trust under NHS terms and conditions are covered by the policy.

All employees have a responsibility for ensuring that they are not placed in a position, which risks – or appears to risk – a conflict between their private interests and their NHS duties.

Continuous maintenance of the individuals’ declarations of interests is the responsibility of the individual. The individual must keep the Trust up to date with any declarations.

6. DECISION MAKING STAFF

Some staff are more likely than others to have a decision making influence on the use of taxpayers’ money, because of the requirements of their role.

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For the purposes of this guidance these people are referred to as ‘decision making staff.’

A common sense approach should be applied to the term ‘close association’. Such an association might arise, depending on the circumstances, through relationships with close family members and relatives, close friends and associates, and business partners.

The decision making staff in this Trust are:

• Executive and non-executive directors (or equivalent roles) who

have decision-making roles which involve the spending of taxpayers’ money;

• Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services;

• Those at Agenda for Change band 8d and above include Clinical, incorporating the consultant body, and Administrative colleagues;

• Administrative and clinical staff who have the power to enter into contracts on behalf of the organisation;

• Administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of goods, medicines, medical devices or equipment, and formulary decisions.

7. IDENTIFICATION, DECLARATION AND REVIEW OF INTERESTS

7.1 IDENTIFICATION & DECLARATION OF INTERESTS (including gifts

and hospitality)

All staff should identify and declare material interests at the earliest opportunity (and in any event within 28 days (for example within 28 days of receiving a gift)). If staff are in any doubt as to whether an interest is material then they should declare it, so that it can be considered. Declarations should be made:

• On appointment with the Trust. • When staff move to a new role or their responsibilities

change significantly. • At the beginning of a new project/piece of work. • As soon as circumstances change and new interests arise (for

instance, in a meeting when interests staff hold are relevant to the matters in discussion).

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Declarations should be made to the Director of Corporate Governance, who will also provide advice on issues relating to the implementation of this policy. The minimum information required is:

• Name and their role with the Trust • A description of the interest declared • Relevant dates relating to the interest

A declaration of interest(s) form is available at appendix (A) or on the intranet at link to be confirmed.

• The Executive Directors, as Executive Sponsors, are responsible for

reviewing current policies and bringing them in line with guidance. • The Director of Corporate Governance is responsible for providing

advice, training and support for staff on how interest should be managed.

• The Director of Corporate Governance is responsible for maintaining the Register(s) of Interests.

• The Director of Corporate Governance is responsible for auditing the policy, process and procedures at least every three years.

Declarations should be made to the employee’s line manager who should sign off on the declared interest, and forwarded to the Director of Corporate Governance, Trust HQ.

After expiry, an interest will remain on register(s) for a minimum of six months, and a private record of historic interests will be retained for a minimum of six years.

The Director of Corporate Governance will prompt ‘decision making staff’ to annually review declarations they have made and, as appropriate, update or make a nil return.

7.2 PROACTIVE REVIEW OF CONFLICTS Decision making staff will be prompted annually by the Director of Corporate Governance to review declarations they have made and, as appropriate, update or make a nil return.

8. RECORDS AND PUBLICATION

8.1 MAINTENANCE

The Trust will maintain the following registers pertaining to this policy:

• Declaration of Interest Register for - Trust Board Directors - Key Decision-Making Staff - Key Decision-Making Staff of Barnsley Facilities Services Ltd

• Gifts, Hospitality and Sponsorship Register.

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8.2 PUBLICATION

The Trust will:

• Publish the interests declared by ‘decision making staff’ in the Declarations of Interest

• Refresh this information on an annual basis. • Make this information available on the website of the

Trust and/or by contacting the Director of Corporate Governance.

In some cases it might not be appropriate to publish information about the interests of some ‘decision making staff’, or their personal information might need to be redacted. If decision making staff have substantial grounds for believing the publication of their interests should not take place please contact the Director of Corporate Governance to provide a rationale. In exceptional circumstances, for instance where publication of information might put a member of staff at risk of harm, information may be withheld or redacted on public registers. However, this would be the exception and information will not be withheld or redacted merely because of a personal preference.

8.3 WIDER TRANSPARENCY INITIATIVES

The Trust fully supports wider transparency initiatives in healthcare, and we encourage staff to engage actively with these.

Relevant staff are strongly encouraged to give their consent for payments they receive from the pharmaceutical industry to be disclosed as part of the Association of British Pharmaceutical Industry (ABPI) Disclosure UK initiative. These “transfers of value” include payments relating to:

• Speaking at and chairing meetings • Training services • Advisory board meetings • Fees and expenses paid to healthcare professionals • Sponsorship of attendance at meetings, which includes registration

fees and the costs of accommodation and travel, both inside and outside the UK

• Donations, grants and benefits in kind provided to healthcare organisations

Further information about the scheme can be found on the ABPI website: http://www.abpi.org.uk/our-work/disclosure/about/Pages/default.aspx

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http://www.abpi.org.uk/our-work/disclosure/about/Pages/default.aspx

http://www.abpi.org.uk/our-work/disclosure/about/Pages/default.aspx

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P3F P

9. MANAGEMENT OF INTERESTS - GENERAL If an interest is declared but there is no risk of a conflict arising then no action is warranted. However, if a material interest is declared then the management actions that could be applied include:

• Restricting staff involvement in associated discussions and

excluding them from decision making • Removing staff from the whole decision making process • Removing staff responsibility for an entire area of work • Removing staff from their role altogether if they are unable to

operate effectively in it because the conflict is so significant

Each case will be different and context-specific, and the trust will always clarify the circumstances and issues with the individuals involved. Line Managers should maintain a written audit trail of information considered and actions taken and of any consultations with HR and Director of Corporate Governance so as to ensure consistency of response.

Staff who declare material interests should make their line manager or the person(s) they are working to aware of their existence.

The Director of Corporate Governance will advise on possible disputes about the most appropriate management action.

10. MANAGEMENT OF INTERESTS – COMMON SITUATIONS

10.1 This section sets out the principles and rules to be adopted by staff in common situations, and what information should be declared. 10.2 Gifts 10.2.1 Staff should not accept gifts that may affect, or be seen to affect, their professional judgement.

10.2.2 Gifts from suppliers or contractors:

• Gifts from suppliers or contractors doing business (or likely to do

business) with the Trust should be declined, whatever their value.

• Low cost branded promotional aids such as pens or post-it notes may, however, be accepted where they are under the value of £6 * in total, and need not be declared.

10.2.3 Gifts from other sources (e.g. patients, families, service users):

• Gifts of cash and vouchers to individuals should always be declined.

• Staff should not ask for any gifts.

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• Gifts valued at over £50 should be treated with caution and only accepted on behalf of the Trust (e.g. payment into an appropriate Trust Charitable Trust Fund) and not in a personal capacity. These should be declared by staff.

• Modest gifts accepted under a value of £50.00 do not need to be declared.

• A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

• Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50.

10.2.4 What should be declared

• Staff name and their role with the Trust. • A description of the nature and value of the gift, including its source. • Date of receipt • Any other relevant information (e.g. circumstances surrounding the

gift, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

10.3 Hospitality

• Staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement.

• Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

• Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors. This can be accepted, and must be declared, if modest and reasonable. Senior approval must be obtained.

10.3.1 Meals and refreshments:

• Under a value of £25 - may be accepted and need not be declared. • Of a value between £25 and £75* - may be accepted and must

be declared. • Over a value of £75 - should be refused unless (in exceptional

circumstances) senior approval is given. A clear reason should be recorded on the Trust’s register(s) of interest as to why it was permissible to accept.

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• A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or a reasonable estimate).

10.3.2 Travel and accommodation:

• Modest offers to pay some or all of the travel and accommodation

costs related to attendance at events may be accepted and must be declared.

• Offers which go beyond modest, or are of a type that the Trust itself might not usually offer, need approval by senior staff, and should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on the Trust’s hospitality register as to why it was permissible to accept travel and accommodation of this type. A non-exhaustive list of examples includes:

o Offers of business class or first class travel and

accommodation (including domestic travel) o Offers of foreign travel and accommodation.


• Staff name and their role with the Trust. • The nature and value of the hospitality including the circumstances. • Date of receipt. • Any other relevant information (e.g. action taken to mitigate against

a conflict, details of any approvals given to depart from the terms of this policy).

10.4 Personal Conduct 10.4.1 Lending or Borrowing The lending or borrowing of money between staff should be avoided, whether informally or as a business, particularly where the amounts are significant. It is a particularly serious breach of discipline for any member of staff to use their position to place pressure on someone in a lower pay band, a business contact, or a member of the public to loan them money.

10.4.2 Gambling No member of staff may bet or gamble when on duty or on Trust premises, with the exception of small lottery syndicates or sweepstakes related to national events such as the World Cup or Grand National among immediate colleagues.

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10.4.3 Trading on Official Premises Trading on official premises is prohibited, whether for personal gain or on behalf of others. Canvassing within the office by, or on behalf of, outside bodies or firms (including non-Trust interests of staff or their relatives) is also prohibited. Trading does not include small tea or refreshment arrangements solely for staff.

