BOARD OF DIRECTORS

This is to advise that there will be a meeting of the Board of Directors on Wednesday 19 March 2014 at 9:00am

in the Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust

AGENDA - PART 1

Presenter 1 WELCOME AND APOLOGIES FOR ABSENCE PW Verbal 2 DECLARATIONS OF INTEREST Verbal Members of the Board are required to declare any interests

relating to items on the agenda

3 MINUTES OF THE PREVIOUS MEETING HELD ON

19 FEBRUARY 2014 PW Appendix 1

To APPROVE the Minutes of the Board of Directors’ meeting

held on 19 February 2014

4 ACTION SHEET PW Appendix 2 5 MATTERS ARISING PW Verbal 6 PATIENT STORY HR Presentation To DISCUSS a patient story and to DISCUSS the current

approach to patient stories

EXECUTIVE DIRECTORS’ REPORTS

7 CHIEF EXECUTIVE’S REPORT PM Appendix 3 To DISCUSS the key current issues affecting the Trust 8 MEDICAL DIRECTOR’S REPORT JH Appendix 4 To DISCUSS key current issues within the Medical Director’s

remit

9 DIRECTOR OF NURSING’S REPORT HR Appendix 5 To DISCUSS key current issues within the Director of Nursing’s

remit

10 CHIEF FINANCE AND COMMERCIAL OFFICER’S REPORT TN Appendix 6 To DISCUSS key current issues within the Chief Finance and

Commercial Officer’s remit

11 BUDGET FOR 2014/15 TN Presentation To APPROVE the budget for 2014/15 12 GOING CONCERN TN Appendix 7 To APPROVE the going concern assessment 13 ERNST & YOUNG BOARD EVALUATION REPORT PW Appendix 8 To RECEIVE the Board evaluation report and to DISCUSS the

actions arising

PERFORMANCE REPORT 14 OPERATING & FINANCIAL PERFORMANCE OVERVIEW TN Appendix 9 To DISCUSS the overall performance of the Trust 15 HR AND WORKFORCE REPORT To NOTE the report and to DISCUSS any specific matters

relating to workforce MA Appendix 10

ITEMS TO NOTE 16 MONITOR Q3 ASSESSMENT JR Appendix 11 To NOTE the Monitor Q3 assessment and executive summary 17 ANY OTHER BUSINESS PW Verbal 18 EXCLUSION OF THE PUBLIC PW Verbal

To RESOLVE to exclude the public from the rest of the meeting by passing the following resolution: The Board of Directors resolves to exclude the public from the rest of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other reasons arising from the nature of the business and the proceedings.

19 DATES AND TIMES OF FUTURE MEETINGS AND EVENTS There will be a meeting of the Board of Directors on

Wednesday 16 April 2014 at 9.00am in the Boardroom, Level 1, Yeovil District Hospital

1

APPENDIX 1 BOARD OF DIRECTORS

19 MARCH 2014

BOARD OF DIRECTORS

Minutes of the meeting of the Board of Directors held on Wednesday 19 February 2014 at Yeovil District Hospital

Present: Peter Wyman Chairman Paul Mears Chief Executive Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Paul von der Heyde Non-Executive Director Mark Saxton Non-Executive Director Jonathan Howes Medical Director & Deputy Chief Executive Tim Newman Chief Finance & Commercial Officer Helen Ryan Director of Nursing & Clinical Governance In Attendance: Simon Blackburn Head of Communications & Marketing Jonathan Higman Director of Urgent Care & Long Term

Conditions Tim Scull Associate Medical Director for Urgent Care &

Long Term Conditions Mark Appleby Head of Workforce Performance and OD Jade Renville Company Secretary Nicola Webber Secretariat Ann Beable Public Governor Apologies: Susan Davies Director of Elective Care

Action 1-19/14 APOLOGIES AND WELCOME

The Chairman welcomed everyone present to the meeting and extended a particular welcome to Tim Scull, Associate Medical Director for Urgent Care and Long Term Conditions (who will take on the role of Medical Director from 1 March 2014 to enable Jonathan Howes to focus on his Deputy Chief Executive role), Jade Renville, newly appointed Company Secretary, Mark Appleby, Head of Workforce Performance and OD and Ann Beable, Public Governor. Apologies for absence were received from Susan Davies, Director of Elective Care. The Chairman welcomed and introduced Jake Arnold-Forster, Carradale Consultancy, as an observer of the Board.