10.4.4 Bankrupt or Insolvent Staff

Any member of staff who becomes bankrupt or insolvent must inform their line management and Human Resources as soon as possible. Staff who are bankrupt or insolvent cannot be employed in posts that involve duties which might permit the misappropriation of public funds or involve the handling of money. 10.5 Outside Employment

• Staff should declare any existing outside employment on appointment and any new outside employment when it arises.

• Where a risk of conflict of interest arises, the general management actions outlined in this policy should be considered and applied to mitigate risks.

• Where contracts of employment or terms and conditions of engagement permit, staff may be required to seek prior approval from the Trust to engage in outside employment.

The Trust may also have legitimate reasons within employment law for knowing about outside employment of staff, even when this does not give rise to risk of a conflict – for example to ensure the requirements of working time regulations are adhered to.


• Staff name and their role with the Trust. • The nature of the outside employment (e.g. who it is with, a

description of duties, time commitment). • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a

conflict, details of any approvals given to depart from the terms of the policy).

10.6 Shareholdings and other ownership issues

• Staff should declare, as a minimum, any shareholdings and other ownership interests in any publicly listed, private or not-for-profit company, business, partnership or consultancy which is doing, or might be reasonably expected to do, business with the Trust.

• Where shareholdings or other ownership interests are declared and give rise to risk of conflicts of interest then the general

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management actions outlined in this policy should be considered and applied to mitigate risks.

• There is no need to declare shares or securities held in collective investment or pension funds or units of authorised unit trusts or in such as large commercial utility firms, banks or large retailers.


• Staff name and their role with the Trust. • Nature of the shareholdings/other ownership interest. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a

conflict, details of any approvals given to depart from the terms of this policy).

10.7 Patents

• Staff should declare patents and other intellectual property rights

they hold (either individually, or by virtue of their association with a commercial or other organisation), including where applications to protect have started or are ongoing, which are, or might be reasonably expected to be, related to items to be procured or used by the Trust.

• Staff should seek prior permission from the Trust before entering into any agreement with bodies regarding product development, research, work on pathways etc, where this impacts on the Trust’s own time, or uses its equipment, resources or intellectual property.

• Where holding of patents and other intellectual property rights give rise to a conflict of interest then the general management actions outlined in this policy should be considered and applied to mitigate risks.


• Staff name and their role with the Trust. • A description of the patent. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a


10.8 Loyalty Interests 10.8.1 Loyalty interests should be declared by staff involved in decision making where they:

• Hold a position of authority in another NHS Trust or commercial,

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charity, voluntary, professional, statutory or other body which could be seen to influence decisions they take in their NHS role.

• Sit on advisory groups or other paid or unpaid decision making forums that can influence how an organisation spends taxpayers’ money.

• Are, or could be, involved in the recruitment or management of close family members and relatives, close friends and associates, and business partners. (please refer to the Relationships at Work Policy)

• Are aware that their Trust does business with an organisation in which close family members and relatives, close friends and associates, and business partners have decision making responsibilities.


• Staff name and their role with the Trust. • Nature of the loyalty interest. • Relevant dates. • Other relevant information (e.g. action taken to mitigate against a


10.9 Donations

• Donations made by suppliers or bodies seeking to do business with the Trust should be treated with caution and not routinely accepted. In exceptional circumstances they may be accepted but should always be declared. A clear reason should be recorded as to why it was deemed acceptable, alongside the actual or estimated value.

• Staff should not actively solicit charitable donations unless this is a prescribed or expected part of their duties for the Trust, or is being pursued on behalf of the Trust’s own registered charity or other charitable body and is not for their own personal gain.

• Staff must obtain permission from the Trust if in their professional role they intend to undertake fundraising activities on behalf of a pre-approved charitable campaign for a charity other than the Trust’s own.

• Donations, when received, should be made to a specific charitable fund (never to an individual) and a receipt should be issued.

• Staff wishing to make a donation to the Trust’s charitable fund in lieu of receiving a professional fee may do so, subject to ensuring that they take personal responsibility for ensuring that any tax liabilities related to such donations are properly discharged and accounted for.

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10.9.1 What should be declared The Trust will maintain records in line with the above principles and rules and relevant obligations under charity law.

10.10 Sponsored Events

• Sponsorship of events by appropriate external bodies will only be approved if a reasonable person would conclude that the event will result in clear benefit to the Trust and the NHS.

• During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation.

• No information should be supplied to the sponsor from whom they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied.

• At the Trust’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event.

• The involvement of a sponsor in an event should always be clearly identified.

• Staff within the Trust involved in securing sponsorship of events should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event.

• Staff arranging sponsored events must declare this to the Trust.

10.10.1 What should be declared The Trust will maintain records regarding sponsored events in line with the above principles and rules. 10.11 Sponsored Research

• Funding sources for research purposes must be transparent. • Any proposed research must go through the relevant health

research authority or other approvals process. • There must be a written protocol and written contract between staff,

the Trust, and/or institutes at which the study will take place and the sponsoring organisation, which specifies the nature of the services to be provided and the payment for those services.

• The study must not constitute an inducement to prescribe, supply, administer, recommend, buy or sell any medicine, medical device, equipment or service.

• Staff should declare involvement with sponsored research to the Trust.

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• The Trust will retain written records of sponsorship of research, in line with the above principles and rules.

Staff should declare:

• Their name and their role with the Trust. • Nature of their involvement in the sponsored research. • Relevant dates. • Other relevant information (e.g. what, if any, benefit the sponsor

derives from the sponsorship, action taken to mitigate against a conflict, details of any approvals given to depart from the terms of this policy).

10.12 Sponsored Posts

• External sponsorship of a post requires prior approval from the Trust. • Rolling sponsorship of posts should be avoided unless appropriate

checkpoints are put in place to review and withdraw if appropriate. • Sponsorship of a post should only happen where there is written

confirmation that the arrangements will have no effect on purchasing decisions or prescribing and dispensing habits. This should be audited for the duration of the sponsorship. Written agreements should detail the circumstances under which Trusts have the ability to exit sponsorship arrangements if conflicts of interest which cannot be managed arise.

• Sponsored post holders must not promote or favour the sponsor’s products, and information about alternative products and suppliers should be provided.

• Sponsors should not have any undue influence over the duties of the post or have any preferential access to services, materials or intellectual property relating to or developed in connection with the sponsored posts.


• The Trust will retain written records of sponsorship of posts, in line

with the above principles and rules. • Staff should declare any other interests arising as a result of

their association with the sponsor, in line with the content in the rest of this policy.

10.13 Clinical Private Practice

Clinical staff should declare all private practice on appointment, and/or any new private practice when it arises* including:

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• Where they practise (name of private facility). • What they practise (specialty, major procedures). • When they practise (identified sessions/time commitment).

Clinical staff should (unless existing contractual provisions require otherwise or unless emergency treatment for private patients is needed):

• Seek prior approval of their Trust before taking up private practice. • Ensure that, where there would otherwise be a conflict or

potential conflict of interest, NHS commitments take precedence over private work.†

• Not accept direct or indirect financial incentives from private providers other than those allowed by Competition and Markets Authority guidelines: https://assets.publishing.service.gov.uk/media/542c1543e5274a131400 0c56/Non-Divestment_Order_amended.pdf

• Declare Private Professional Services or Fee Paying Services for other organisations. i.e. consultancy work such as medical assessments for insurance companies

Hospital Consultants should not initiate discussions about providing their Private Professional Services for NHS patients, nor should they ask other staff to initiate such discussions on their behalf.


• Staff name and their role with the Trust. • A description of the nature of the private practice (e.g. what, where

and when staff practise, sessional activity, etc). • Relevant dates. • Any other relevant information (e.g. action taken to mitigate against

a conflict, details of any approvals given to depart from the terms of this policy).

10.14 Criminal Investigation

If a member of staff becomes aware that they are subject to any criminal investigation, either by receiving a formal interview under caution appointment letter or by being placed under caution at a formal interview, or is arrested, convicted or cautioned for any offence they must inform their line management immediately. This responsibility also includes any welfare benefit or tax credit fraud investigations or sanctions, please refer to the Trust Criminal Records Check Policy. This is an on-going responsibility additional to the requirement to complete a self-declaration form as part of the appraisal process.

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https://assets.publishing.service.gov.uk/media/542c1543e5274a1314000c56/Non-Divestment_Order_amended.pdf



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11 MANAGEMENT OF INTERESTS – ADVICE IN SPECIFIC CONTEXTS 11.1 STRATEGIC DECISION MAKING GROUPS

In common with other NHS bodies the Trust uses a variety of different groups to make key strategic decisions about things such as:

• Entering into (or renewing) large scale contracts. • Awarding grants. • Making procurement decisions. • Selection of medicines, equipment, and devices.

The interests of those who are involved in these groups should be well known so that they can be managed effectively. For this Trust these groups are:

Board of Directors Finance, Performance and Workforce Committee and associated relevant Sub-Committees Quality & Governance Committee and associated relevant Sub- Committees Board of Barnsley Facilities Services Limited Medicines Management Committee Charitable Funds Committee Research & Development Committee

These groups should adopt the following principles:

• Chairs should consider any known interests of members in

advance, and begin each meeting by asking for declaration of relevant material interests.

• Members should take personal responsibility for declaring material interests at the beginning of each meeting and as they arise.

• Any new interests identified should be added to the Trust’s register(s). • The vice chair (or other non-conflicted member) should chair all or

part of the meeting if the chair has an interest that may prejudice their judgement.

If a member has an actual or potential interest the chair should consider the following approaches and ensure that the reason for the chosen action is documented in minutes or records:

• Requiring the member to not attend the meeting. • Excluding the member from receiving meeting papers relating

to their interest. • Excluding the member from all or part of the relevant

discussion and decision. • Noting the nature and extent of the interest, but judging it

appropriate to allow the member to remain and participate.

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• Removing the member from the group or process altogether.

The default response should not always be to exclude members with interests, as this may have a detrimental effect on the quality of the decision being made. Good judgement is required to ensure proportionate management of risk.

11.2 PROCUREMENT

Procurement should be managed in an open and transparent manner, compliant with procurement and other relevant law, to ensure there is no discrimination against or in favour of any provider. Procurement processes should be conducted in a manner that does not constitute anti-competitive behaviour - which is against the interest of patients and the public.

Those involved in procurement exercises for and on behalf of the Trust should keep records that show a clear audit trail of how conflicts of interest have been identified and managed as part of procurement processes. At every stage of procurement steps should be taken to identify and manage conflicts of interest to ensure and to protect the integrity of the process.

12. DEALING WITH BREACHES

There will be situations when interests will not be identified, declared or managed appropriately and effectively. This may happen innocently, accidentally, or because of the deliberate actions of staff or other organisations. For the purposes of this policy these situations are referred to as ‘breaches’.

12.1 IDENTIFYING AND REPORTING BREACHES

Staff who are aware about actual breaches of this policy, or who are concerned that there has been, or may be, a breach, should report these concerns to the Director of Corporate Governance.

To ensure that interests are effectively managed staff are encouraged to speak up about actual or suspected breaches. Every individual has a responsibility to do this. For further information about how concerns should be raised please access the following link:

http://intranet.bdgh-tr.trent.nhs.uk/teams/other/freedom-speak-guardian/

The Trust will investigate each reported breach according to its own specific facts and merits, and give relevant parties the opportunity to explain and clarify any relevant circumstances.

Following investigation the Trust will:

• Decide if there has been or is potential for a breach and if so

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what severity of the breach is. • Assess whether further action is required in response – this is likely

to involve any staff member involved and their line manager, as a minimum.

• Consider who else inside and outside the Trust should be made aware.

• Take appropriate action as set out in the next section.

12.2 TAKING ACTION IN RESPONSE TO BREACHES

Action taken in response to breaches of this policy will be in accordance with the disciplinary procedures of the Trust and could involve Trust leads for staff support (e.g. Human Resources), fraud (e.g. Local Counter Fraud Specialists), members of the management or executive teams and Trust auditors.

Breaches could require action in one or more of the following ways:

• Clarification or strengthening of existing policy, process and procedures.

• Consideration as to whether HR/employment law/contractual action should be taken in relation to staff or others.

• Consideration being given to escalation to external parties. This might include referral of matters to external auditors, NHS Counter Fraud Authority, the Police, statutory health bodies (such as NHS England, NHS Improvement or the Care Quality Commission (CQC)), and/or health professional regulatory bodies.

Inappropriate or ineffective management of interests can have serious implications for the Trust and staff. There will be occasions where it is necessary to consider the imposition of sanctions for breaches.

Sanctions should not be considered until the circumstances surrounding breaches have been properly investigated. However, if such investigations establish wrong-doing or fault then the Trust can and will consider the range of possible sanctions that are available, in a manner which is proportionate to the breach. This includes:

• Employment law action in relation to staff, which might include

o Informal action (such as signposting to training

and/or guidance) o Formal disciplinary action (such as formal warning,

the requirement for additional training, re-arrangement of duties, re-deployment or dismissal)

• Reporting incidents to the external parties described above (third bullet point in previous section) for them to consider what further investigations or sanctions might be.

• Contractual action, such as exercise of remedies or sanctions against the body or staff that caused the breach.

• Legal action, such as investigation and prosecution under fraud,

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bribery and corruption legislation. 12.3 LEARNING AND TRANSPARENCY CONCERNING BREACHES

Reports on breaches, the impact of these, and action taken will be considered by the Audit Committee at least every six months. To ensure that lessons are learnt and management of interests can continually improve, anonymised information on breaches, the impact of these, and action taken will be prepared and published as appropriate, or made available for the public upon request.

12.4 WORKING WHILST ABSENT DUE TO SICKNESS

Where an employee holds another appointment outside the Trust, including self-employment and is off sick from their Trust post, or on Carers’ or Bereavement leave, they should not normally undertake any paid work during the period of sickness and any intention to do so should be agreed with their manager in advance.

Where an employee is found to be working elsewhere, including self- employment, whilst in receipt of contractual sick pay and a GP Fit Note (which stated that the employee could work elsewhere) cannot be provided to confirm their eligibility to work, this may be treated as gross misconduct under the Trust’s Disciplinary Procedure. The Trust’s Local Counter Fraud Specialist will be notified, which could result in criminal prosecution.

12.5 WORKING WHILST ABSENT DUE TO STUDY LEAVE

Employees must not take up any paid or unpaid employment during periods of Study Leave. Such conduct may be treated as gross misconduct under the Trust’s Disciplinary Procedure and a referral will be made to the Trust’s Local Counter Fraud Specialist in line with the Counter Fraud, Bribery and Corruption Policy.

13 REVIEW

This policy will be reviewed on a maximum 3 yearly basis unless an earlier review is required. This will be led by the Director of Corporate Governance.

14 ASSOCIATED DOCUMENTATION

• Freedom of Information Act 2000 • ABPI: The Code of Practice for the Pharmaceutical Industry (2014) • ABHI Code of Business Practice • NHS Code of Conduct and Accountability (July 2004)

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• Requisitioning, Ordering and Receipts of Goods Procedure • standing Financial Instructions • Receipt of Donations to Charitable Funds Policy • Counter Fraud, Bribery and Corruption Policy • Employee Handbook

15 REFERENCES

https://www.england.nhs.uk/publication/managing-conflicts-of-interest-in-the- nhs-guidance-for-staff-and-organisations/ https://www.england.nhs.uk/ourwork/coi/ http://www.abpi.org.uk/ethics/ethical-responsibility/disclosure-uk/

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https://www.england.nhs.uk/publication/managing-conflicts-of-interest-in-the-nhs-guidance-for-staff-and-organisations/

https://www.england.nhs.uk/publication/managing-conflicts-of-interest-in-the-nhs-guidance-for-staff-and-organisations/

https://www.england.nhs.uk/ourwork/coi/

http://www.abpi.org.uk/ethics/ethical-responsibility/disclosure-uk/

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16 APPENDIX A – Declaration of Interests Form

Name:

Position within, or relationship with, the Trust :

Detail of interests held (complete all that are applicable):

Type of Interest*

*See Managing Conflicts of Interest Policy for details

Description of Interest (including for indirect Interests, details of the relationship with the person who has the interest)

Date interest relates

From & To

Actions to be taken to mitigate risk

(to be agreed with line manager, as appropriate)

The information submitted will be held by the Trust for personnel or other reasons specified on this form and to comply with the policies of the organisation. This information may be held in both manual and electronic form in accordance with the Data Protection Act (DPA) 2018. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the Trust holds. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the Trust as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result. I do / do not [delete as applicable] give my consent for this information to published on registers that the Trust holds. If consent is NOT given please give reasons:

Signed: Date: Please return to: [email protected]

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Types of interest

Type of Interest

Description

Financial Interests

Where an individual may get direct financial benefits* from the consequences of a decision their organisation makes. This could include: • A director (including a non-executive director) or senior employee in another organisation which is doing, or is likely to do business with an organisation in receipt of NHS funding • A shareholder, partner or owner of an organisation which is doing, or is likely to do business with an organisation in receipt of NHS funding • Someone in outside employment • Someone in receipt of secondary income. • Someone in receipt of a grant. • Someone in receipt of other payments (e.g. honoraria, day allowances, travel or subsistence). • Someone in receipt of sponsored research.

Non-Financial Professional Interests

Where an individual may obtain a non-financial professional benefit* from the consequences of a decision their organisation makes, such as increasing their professional reputation or status or promoting their professional career. This could include situations where the individual is: • An advocate for a particular group of patients. • A clinician with a special interest. • An active member of a particular specialist body. • An advisor for the Care Quality Commission or National Institute of Health and Care Excellence. • A research role.

Non-Financial Personal Interests

This is where an individual may benefit* personally from a decision their organisation makes in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is: • A member of a voluntary sector board or has a position of authority within a voluntary sector organisation. • A member of a lobbying or pressure group with an interest in health and care.

Indirect Interests

This is where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit* from a decision they are involved in making. This would include**: • Close family members and relatives. • Close friends and associates. • Business partners.

*A benefit may arise from the making of gain or avoiding a loss. **A common sense approach should be applied to these terms. It would be unrealistic to expect staff to know of all the interests that people in these classes might hold. However, if staff do know of material interests (or could be reasonably expected tp know about these) then these should be declared.