1-20/14 DECLARATIONS OF INTEREST The Chairman declared that he is Treasurer and a member of the Council of the University of Bath.

Page 2

1-21/14 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 22 January 2014 were approved as a true and accurate record, subject to an amendment at 1-14/14 where “Assurance Committee” should be amended to read “Clinical Governance Assurance Committee”.

JR

1-22/14

ACTION SHEET The Board noted that all actions from previous meetings will be reviewed and progressed by the Company Secretary. A revised action sheet will be presented at the next meeting of the Board to be held on 19 March 2014.

JR

1-23/14

MATTERS ARISING There were no matters arising not on the agenda.

1-24/14 PATIENT STORY Helen Ryan provided an introductory briefing to the patient story, explaining that this particular experience highlighted a number of communication issues. A relative of the patient was invited to share this experience with the Board and the Chairman welcomed him to the meeting, indicating that it is the practice of the Board to start each meeting with a patient story in order to obtain valuable feedback which can then be used to improve services. The relative spoke of the importance of listening and sharing positive stories as a way of promoting best practice. The relative summarised the experience to the Board, from which the following key issues were noted: • effectiveness of staff handover between shifts, resulting in the

patient repeatedly being asked for information which had already been provided

• family members not being listened to or kept fully informed • treatment of physical issues not balanced with other factors that

may impact the patient’s health and wellbeing and ability to provide information

• miscommunication between staff, the patient and their family and community services regarding discharge and issues in arranging transport

The Board expressed disappointment at the contents of the patient story and discussed the learning from the incident, reinforcing the importance of listening to and communicating with patients and recognising their family as experts in their care. The Chief Executive also reflected on an ongoing programme of work to improve the integration of hospital, community and GP services so that care is seamless between these agencies.

Page 3

The Chief Executive also advised that there is a dementia nurse specialist in post and part of their remit would be to improve training for staff which would take into account the importance of understanding the impact of non-physical issues and of communicating effectively with patients and their family. Members agreed that ongoing actions included improving staff communication and listening skills, improving the transfer of information (including any relevant information not related to the patient’s physical treatment) at staff handover, ongoing work to improve integrated working between health and care services and training staff in these areas. The Chairman asked the Director of Nursing and Clinical Governance to provide an update at the seminar session in April about the actions that have been put in place to mitigate such issues from occurring, with particular focus on those that are in place to improve communications as this is a common theme that arises from complaints. It was also agreed that the Head of Communications and Marketing would speak with the family and ask for their story to be filmed and shared with staff which would reinforce the training programme.

HR

SB

1-25/14 CHIEF EXECUTIVE’S BRIEFING The Chief Executive updated the Board on a number of points including: • Dr Tim Scull, Associate Medical Director for Urgent Care and Long

Term Conditions will take on the role of Medical Director from 1 March 2014 on a 12 month secondment. The Chief Executive explained that this will enable Jonathan Howes to focus on his Deputy Chief Executive role, taking a more strategic leadership role on the Board, particularly in leading the development of clinical integration across primary and secondary care, the implementation of the Electronic Health Record and the development of clinical partnerships with other providers. Dr Tim Scull will continue to fulfil his role as Associate Medical Director for Urgent Care and Long Term Conditions in addition to his new Medical Director responsibilities. The Board welcomed another medical presence on the Board.

• The recruitment process for the currently vacant post of Director of Organisational Development and Workforce is underway. The candidates had been long listed with interviews taking place on 10 March 2014. An update will be provided at the next meeting of the Board to be held on 19 March 2014.

• The Chief Executive asked the Director of Urgent Care and Long

Term Conditions to provide an update on the Stroke Review. He advised that a business case, led by the South West Commissioning Support Unit (CSU) will be developed over the coming months with a proposal being taken to the Somerset Clinical Commissioning Group (CCG) in June. Members commented that there would need to be an overwhelming case for change to justify making one and that there had been significant progress in Stroke performance at the Trust with staff working tirelessly to provide a high quality clinical service.