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SUBJECT: TRUST OBJECTIVES 2020/21 DATE: 5 MARCH 2020 PRIVATE & CONFIDENTIAL

PURPOSE:


applicable For decision/approval √ Assurance √ For review Governance √ For information Strategy √

PREPARED BY: Katherine Sowden, Associate Director of Strategy & Planning SPONSORED BY: Bob Kirton, Chief Delivery Officer & Deputy CEO PRESENTED BY: Bob Kirton, Chief Delivery Officer & Deputy CEO STRATEGIC CONTEXT

The Trust’s Objectives were developed with the Trust Strategy 2018-2021. To support delivery of the strategy the Trust now needs to redefine its Objectives for 2020/21. These will be key to delivery of the Trust’s Strategic vision.

EXECUTIVE SUMMARY Significant work has been undertaken to date to develop the Trust’s Objectives for 2020/21 including an Executive/CBU Workshop in December 2019, individual meetings with each Director, continued progress reviews at the Executive Team meeting and Board review of the draft objectives. From this work a final version of the Trust Objectives report and high level communication material have been developed (see Attachment A and B). We have included all submissions to date, incorporated suggestions from the Board review in February and also ensured that the objectives encompass all required areas of focus from the NHS Long Term Plan. The objectives will be cascaded through the usual communication channels including Trustwide posters, Hub/External Site/Social Media and in Barnsley Hospital News. They will be launched at Team Brief in April 2020 and presented to all key stakeholders including Trust Governors, local partners and external stakeholder meetings. A further cascade to staff will take place through the appraisal process and a Director led CBU development session will be held on 27th March to cascade to the wider CBU teams. Progress against the Trust Objectives will be reported on a quarterly basis to Trust Board in public. Areas of outstanding work: There is a requirement to add more specific objectives under the Barnsley partnership, this work is emergent and requires finalisation. A workshop involving system partners is taking place in March to support the agreement of these. RECOMMENDATIONS

1. The Board are asked to review and approve these objectives along with the high level communication material to allow the team to progress with the communication plan in March.

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Subject: Trust Objectives 2020/21 Ref: BoD: 20/03/05/15

1. STRATEGIC CONTEXT

The Trust’s Objectives were developed with the Trust Strategy 2018-2021. To support delivery of the strategy the Trust now needs to redefine its Objectives for 2020/21. These will be key to delivery of the Trust’s Strategic vision.

2. INTRODUCTION 2.1 Significant work has been undertaken to date to develop the Trust’s Objectives for

2020/21 including an Executive/CBU Workshop in December 2019, individual meetings with each Director, continued progress reviews at the Executive Team meeting and Board review of the draft objectives.

2.2 From this work a final version of the Trust Objectives report and high level

communication material have been developed (see Attachment A and B). We have included all submissions to date, incorporated suggestions from the Board review in February and also ensured that the objectives encompass all required areas of focus from the NHS Long Term Plan.

2.3 The objectives will be cascaded through the usual communication channels including

Trustwide posters, Hub/External Site/Social Media and in Barnsley Hospital News. They will be launched at Team Brief in April 2020 and presented to all key stakeholders including Trust Governors, local partners and external stakeholder meetings. A further cascade to staff will take place through the appraisal process and a Director led CBU development session will be held on 27th March to cascade to the wider CBU teams.

3. RECOMMENDATIONS

3.1 The Board are asked to review and approve these objectives along with the high level communication material to allow the team to progress with the communication plan in March.

4. CONCLUSION 4.1 Areas of outstanding work: There is a requirement to add more specific objectives

under the Barnsley partnership, this work is emergent and requires finalisation. A workshop involving system partners is taking place in March to support the agreement of these.

4.2 Following review and sign off by the Board, the team will progress with the communication plan to cascade the Objectives throughout the organisation and to key stakeholders including Trust Governors, local partners and external stakeholder meetings.

4.3 Progress against the Trust Objectives will be reported on a quarterly basis to Trust Board.

Appendices: - Attachment A - Trust Objectives 2020/21 - Attachment B - High Level Trust Objectives 2020/21

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BARNSLEY HOSPITAL TRUST OBJECTIVES 2020 - 2021

Vision: To provide outstanding, integrated care Aims:

Patients: Patients will experience outstanding care Partners: We will work with partners to deliver better, more integrated care

People: People will be proud to work for us Performance: We will achieve our goals sustainably

Aim Objectives (SMART) Key Actions/KPIs/Milestones Lead Director Completion Date

Patie

nts w

ill e

xper

ienc

e ou

tsta

ndin

g ca

re

We will deliver a new co-located Paediatric Emergency Department and Children’s Assessment Unit to transform emergency and inpatient paediatric care in 2020/21

•Deliver Phase 2 & 3 of the new build: - Completion of Paediatrics - Completion of Majors

•On-going development of the Women’s and Children’s block

Bob Kirton Q3 20/21 Q4 20/21 On-going

We will develop a Nursing and Midwifery Strategy in 2020/21 which will set out what we expect of our nurses and the care they deliver to our patients

•Engagement stage •Draft Plan developed •Implementation commenced from Aug 2020

Jackie Murphy Q1 20/21 Aug 2020 Mar 2021

We will implement a Mental Health Strategy in 2020/21 to ensure the care we give accommodates both the mental and physical needs of our patients, delivered by a trained and knowledgeable workforce

•Establish a mental health implementation group •Develop the Dementia and LD Strategy •Undertake a training needs analysis and develop a training plan •Implement the training plan

Jackie Murphy Jun 2020 Jul 2020 Dec 2020 Mar 2021

We will deliver a Quality Improvement and Innovation Strategy in 2020/21

•Establish a Proud to Improve Group and Innovation Forum •Facilitate an improvement culture by recognising its importance in job descriptions and implementation of Bronze Training QI for ALL staff •Have a Virtual and Physical Hub space available with supporting resources •Establish the framework for assessment delivery of innovations and improvements •Bespoke Silver Level QI training •Strengthen partnerships with external experts (The Improvement Academy and the Allied Health Science Network)

Jackie Murphy Simon Enright

May 2020 Jun 2020 Aug 2020 Sep 2020 Oct 2020 Dec 2020

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We will change and develop how we work with implementation of our Clinical Strategy in 2020/21

• Increase the proportion of admissions being cared for in ambulatory care • Continue to develop the frailty pathway and work with

commissioners, community services and GPs to support frail patients in care homes • Continuing development of digital solutions to allow delivery of

clinical strategy and quality goals • Through audit continue to ensure evidence based best practice

is adhered to • Increase the number of deaths scrutinised by the medical

examiners process • Staff survey: increase the number of staff who agree patient

care is our top priority, increase percentage of staff happy to have a friend or relative treated in the trust • Reduce the number of Serious Incidents resulting from lapses in

care

Simon Enright Jackie Murphy

Mar 2021

We will deliver our Ready Together Out-Patients Programme in 2020/21 to improve patient experience, productivity and efficiency

•Delivery of agreed milestones for 2020/21 and KPIs monitored throughout the year with regular organisational updates. The 5 priorities are: -Work with patients to understand their needs and gather ideas for transformation and improvement -Undertake further staff and clinical engagement to understand ideas for transformation to ensure pathway changes are clinically led -Support services to deliver their agreed service changes eg. RAS and patient led follow up -Understand and test the requirements to reduce face to face contacts as per the Long Term Plan -Analysis of current clinical space utilisation to ensure optimisation of space

Bob Kirton Mar 2021

We will improve patient flow internally and across the system in 2020/21

•Develop a plan based on lessons learned from Winter 2019: -Review of space and changes -Staffing proposals -System actions -Improved processes and data

•Reduce general and acute bed occupancy levels to a maximum of 92% •Increase the proportion of patients seen and treated on the same day to regionally agreed levels

Bob Kirton Jackie Murphy

Q1 20/21 Mar 2021 Mar 2021

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•Continue the Ready Together Flow programme including Proward rollout:

-Complete Surgical Ward Areas -Commence Women & Children’s Ward Areas

Dec 2020 Jan 2021

We will work with partners to develop a Barnsley Cancer Strategy and improve patient pathways in 2020/21

•Development and sign off of Cancer Strategy •Implement a Macmillan Information Hub with Info Pod Points Trustwide

Bob Kirton Dec 2020 Aug 2020

We will increase the level of engagement/involvement of service users and carers in developing and enhancing our services

•Use expert patients and set up an engagement group •Increase service user feedback •Involve patients in service improvement •Use patient surveys and other sources of feedback to inform

service development • Improve Patient Experience and Communications through:

- Development and launch of the re-designed Trust Website - Increasing the followers of our social media channels by 10%

(baseline required prior to Objectives launch)

Jackie Murphy Emma Parkes

Q2 20/21 Q4 20/21 Q4 20/21 Q4 20/21 Nov 2020 Mar 2021

We will use technology to enhance patient care and safety and enable more efficient and productive ways of working in 2020/21

• Delivery of the Digital Roadmap projects including Medway Stabilisation

• Delivery of new technology to support our patients including: -Patient Flow: Work with services to roll out e-handover and

Careflow connect -E-Prescribing: Agree PID and commence project -Shared Care Records: Establish governance in co-production

with Barnsley Place organisations throughout 2021 -Direct Entry EPR: Convert Paper Forms to Electronic capture

eg. Weekend Handover Proforma and Paediatric Care plans -Scanning of Medical Records: Present scanning strategy and

establish project -Speech Recognition: Enable the supporting technology -Investigate Patient Portal including direct appointment

booking -Explore Automation/Artificial Intelligence -Deliver Radiology Picture Archiving Enterprise imaging

solution

Tom Davidson

Mar 2021 Q3 20/21 Jun 2020 On-going On-going Start 2020 TBC Mar 2021 Q4 20/21 Jul 2020

We will undertake a full and comprehensive review of parking for the organisation in line with the Active Travel Plan in 2020/21

Finalised actions and deadlines will be included in an update to Trust Board in April

Richard Jenkins Lorraine Christopher

TBC

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Part

ners

: W

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ill w

ork

with

par

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deliv

er b

ette

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ore

inte

grat

ed c

are

We will play a leading role in integrating care in Barnsley, building on existing relationships with key partners in 2020/21

• Continue to work with partners from across the system on the Integrated Care Delivery Group priorities including:

- Population Health Management - Primary Care Networks/Neighbourhoods - Support of an integrated infrastructure including

workforce, IT, Estates and Communications - Prevention: QUIT, Active Hospital, Alcohol Care Team - Barnsley 2030 Plan

Awaiting finalised system priorities for 2020/21

Bob Kirton

Mar 2021

We will work with local Trusts and build on existing partnerships in 2020/21 to sustain local services for the people of Barnsley

• Continue to work with local partners on existing and new pathways including:

- Pathology Partnership (Rotherham) - Gastroenterology (Rotherham) - Urology (Mid Yorkshire) - Plastic Surgery (Mid Yorkshire)

Bob Kirton Mar 2021

We will work with partners across the NHS including Social Care and the developing South Yorkshire & Bassetlaw Integrated Care System to ensure sustainable local services and support others regionally in 2020/21.

• Support delivery of Integrated Care System priorities The Five Year Plan has been signed off – a delivery plan will be agreed locally and we will confirm the approach by the April Trust Board meeting

Bob Kirton Richard Jenkins

Mar 2021

We will work with our partners in the South Yorkshire & Bassetlaw Integrated Care System in 2020/21 to implement the new Hosted Networks across the region

• We will lead the Urgent & Emergency Care Hosted Network and support the four other Hosted Networks

Simon Enright Mar 2021

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Peop

le:

Will

be

prou

d to

wor

k fo

r us

We will work to enable a sufficient, capable, motivated and sustainable workforce in 2020/21

• Delivery of key actions from the People Strategy with quarterly reporting via P, F & P including:

Engagement • Develop improvement plan and actions to address the key

areas of concern in staff survey: - Improve the way in which appraisals help me to do my job

(Improve from below average to above average in next staff survey)

- Improve the way in which staff receive feedback from patients and service users (Increase current score by 5%, from 62% to 67%)

- Increase the opportunities staff have to make changes for the better (link to QI)

• Achieve a staff survey overall engagement score in the top 20%

Steve Ned

Feb 2021 Feb 2021 Feb 2021 Sep 2020

Jun 2020

Equality, Diversity & Inclusion

• Continue engagement to promote the Trust as an employer of choice to be measured with improvement in our Workforce Race/Disability Equality Standards questionnaire metrics.

• Further development of staff networks, working on feedback given to produce and implement an action plan

Leadership Development • Agree and implement a Talent Management & Succession Plan

to include: - Coaching and mentoring for managers - Further development of the learning and development

programme - Identification of roles and individuals for talent pipeline - 360 degree feedback for managers

• Ensure achievement of Trust target for completed appraisals and Statutory and Mandatory training (90%)

• Implement plan to ensure quality appraisal conversations • Develop an action plan to create a positive workplace culture

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Health & Well Being • A reduction in sickness to an average of 3.75% by the end of

the year by: - Identifying best practice approaches and - Implementing these in the Trust

• Deliver two Health & Well Being Educational Programmes and Workshops per year

• Produce, implement and communicate a mental health at work plan to encourage and promote good mental health

Jackie Murphy

Mar 2021 May 2020 Sep 2020 Jan 2021 Jul 2020

On-going Jul 2020

Staff Retention & Recruitment • Implement steps to retain our existing nursing workforce • International Nurse Recruitment

Workforce Planning • Development of a Trustwide Workforce Plan • Review of Nursing/Staffing & Nursing Roles • Explore new clinical roles and team roles in the organisation • Review ward staffing and align to the use of new roles in the

organisation

Steve Ned Jackie Murphy Simon Enright/ Jackie Murphy

Jul 2020 On-going On-going On-going

We will ensure all teams are aware of the Trust objectives and performance targets by June 2020

• Publication of Trust Objectives • Briefings with teams and key stakeholders • We will undertake on-going communication and provide clarity

to staff on the Trust Objectives – ‘making it real’

Bob Kirton Emma Parkes

Apr 2020 Mar 2020 March 2021

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Aim

Objectives (SMART) Key Actions/KPIs/Milestones Lead Director Completion Date Pe

rfor

man

ce: W

e w

ill a

chie

ve o

ur g

oals

sust

aina

bly

We will achieve our agreed financial plan in 2020/21

• Delivery of the 2020/21 cost improvement target of £5.9m • Continue reduction in medical agency/locum spend • Review Nurse/AHP Staffing Spend Control and reduce

agency spend • Improved productivity through the rollout of PLICS, GIRFT

action plans, business planning and up-to-date job plans

Chris Thickett Simon Enright Bob Kirton Jackie Murphy

Mar 2021

We will work collaboratively with partners to achieve a balanced Barnsley place financial position in 2020/21

• Understand future financial/contractual models and progress their implementation where appropriate, working with colleagues across the system

Chris Thickett Mar 2021

We will plan our multi-year capital requirements and remain ready and open to the possibility of transformational funding opportunities in 2020/21

• Further assessment of capital requirements and funding opportunities with services to prioritise spend and obtain Board approval to progress

• Work with service leads to ensure readiness of business cases for tranches of transformational funding

Chris Thickett Bob Kirton

Q1 2020 On-going

We will develop and deliver a Trust Sustainability Plan in 2020/21 to ensure we operate sustainably in relation to the environment

• Deliver actions to reduce our carbon footprint • Promote electric vehicle usage on site • Reduce single use plastics • Active Travel Plan • L.E.D lighting implementation

Bob Kirton Lorraine Christopher

Mar 2021 Mar 2021 Mar 2021 Mar 2021 Oct 2021

We will achieve the highest possible standards of sustainable performance in 2020/21

• Achieve top quartile nationally in all performance areas • On-going delivery of all constitutional standards and

implementation of new standards when finalised • All patients will be offered the choice of an alternative

provider if waiting for 26 weeks on RTT pathway • Achieve “Outstanding” in our CQC assessment in 2020/21

Bob Kirton Jackie Murphy

Mar 2021

We will develop a new 5 Year Trust Strategy for the organisation in 2020/21 to commence delivery from April 2021

• Sign off approach and road map • Information gathering • Impact modelling & analysis • Strategy developed and approved at Trust Board

Bob Kirton May 2020 Jul 2020 Aug 2020 Dec 2020

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We will implement new and improved governance arrangements for the Trust in 2020/21

• Review of existing governance structure, system and processes: - Review of Trust Risk Management Strategy - Review of Board & Committee frequency - Scope Governors’ training needs including Executives, Non-

Executive Directors and Governors • Benchmark with regulatory and legislative requirements and

good practice • Refresh the Board Assurance Framework (BAF for 2020/21) • Review the Risk Management approach of the Trust linked

to the 5 year strategy review to support investment and operational decision making

• Scope digital governance solutions • Re-design governance infrastructure

Margaret Saunders Apr 2020 Apr 2020 May 2020 Dec 2020 Dec 2020 Mar 2021

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Partners: we will work with partners to deliver better, more integrated care

We will play a leading role in integrating care in Barnsley, building on existing relationships with key partners We will work with local Trusts and build on existing partnerships in 2020/21 to sustain local services for the people of Barnsley We will work with partners across the NHS, including Social Care and the developing South Yorkshire & Bassetlaw Integrated Care System, to ensure sustainable local services and support others regionally in 2020/21 We will work with our partners in the South Yorkshire & Bassetlaw Integrated Care System to implement the new Hosted Networks across the region

People: will be proud to work for us We will work to enable a sufficient, capable, motivated and sustainable workforce in 2020/21 through:

- Increased staff engagement - A focus on staff retention and recruitment: making the Trust

an employer of choice - Developing our Leaders - Ensuring that we create an environment where our people

are physically and emotionally sustained

Performance: we will achieve our goals sustainably We will achieve the highest possible standards of sustainable performance We will achieve our agreed financial plan by:

- A continued focus on cost reduction and further improving productivity

- Effectively planning multi-year capital priorities and remaining ready and open to the possibility of future external funding opportunities

We will work collaboratively with partners to achieve a balanced Barnsley place financial position We will develop and deliver a Trust Sustainability Plan to ensure we operate sustainably in relation to the environment We will implement new and improved governance arrangements

Our Vision: To provide outstanding, integrated care

Our Values: Treat people how we would like to be treated ourselves We work together to provide the best quality care

We focus on your individual & diverse needs

Trust Objectives 2020/21

Patients: will experience outstanding care We will deliver a new co-located Emergency Department and Children’s Assessment Unit to transform emergency and inpatient paediatric care We will develop a strategy to define what we expect of our nurses and the care they deliver We will ensure the care we give accommodates both the mental and physical needs of our patients, delivered by a trained and knowledgeable workforce We will change and develop how we work with implementation of our Clinical, Quality Improvement and Innovation Strategies We will improve patient experience, productivity and efficiency through delivery of our Ready Together Out-Patients Programme We will improve patient flow internally and across the system We will work with partners to develop a Barnsley Cancer Strategy and improve patient pathways We will increase the level of involvement of service users and carers in developing and enhancing our services

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD: 20/03/05/17 SUBJECT: INTELLIGENCE REPORT DATE: 5 MARCH 2020

PURPOSE:

Tick as applicable Tick as applicable


PREPARED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNICATIONS SPONSORED BY: DR RICHARD JENKINS, CHIEF EXECUTIVE PRESENTED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNICATIONS

To provide a brief overview of NHS Choices reviews and ratings together with information on relative key developments, news and initiatives across the national and regional healthcare landscape which may impact or influence the Trust’s strategic direction.