PM

Page 4

• The Trust had been successful in a bid for £200,000 of funding

from the Department of Health which will be utilised to improve the environment for visitors, especially for fathers, attending births and to upgrade Freya ward. The Chief Finance and Commercial Officer advised that this is a second allocation of funding from the Department of Health, in addition to investment in the special care baby unit which, overall, will significantly contribute to a better experience for mothers and their families. Members noted and thanked James Kirton for his significant contribution in writing the bid to secure this funding.

• The Chief Executive asked the Head of Workforce Performance

and OD to provide an update on the leadership development programme. He confirmed that the programme has commenced with two cohorts of senior clinical and non-clinical staff within the organisation. The Head of Workforce Performance and OD advised that another management development programme for staff of band 7 and below will be launched in the summer. He confirmed that he would welcome observation from Non-Executive Directors at the sessions and this would be arranged outside the Board meeting.

MA/MD

1-26/14 MEDICAL DIRECTOR’S REPORT The Medical Director reported that Dr Foster will now release data on a quarterly basis for the four key measures of quality: hospital standardised mortality ratio (HSMR), emergency HSMR for weekday and weekends and deaths in low risk diagnosis groups. The Medical Director also advised that feedback has been received from the Deanery/General Medical Council visit that took place on 17 January 2014. In general, the feedback was positive but a number of areas for development had been identified. In terms of staff workload, it was recognised that junior members of staff could be utilised to undertake certain tasks. In addition, members reflected that more could be done to support junior doctors, noting that the Care Quality Commission’s (CQC) new inspection regime includes peer-to-peer discussions with them and that they will be essential in achieving the strategic vision for the hospital. An action plan will be put in place in response to this and a formal response prepared.

JH

1-27/14 DIRECTOR OF NURSING AND CLINICAL GOVERNANCE’S REPORT The Director of Nursing and Clinical Governance confirmed that she will produce a written report from March 2014. She then updated the Board on a number of key points. There had been a positive meeting with the Patients Association and there will be changes to what was known as the PPI Group. The newly formed group will be called Patient Voice and will focus on widening levels of representation, particularly from protected groups. She confirmed that she will work with the Non-Executive Directors on how information and feedback from Patient Voice should be cascaded to the Board.

HR

Page 5

The Director of Nursing and Clinical Governance also initiated a discussion on how wards display information to patients and visitors in response to recommendations in the Francis Report. Displays are to include expected and actual staffing levels. She also advised that the Friends and Family Test results are now available by ward. It was suggested that information could be displayed on monitors in lift areas and the Head of Communications and Marketing was tasked with considering electronic display options. The CQC is to publish the intelligent monitoring report for the Trust. The report helps the CQC identify possible areas of risk and provides them with an early indication of where and what to inspect. The report groups trusts into six bands based on the risk that people may not be receiving safe, effective, high quality care - with band 1 being the highest risk and band 6 the lowest. Overall, it is indicated that the Trust will be rated at Band 5. The Director of Nursing and Clinical Governance will ensure that any actions and learning points arising from the report are followed up through her team.

SB

HR

1-28/14 CHIEF FINANCIAL AND COMMERCIAL OFFICER’S REPORT The Chief Finance and Commercial Officer reported that the Trust had a year-to-date surplus in January of £600k, although challenges remained in delivery of the annual plan. He stated than an OJEU had been launched for the strategic estates partnership and that there will be an open day for bidders. He advised that a residents meeting regarding the estates masterplan is taking place on the evening of Tuesday 25 February 2014. The state of the roof was discussed in the light of recent leaks and it was confirmed that that the estates team had been asked to do all that is needed to ensure the integrity of the Trust buildings. It was noted that the estates masterplan was essential in ensuring the long term sustainability of the hospital building.