Summary of content:

• MY NHS/NHS Choices Feedback• NS review of national targets• NHS capital framework• Digitalisation of GP records• Register for NHS Directors• Single national database for patient safety data• Digitalisation of diagnostic test results

The Board of Directors is asked to receive the contents of this report for information.

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WatsonL

Typewritten Text

Subject: INTELLIGENCE REPORT Ref: BoD: 20/03/05/17

*please note that this is not an exhaustive report, submissions welcome to [email protected] Release Type

Detail Impact/ Action/

My NHS/ NHS Choices

NHS Choices User Rating – 4.5* (5* is Excellent) Feedback Emergency Department: Fabulous service ★★★★★ I was sent in via the Dr with a suspected broken elbow. From the time it took to get checked in, seen and sent for an x Ray to be seen again and discharged and then back to the ticket machine to pay for parking, 28 minutes! I’ve never been seen so fast! So efficient! Very helpful staff! Explained everything to me and gave advice on how to proceed! Very happy and impressed with the service! Outstanding A&E department ★★★★★ Went to department yesterday, a very busy department while I was there. I was triaged quickly and looked after by the Dr and nurses so well, all the staff were friendly and helpful and I feel lucky to have an A&E this friendly and efficient on my doorstep. Everything was explained to me at point of contact and I was kept informed. Great service ★★★★★ I took my teenage daughter along to the Emergency Department as we suspected she had broken her wrist whilst ice skating. We were shown to the teen waiting area, what a brilliant idea - lots of thought had gone into having that facility and the wall displays. The nurse was lovely with her and knowledge. When we saw the Doctor he gave her arm/hand/wrist a thorough check and had a great manner. We went to X-ray, great service again. The Doctor sought a second opinion just to be sure, again great manner and information given. We left feeling fully satisfied she had had a thorough check, given advice and strapping to help heal quickly. Thank you to everyone involved. Wonderful professional caring department ★★★★★ Check in all staff I came in contact were helpful, considerate and proud to call my home town hospital thank-you clerk, triage treatment you all rock. Good experience ★★★★★ The nurses were there as soon as I arrived. I found the staff very helpful and friendly. The Dr was very informative and caring the Ambiance crew were cheerful and friendly and very efficient they put me at ease I felt very safe in their hands.

Potential impact on reputation / All postings responded to / Board to note for information

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Release Type


Rheumatology: No problems with this Hospital ★★★★★ I have been a frequent visitor to several clinics for the last 5 years and see first-hand what the staff have to put up with and how busy they are, yes the waiting times at some clinics can be long, I have several long term illness and expect to be visiting for the foreseeable future and appreciate all the care I am receiving, I have also had 2 short stays in hospital this year and same again cannot fault the nursing staff on any of the wards I was on total respect for all of them. I am now on a home care plan to help me manage my illnesses and keep me out of the hospital, very pleased with all the care I have received at Barnsley Hospital. Accessible information ★★★★ Hard of hearing people sat in the waiting area may not be able to hear their name being called, as is the current system. The waiting area needs a screen stating who is being called for their appointment.

National – NHS targets

NHS Review of NHS Targets Proposes ‘Maximum time to assessment’ target for those attending ED Healthwatch England has interviewed patients, carried out surveys and analysed feedback, to formally advise the NHSE clinical review of standards. One of the measures being tested in NHSE’s pilot sites for emergency department measures is the time to initial clinical assessment. Healthwatch recommends continuation of reporting against the current four-hour target, at least for a transition period, to help compare performance over time compare it in some way with the current target. The report, based on interviews with 330 patients in six of the EDs trialling the new measures, also restated Healthwatch’s previous observation that long waits are not the overriding factor which matters to patients. It is attached for information. Patient experience in A&E is also driven by factors such as the quality of care, communication, attitude of staff, how joined up the department is to services such as NHS 111 and GPs and the quality of the facilities themselves, Healthwatch found. Healthwatch interviewed patients at Cambridge University Hospitals Foundation Trust, Portsmouth Hospitals Trust, Imperial College Healthcare Trust, West Suffolk FT, Poole Hospital FT, and Mid Yorkshire Hospitals Trust. The full report is appended for information.

Board to note for information

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Release Type


National – capital

NHS capital through a new national framework to support the delivery of 40 new hospitals by 2030. The Department of Health and Social Care is expected to launch a procurement drive to find the construction companies which will be tasked with delivering the new builds. Previously, many NHS trusts used the DHSC’s P22 framework to choose from six construction companies to deliver their capital projects. This framework expires in September, and the new framework — called Procure 2020 — will replace it. There will be two national lots: one for projects costing between £25m and £100m, and one for those costing more than £100m. The latter is expected to be the purchasing route for the trusts allocated capital in the HIP. These projects are anticipated to cost between £350m and £650m. Additionally, the DHSC intends to take a more regional approach to smaller capital projects such as refurbishments. According to a webinar for suppliers, hosted by DHSC last month, officials are planning a third lot which will be split into four regional categories covering the North, Midlands, London and the South. This will be used to select contractors for projects with a capital cost of up to £25m, enabling smaller companies to qualify. Between six and 10 suppliers will be selected for each of two national and four regional lots. The DHSC anticipates selecting suppliers for the framework in July with the new framework expected to go live on 1 October.


National – digital

National approach to the digitalisation of old medical records in GP practices. Older records stored on GP premises are to be digitised and stored in a cloud-based solution or in the GP practice’s IT system. NHSE is consulting with technology suppliers for input in shaping the project of digitising these records, ahead of launching a procurement for an open framework of companies from which clinical commissioning groups and sustainability and transformation partnerships/integrated care systems can buy solutions for digitising the records. It hopes to launch the procurement in April.


National Recommendations to introduce a compulsory register for NHS directors may become a voluntary register. The 2019 Kark review of the fit and proper person test called for a central database of all NHS directors’ qualifications and history. It also called for the creation of a new body, which Tom Kark QC called the “health directors’ standards council”, with the power to investigate complaints of serious misconduct by directors, and bar them from sitting on NHS boards.


Pack page 189

Release Type


The working group set up to consider the NHS’ response to the review as part of the NHS People Plan programme is considering a voluntary register as a possible solution. The working group is chaired by former trust chief executive and former Department of Health workforce director Andrew Foster, and includes representatives from the regulatory world, provider trusts, unions and whistleblowers. It is finalising its recommendations to be passed on to NHS Improvement chair Baroness Dido Harding, who is leading work on the NHS people plan. A final decision is not expected until it is published, currently due to be March or April.

National – digital

Plans for a single database for patient safety data across the NHS and private sector. NHS Digital and the Private Healthcare Information Network (PHIN) — a government-mandated and not-for-profit organisation which collates information about private healthcare — have launched a six-week consultation on the proposed online database, which would bring together consultants’ performance data across both sectors. Under the changes proposed in the acute data alignment programme — known as ADAPt — PHIN would share its national dataset of private patient care with NHS Digital, creating a single source of healthcare data in England which will record activity, quality and risk in a consistent way. NHS Digital would also pilot collecting data directly from independent providers on privately funded care within its secondary uses service — which holds anonymised reports and statistics on patient records to support research, planning and service delivery — to reduce the administrative burden on hospitals and to share this information with PHIN.


National National officials are working with radiologists on systems to digitally inform patients of diagnostic test results NHSX are exploring creating a method of digitally notifying patients of significant radiology results to establish potential solutions and guidance that NHSX can provide to improve digital practice and ultimately patient safety. The Royal College of Radiologists has assessed which conditions should always trigger an alert when discovered, following recommendations from HSIB.


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interim update

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https://www.england.nhs.uk/wp-content/uploads/2019/03/CRS-Interim-Report.pdf

submission to the NHS Mandate Refresh for 2018/19

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https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20171012_nhs_mandate_refresh_2018_-_2019_final.pdf

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Trust C

"Full explanation about what had happened and what to look for in the future - very

clearly explained and leaflet given."

Trust F

"Very impressed by communication at all stages. Seemed very organised - told what

would happen next. A&E was very crowded, but everyone stayed very calm. When there

was a hold up, a nurse explained the situation."

Trust A

"I was unconscious, have not been told what is wrong."

Trust B

"She doesn’t want to hassle people, but is still waiting for nurse to advise about waiting

time or drip and needs that information to re-organise hospital transport. Staff don't

seem to understand that she will be stuck now that she can't get to the 12.30 pick -up and

doesn't know how she will get home when drip finishes. Needs more information and

help contacting patient transport."

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Trust C

"Have had usual checks and x-ray, now waiting for results. In the meantime, have started

steroids but wasn't sure what they were for."

Trust E

"There was so much confusion about whether I was staying here or not. I'm type 1

diabetic and had hypo. Wife could have gone home [if we knew I was staying here]."

Trust F

"Waited 2.5 hours approximately in total, including triage in x-ray. Did not understand

why as there were no other people in both departments."

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polling conducted for this project

Trust D

"It Is a lot quieter than expected, thankfully."

Trust F

"I expected to wait longer before being seen. Waited for a short while, communication

also much better than expected."

Trust A

"Screen says 0 minutes but its 8-9 hours to see a Dr, but we have been seen by staff and

they have told us all what's going on."

- A patient who has been in the department four and half hours so far and rated their time

in department four out of five, commenting "they are doing a good job under immense

pressure." The patient also rated their overall experience as a five out of five.

Pack page 200

https://www.healthwatch.co.uk/report/2019-03-11/peoples-views-ae-waiting-times

https://www.healthwatch.co.uk/news/2019-10-31/people-share-what-good-ae-experience-looks

Trust C

" Saw a nurse +HCA very quickly. Treated with empathy. Observations, bloods were don e

very quickly. Had an X-ray then the Doctor came […] He has been kept well informed. He

is satisfied. Feels that he has been dealt with quickly this time, as although he has been

here since 03:00 he has been investigated. Feels that the actual discharge may hold him

up."

- A patient who has been in department for seven hours, and rated their time in

department and overall experience a four out of five.

Trust D

"Spoke to the front desk. Saw navigator nurse after 3/4 hour. Very helpful and polite.

The experience has been better than expected. Quiet and relaxed atmosphere."

- A patient who spent more than four hours in the department but did not mention their

overall wait and rated their time in department and overall experience four out of five.

Trust E

"Nothing has been too much trouble… I've received good care so far… It's quite surprised

me really - they've been very good and above my expectations. They explain as they go

along. They are all happy and nice to you. I'm quite happy but in pain."

- A patient interviewed in the AAU who spent seven hours in ED and rated their overall

experience five out of five.

Trust A

"I know It's busy and I know I have to wait."

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Trust B

"Quicker would be nice but understand why it is as it is.

Trust F

"A couple more hours to wait. Yes, I was expecting a lots of hours as A&E are usually

busy."

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Trust F

"Listened to me when I explained what I am worried about. Listened when I said I want

to stay overnight."

Trust C

"The doctor has informed me of choices available to me, and changed my pain relie f

medication after discussion."

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Trust E

"They tend to talk over you although they weren't that bad and they did apologise."

"They work hard - they don't get the time for conversation."

Trust A

"Grateful to be here. NHS a wonderful thing. Little things would make it a lot better."

Trust E

"We are so lucky to have this service."

A&E patient experience survey

found

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https://www.cqc.org.uk/sites/default/files/20191023_uec18_statisticalrelease.pdf

https://www.kingsfund.org.uk/publications/what-does-public-think-about-nhs

Trust C

"Now sat waiting for blood results, which doctor said he can't find. Yes staff have cared

for me would say about 50/50.

Trust D

"Thought there would be more examination by triage."

Trust F

"Arrived and been laying down in agony (pregnant). Blood test done. Still waiting.

Provided pain relief but nothing happened. Very scared, no-one helping."

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Trust A

"Knew it would be a long time, they have to prioritise if someone's had an accident."

Trust C

"Was expecting to be seen quicker but understand there are people with more urgent

clinical conditions need to be seen ahead of him."

Trust D

"Wait was what I expected. People who arrived after go in before me. Waiting time

board not kept up to date (last done 7.30am, now 3.45pm!)."

Trust A

"Mixed, staff have been helpful but my mum has an ongoing heart condition and I didn't

get the impression that they were taking it that seriously though."

Trust C

"Not what was expected. Feels his situation (badly and deeply cut arm that won't stop

bleeding) warrants more urgent clinical attention."

Trust B

"No special allowance for disability. Worried that getting bored and uncomfortable in

wheelchair. Like getting hoist ready but hasn't happened, but have provided a packed of

sandwiches."

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national polling

Trust C

"Contacted own GP at 8.10 and triage nurse rang back about 10am. Was offered a triage

nurse app in 4 days and GP after 7 days. I thought I would come to the UTC and see if can

get it sorted before appointment and then will cancel GP appointment."

Trust D

"Local medical centre at 11am. Phoned 111. Optician, no appointment available. Came to

QA [Queen Alexandra Hospital]. Eye department shut! Referred to A&E 1pm."

Trust B

"Thought had been referred by GP. Been told that should have had a letter with her."

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https://www.healthwatch.co.uk/news/2019-10-31/people-share-what-good-ae-experience-looks

Trust D

"Didn't expect to be referred to QA [Queen Alexander Hospital] but to be dealt with at

the walk-in unit."

Trust D

"The nurse contacted the eye specialists who said they won't come and see the patient

until the same tests done today at Specsavers are repeated by a health professional in

hospital. Kept informed but not happy about it."

Trust F

"Already spent the night in A&E Liverpool due to swollen knee/very painful. We are now

having to go back to square one as the notes do not transfer. I live in London (was in

Liverpool for work). Plus one full night in Liverpool going through the exact same

process. Shared notes on a system between hospitals would save so much time and

money."

Trust A

"Transport a 4 hour wait! Excellent A&E."

Trust E

"Waiting for physio and occupational therapist to make sure what I need as I live on my

own - they won't let me out till all this is done." [Patient had been In A&E for 7 hours]

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Trust A

"Feeling hungry - what's happened? Not told what is going to happen. Perhaps a

note/poster could be put up 'Please ask if you would like a drink'."

Trust F

"No option to go out and eat - not easy facilities for parents with children or babies. No

accessible food or water."

Trust B

"Machine out of order. People going out to get refreshments - missing being called."

Trust C

"Was not offered any food or drink and didn't want to walk the long distance to get

something in case they missed the medical staff coming back with results."

Trust C

"Uncomfortable chairs in a waiting area."

Trust D

"Nowhere to sit. Stood in doorway."

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Trust F

"Everyone sat in together, don't know who has infections. I have an immune disorder o n

suppressants and doctor said would separate us, but hasn’t yet."

Trust B

"Lady came round with drinks and snacks - very helpful."

Trust E

"At the end I had sandwiches - unexpected and very gratefully received."

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https://www.ipsos.com/sites/default/files/publication/1970-01/SRI_Health_FFT_Qualitative_Research_Report_July_2014.pdf

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BoD March2020: Celebrating our People

EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT


SUBJECT: CELEBRATING OUR PEOPLE

DATE: 5 MARCH 2020

PURPOSE:

Tick as applicable

Tick as applicable


PREPARED BY: Katie Claydon, Communications Assistant

SPONSORED BY: Richard Jenkins, Chief Executive

PRESENTED BY: Emma Parkes, Director of Marketing & Communications

To provide an update to the Board on the Trust’s Brilliant Award winners as part of the reward and recognition process for celebrating the excellent work within the hospital.

The Trust employs over 3,000 people, each of whom play an integral role in the hospital’s overall performance and successful achievement of strategy and objectives. Each month, the Trust recognises staff who are nominated by colleagues and the public by presenting three Brilliant Staff Awards as part of a monthly award scheme which recognises individuals or teams that have gone above and beyond their role. There are three award categories: - Individual Brilliant Award (nominated by any member of staff) - Team Brilliant Award (nominated by any member of staff) - Public Brilliant Award (taken from feedback received by members of the public)

Each month the Chairman and Chief Executive jointly agree the winners, who are then presented with a certificate by the Chairman at a surprise presentation which is then promoted throughout the Trust. The Brilliant Staff Awards are sponsored by ISS who provide food and hospitality services for the Trust.

This paper will highlight the winners and nominees within each award for the previous month.

The Board is asked to review the content of this report.

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Subject: CELEBRATING OUR PEOPLE REPORT Ref: BoD: 20/03/05/18

1. STRATEGIC CONTEXT

This report provides the Board with an understanding of the Trust’s winners and nominees for the monthly Brilliant Staff Awards. The Brilliant Awards are a key part of the Trust’s recognition of our people. Winners are celebrated across the Trust in a variety of communications media, including online on the Hub and, from December, on display in the main Reception area. Winners are also celebrated externally via social media.