1-29/14 OPERATING AND FINANCIAL PERFORMANCE REPORT The Board reviewed the previously circulated report and the Chairman asked the executive directors to verbally advise the Board of any updates since the papers were prepared. Members referred to page16 and questioned the follow up DNA rate and whether the figure should be lower. The Director of Urgent Care and Long Term Conditions confirmed that he will work with the information team to analyse the data. Members reflected on the work of the access team and the contact strategy to improve further the DNA rates. It was suggested that there should be a future seminar session on the contact strategy. The Chief Finance and Commercial Officer explained that the report is prepared manually and provided assurance that there has been investment in information software which will enable automated information to be collated, leading to improved data quality. Members were advised to notify the Chief Finance and Commercial Officer of any comments on the quantity, quality or format of the information now being provided routinely to the Board.

JHig

JR/SS

ALL

Page 6

It was agreed a seminar session will be held in May 2014 to discuss the information that is contained within the report and to consider whether more information is required. Members asked about the two week target for breast screening and whether breaches were as a result of patient choice. The Director of Urgent Care and Long Term Conditions stated that there had been situations where patients had been referred who were not in a position to undertake screening. Conversions were ongoing with local GPs to ensure that, at the point of referral, patients are fit and able to be so. The Board discussed HSMR levels which had trending upwards slightly. The Medical Director advised that this was likely to be related to issues in coding and training in this area would be reinforced to rectify this issue. The Board discussed the need for data within the report to be linked to CQC requirements and aligned with the risk register. While the Board is ultimately and collectively responsible, it was recognised that the detail behind the report should be analysed by the assurance committees. The Company Secretary will work with the chairs of the committees on reviewing their terms of reference, if required, and the chairs are to work with the Head of Information to consider what information is required to provide the appropriate levels of assurance. Members asked whether the Frail Older Persons Assessment Service (FOPAS) had impacted on ED attendances. The Executive Team advised that as FOPAS is still evolving, that any impact of the work will not be seen in the statistics at this time. The Board welcomed more the detailed information on complaints, reflecting that it provides a realistic picture of the nature of complaints. It was noted that while complaints relating to ward 6A had improved, but that they are still an outlier. The Director of Nursing and Clinical Governance advised that 6A is a challenging environment as there were a number of patients on the ward with dementia. There is a new sister on the ward and she and her team will be supported to improve the patient experience in that environment. The challenges of benchmarking complaints against other trusts was discussed, as different organisations categorise them in varying ways. It was recognised that of paramount importance is to have an open culture of reporting rather than focusing on data analysis. The Head of Workforce Performance and OD updated the Board on workforce data. He expressed disappointment that mandatory training performance had plateaued and suggested the target should be set at 90% from April. To help improve performance, each staff member will receive a print out of their training record to date and will be prompted when training is due for renewal. He confirmed that members of staff who do not currently have email or computer access will be provided with it. He also advised that a new appraisal policy had been ratified which includes sanctions for not undertaking mandatory training. He advised that sickness absence rates had increased but that a new sickness absence policy had been developed to support managers in dealing with this issue.

TN/NK

JR NEDs

Page 7

Following discussion regarding recruitment performance, the Head of Workforce Performance and OD agreed to include a graph depicting “the time from job offer to letter sent” in the next report.

MA

1-30/14 PATIENT EXPERIENCE COMMITTEE The Board noted the minutes of the Patient Experience Committee held on 10 January 2014.

1-31/14 ANY OTHER BUSINESS There was no further business to discuss.

1-32/14 DATE OF NEXT MEETING The next meeting will be held on Wednesday 19 March 2014.

1

APPENDIX 2 BOARD OF DIRECTORS

19 March 2014

BOARD OF DIRECTORS – ACTION SHEET

19 March 2014

Minute Action Outcome Due By

142/13 Resourcing of Complaints & PALS Provide an update

Complete 22 January 2014 HR

143/13 Assurance Framework Present a populated, updated version

Complete 18

December 2013

PM

185/13

South West Patient Safety Programme (Safer Care South West) – Invite Jo Howarth, Rachel Johns and Zubair Khan to a future Board meeting

See also 75/13 to consider whether consultants from

other trusts should attend the session

May 2014 HR

190/13

Performance Report Consider holding seminar session on the pathway administration project

To consider Spring 2014 JHig

1-6/14 Patient Story Set up working group to review learning and training requirements