. 1. INDIVIDUAL BRILLIANT AWARD

Winner: Julie Ellis, Healthy Lifestyle Facilitator During quarter two and quarter three of 2019/20 Julie has worked on her own to implement the Alcohol and Tobacco CQUIN which requires every adult admission having a hospital stay of one night or more is: - Screened for alcohol & tobacco use - Where required are given brief advice - Where appropriate and required people are referred to support services In quarter 3 Julie has screened 62% of patients in the CQUIN cohort. This is an amazing achievement! Julie has worked to ensure the continued implementation of this CQUIN despite the pressures of long-term sickness within the team. I would like to thank Julie on behalf of the Trust and believe Julie deserves recognition for this amazing effort. Nominees: Steven Robinson, Porter Steven is a pleasure to work with, always willing to go the extra mile for staff and patients. nothing is ever too much, he's an absolute star, I wish I could have Steven on my shift every day!! Dawn Barber, Environmental Coordinator Dawn is a huge asset to the unit. She is caring, compassionate and puts the needs of others at the top of her agenda. She has a great personality and a fantastic rapport with patients, always making them feel at ease. Her knowledge of the patients on the ward and her ability to risk assess and make appropriate recommendations, is above and beyond what is expected of any environmental coordinator. Whenever the ward is short staffed she is always at hand to offer her assistance, whether it be feeding a patient, helping with dinners, or just day to day cares, Dawn will never see a patient go without the quality of care they need during their stay. Dawn is a true team player and never stops, even when her work is done. Dawn is proud to maintain high standards and is a true asset to this Trust. Dawn has worked on the unit for a very long time and deserves the recognition for what she provides not only to the patients but also the staff. She's the backbone to this unit! Brooke Haigh, Auxiliary Nurse Brooke and a Porter were in the lift transporting a patient to theatre for an operation. The patient had some learning difficulties and was very agitated. Brooke was calming the patient very effectively, she was using both verbal and non verbal ways to communicate with him. The patient responded to this.

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2. TEAM BRILLIANT AWARD

Winner: Acute Medical Unit I would like to nominate the Acute Medical Unit team who dealt with my unscheduled visit to Barnsley Hospital in January. The whole team were so professional and caring making my stay as comfortable as possible in the circumstances. This includes the non medical staff. I would particularly single out Gail, the part time member of nursing staff who is just a star but the effort and care of all was strongly evident. Keep up the good work, you are a credit to the NHS.

2.2 Nominees:

No other nominations this month.

3. PUBLIC BRILLIANT AWARD

Winner: Children’s Ward I would like to nominate the children’s ward for their fantastic care of my daughter during our visit in January 2020. Brilliant care plus little touches such as providing activities for my daughter plus food and drink. Taking the time to really listen to her and investigate her problems and making sure a thorough investigation took place. I’m sorry unable to remember all names but the great lady in the white uniform top, both students in grey (I know one is Alice) the kind student doctor giving Alex high fives. The nurse in the light blue uniform encouraging her to eat. The fantastic nurse in the dark blue uniform. The doctors Emmanuel and Rhian Dina. Nominees: Gynaecology Department I had emergency surgery in the women’s services/gynaecology department last night and have never been as settled as I have by Jos, Lindsey and Lauren (who I was shocked to find out was just new to the role!) never have I felt so comforted! I’m such a wuss, just with needles and was petrified about being put to sleep but the bubbly yet professional nature of each and every one of them made me so calm and I just wish I got the chance to thank them personally afterwards! I’m praying I got their names right as I was a little dosed up! But thank you for being so settling and doing an amazing job. I hope lauren has the best time when she goes to uni later on this year. She is going to make an AMAZING nurse! X

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT


SUBJECT: CHAIRMAN’S REPORT DATE: 5 March 2020

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance


PREPARED BY: Trevor Lake, Chairman SPONSORED BY: N/A PRESENTED BY: Trevor Lake, Chairman

To report particular events, meetings, publications and decisions that the Chairman would like to bring to the Board’s attention.

This report is a brief summary of key meetings and events attended by the Chairman.

• As at period 10 (January 2020) the Trust’s overall financial position continues to be delivered slightly favourable to plan and is forecasting to deliver to plan for the year end.

• In January the Trust 4 hour access achievement improved on the December figure to 86.92%.Challenges in achieving the target over the winter period remain with Emergency Department attendance and non-elective admission activity levels continuing to be significantly above plan.

• The Charity and the Marketing and Communications Team have had a further busy period and celebrated the tremendous success of the Tiny Hearts appeal achieving its £1m target total with a special event on 11 February.

The Board of Directors is asked to receive and note this report.

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Subject: CHAIRMAN’S REPORT Ref: BoD: 20/03/05/19 1. STRATEGIC CONTEXT

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chairman since the last meeting and a review of any key updates. The items below are not reported in any order of priority.

2. BARNSLEY HOSPITAL POSITION

2.1 The Trust’s 4 hour access performance remained below target in January 2020 but improved to 86.92% compared with 80.7% in December 2019. Challenges in achieving the target over the winter period remain with Emergency Department attendance and non-elective admission activity levels continuing to be significantly above plan.

2.2 The year-to-date CIP programme continues to be delivered ahead of plan and the

capital programme still remains slightly underspent; however it is forecast to be on plan by the year end with all capital schemes identified.

2.3 PWC are undertaking their Well Led Review process involving observing the Board

and all the sub-committees alongside reviewing a considerable amount of documentation and will report back to the Board by the end of March/Early April.

3. COUNCIL OF GOVERNORS

3.1 The Trust welcomed Governors to a Governors training session on “Holding to Account” on 19 February.

3.2 Progress continues to be made in improving the resources to enable Governors to

deliver greater community engagement with a number of engagement events proposed for the remainder of the year being supported with a wide range of marketing and promotional material.

4. NEWS AND EVENTS: 4.1 In addition to the Trust Board Workshop and Council of Governors’ meeting I attended

a number of formal, informal and ad-hoc visits and meetings.

These included visiting the Theatres with the Theatre Manager to view the new 3D Camera facility for laparoscopic surgery, meeting newly appointed consultants, chairing the Organ Donation Committee, meeting with Staff Governor representatives and chairing the ICPG Barnsley Place meeting.

4.2 I visited a number of services in the Trust and presented several Brilliant Awards

including Ward 30, Dermatology, ICT, the Education Centre, the Birthing Centre, Breast 2 week wait and symptomatic service, anaesthetists and the Children’s ward.

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4.3 Along with colleagues from the Children’s Assessment Unit (CAU) ED team and Barnsley Facilities Services, Bob Kirton and myself supported the PR event to mark the start of the phase 2 CAU ED new build project by attending a ground-breaking Golden Shovel event.

5 Barnsley Hospital Charity

5.1 Barnsley Hospital Charity continues to achieve success and confirmed the significant achievement of the goal of raising the £1million target for the Tiny Hearts appeal. A Tiny Hearts celebratory event was held on 11 February and was well attended by a wide range of fund raising donors, recipients of care from the neonatal unit, staff colleagues and local celebrity Dickie Bird, OBE, who has contributed not only his time and availability freely but has also made a significant personal financial donation to the success of the fund.

Trevor Lake Chairman March 2020

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EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT


SUBJECT: CHIEF EXECUTIVE’S REPORT DATE: 5 MARCH 2019

PURPOSE:

Tick as applicable

Tick as applicable

For decision/approval

Assurance


PREPARED BY: Emma Parkes, Director of Marketing & Communications SPONSORED BY: Dr Richard Jenkins, Chief Executive PRESENTED BY: Dr Richard Jenkins, Chief Executive

To report particular events, meetings publications and decisions that the Chief Executive would like to bring to the Board’s attention.

This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last meeting and highlight a number of items of interest. The items are not reported in any order of priority.

The Board of Directors is asked to receive and note this report.

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Subject: CHIEF EXECUTIVE’S REPORT Ref: BoD: 20/03/05/20

1 BARNSLEY HOSPITAL

1.1 Operational Performance

February continued to prove challenging in terms of both the number of attendances to the Emergency Department and a higher level of acuity in these patients, resulting in pressure on beds across the hospital and also within the wider Barnsley place. Performance against the four hour emergency access target is now showing signs of improving. Performance against Cancer, diagnostics and referral to treatment remains consistently high.

1.2 Coronavirus (COVID-19) Update

In line with national NHS preparations in regards to Coronavirus, Barnsley Hospital has put in place NHS 111 Pods within the entrance to the Emergency Department. This is to enable anyone attending the hospital with symptoms of Coronavirus to be kept isolated from other patients while they contact 111 for advice in accordance with national guidance issued. Communications have been issued within the department and on social media. National advice is being frequently updated to reflect the developing pattern of infections worldwide and the Trust is adhering to the developing guidance.

1.3 Staff Engagement

1.3.1 NHS Staff Survey Results

I am delighted to report that the NHS Staff Survey results for Barnsley Hospital have demonstrated an overall improvement for the third consecutive year.

Notable improvements include Barnsley Hospital being one of the best performing hospitals in England for Equality, Diversity and Inclusion. This is has been an area of focus since the last staff survey indicated that staff with a disability was not always having the same experience as others.

A full briefing has been issued to staff and Clinical Business Units are now focussing on the detail to further improve how it feels for staff to work at Barnsley Hospital. A face-to-face staff briefing session will form part of the March Team Brief.

1.3.2 Paediatric Emergency Department and Children’s Assessment Unit

Phase 2 of the works to co-locate a newly designed Paediatric Emergency Department and Children’s Assessment Unit commenced this month with the build expected for completion in November 2020.

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2 SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM (ICS)

On 10 February I commenced the agreed 12 month secondment as part time, interim CEO of the Rotherham NHS Foundation Trust, whilst still retaining my substantive role as CEO of Barnsley Hospital NHS Foundation Trust.

Dr R Jenkins Chief Executive 5 March 2020

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