In progress - see also 1-24/14 April 2014 HR

1-12/14 Staff Survey To update on the Trust’s response plan to the staff survey

Not yet due April 2014 MA

1-13/14

Operating and Financial Performance Report and Q3 Quality Report FFT response rates to be presented on a per ward basis

In progress April 2014 HR

1-21/14

Minutes of Previous Meeting Amend minutes of the 22 January 2014 meeting at 1-14/14 where “Assurance Committee” should state “Clinical Governance Assurance Committee”

Complete February 2014 JR

1-24/14

Patient Story Review learning and training for staff, particularly on communicating with patients and their families – update on progress to be provided 1-24/14 patient story to be filmed to enhance staff training

In progress April 2014

HR

SB

1-25/14

CEO Report Update on outcome of the recruitment process for the Director of Organisational Development and Workforce

Complete 19 March 2014 PM

2

1-25/14

CEO Report – Leadership Programme Co-ordinate NED observation of the leadership development programme

In progress March 2014 MA/MD

1-26/14

Medical Director Report Action plan to be put in place in response to Deanery/General Medical Council visit

In progress March 2014 JHo

1-27/14 Nursing and Clinical Governance Director Report Written report to be produced

Complete 19 March 2014 HR

1-27/14

Nursing and Clinical Governance Director Report Options to be considered for displaying information electronically to patients and visitors

In progress March/April 2014 HR /SB

1-27/14

Nursing and Clinical Governance Director Report Actions arising from the CQC Intelligent Monitoring Report to be followed up through the Clinical Governance team

In progress March/April 2014 HR

1-29/14

Operating and Financial Performance Report Future seminar session on the contact strategy to be organised

Not yet due June 2014 JR/SS

1-29/14

Operating and Financial Performance Report Members to notify the CFO of comments on the quantity, quality and formation of information provided and what is required by the assurance committees - Future seminar session on the topic to be held

Ongoing May 2014

All

TN/NK

1-29/14 Operating and Financial Performance Report Analyse data on DNA rates

In progress February /

March 2014

JHig

1-29/14

Operating and Financial Performance Report Review terms of reference with the chairs of the assurance committees (if required)

In progress May 2014 JR

1-29/14

Operating and Financial Performance Report Recruitment target graph to be included in the next report

Complete 19 March 2014 MA

APPENDIX 3

BOARD OF DIRECTORS 19 MARCH 2014

Report to: Board of Directors

Report from: Chief Executive Subject: Monthly update

Date: 19 March 2014

Chief Executive’s Report

Director of OD and Workforce

Following the interviews on 10th March we have a preferred candidate for this post. We are following up with this candidate and arranging a final visit to both Dorset County Hospital and YDH in the coming weeks to confirm the appointment process. Further information will be provided to the board as soon as this is concluded.

Dorset County Hospital

Board members will know that we have a very positive relationship with Dorset County Hospital (DCH) which has developed over the past two years to include joint posts in support services. We recently agreed to pilot a shared Head of Midwifery and this is going well.

Both Chairs and Chief Executives of the two organisations have agreed to develop our collaboration over the coming months to explore areas where there may be opportunities to collaborate on clinical services. There is a real opportunity to develop clinical collaborations for both organisations as a way of ensuring sustainability of local services for people in Dorset and Somerset.

The two Chairs met recently with Monitor to brief them on our collaboration and were supportive of the approach being taken. We will be developing a plan for the coming twelve months to explore options for collaboration and will ensure that the board are kept up to date on this as the discussions progress.

Update Call with Monitor

We recently took part in the regular call with Monitor to review our performance for Q3. We had a good discussion about the challenges facing the trust for the rest of this year including winter pressures and CIP. We also discussed the forward position with Monitor looking at next year’s financial plan. Monitor were positive about the progress the trust has made against our objectives for the current year and we will be providing further detail on our plans for the coming two years within our annual plan which is due for submission by the 4th April.

Nursing Technology Fund

Board members will be aware that we have been successful in our bid for £320,000 to support electronic observation recording. The trust have now procured VitalPAC as the supplier to implement this across the trust and we will begin rolling out the solution in April.

This is an important step forward on our journey to implement more technology into the clinical environment and it is a great opportunity to further improve patient safety across the trust.

SmartCare

We are currently in the final stages of the procurement process for our SmartCare EHR solution. Recently there have been demonstrations from all shortlisted vendors and a decision on the preferred supplier is due by the end of March.

Work is now underway within the trust to plan for the implementation from April.

NHS Expo

We recently attended the NHS Expo organised by NHS England in Manchester. This was an event to showcase new technologies and ideas to support the transformation of the health and care system in the future. The Expo was a good opportunity to see and hear from influential voices in healthcare policy and was also an opportunity to meet and discuss with a range of people from the NHS nationally about the work we are undertaking locally to develop our integrated care work. Feedback from many people we met was very positive about the

Paul Mears Chief Executive 19 March 2014

Appendix 4

Board of Directors 19 March 2014

Report to: Board of Directors

Report from: Medical Director Subject: Medical Director’s Report

Date: 19 March 2014

Revalidation

Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the GMC. Licensed doctors have to revalidate, usually every five years, by having regular appraisals that are based on the GMC’s core guidance for doctors. Patients can help their doctors improve their practice by providing them with regular feedback about the care they have received.

Revalidation started on 3 December 2012 and we expect to revalidate the majority of licensed doctors by March 2016.

To date there have been 29 positive recommendations, 4 deferrals due to inadequate information (1 sabbatical, 1 maternity leave, 1 new starter, 1 incomplete patient MSF data), 0 deferrals due to failure to engage.

National YDH (total) YDH (those eligible)

Consultant 75% 91% 95%

SAS 61% 86% 100%

Note: National data at end March 2013, local data at end Feb 2014

Zircadian Electronic Job Planning System

Job Plans for all Consultants and SAS doctors have now been uploaded on to the Zircadian system. A number of staff have been trained a s ‘super users’ and training for Consultants and doctors on how to view and update their e-job plans will be provided in April/May/June.

The benefits of the e-job planning system include:

• Improved job plan management, data quality, reporting, cost budgeting and productivity.

• Standardisation of job plan formats, PA calculations and language used.

• Reduced costs via time saving through eliminating hours spent building job plans and duplication of tasks.

Updating of Guide to Job Planning Process for Consultant Medical Staff

Until now Consultants have had a core allowance of 2.5 Supporting Professional Activities as part of their job plans. Moving forward an allowance of 1.5 SPAs will now be applied for each Consultant. Where there is a specific requirement to undertake additional activities that fall within the definition of SPA, the allocation may be increased by 1 SPA. Such additional activities will include, for example, extra teaching and training commitments, discreet project and service improvement work, and specific divisional or Trust responsibilities, such as appointment to clinical leadership roles.

The aim of this change is to ensure Consultants have an increased amount of time allocated to Direct Clinical Care and this will additionally provide financial benefit to the Trust (exact figures yet to be quantified).

Tim Scull Medical Director 19 March 2014

APPENDIX 5

BOARD OF DIRECTORS 19 MARCH 2014

Report to: Board of Directors

Report from: Director of Nursing and Clinical Governance Subject: Directors of Nursing’s Report

Date: 19 March 2014

Patient Safety

I am pleased to be able to report that we are on target to have a 40% reduction in hospital acquired pressure ulcers which has been a huge achievement for the whole team, and is in no small way due to the investment of £20,000 made at the beginning of the year to ensure adequate heel protection, for patients being admitted from the Emergency Department. We are currently negotiating our target for year 2014/15.

We have also managed a reduction in falls of 10% and in particular have seen a large reduction in the falls resulting in harm. There is still a great deal of work to be done around the assessment of patients and prevention of falls. Jo Howarth is leading on this with a falls prevention working group that are already putting into action some key preventive measures.

We have appointed into Jo Howarth’s team a Patient Safety Improvement Lead, Liz Jagleman who has already started 1 day a week and will be full-time in April. Liz will provide the much needed support to the patient safety projects at ward level and this has been a welcome addition to the team.

I am also pleased to report the cleanliness dashboard is showing a consistent improvement. This has demonstrated the additional work that the House Keeping team have put in to ensure our wards and departments are at the highest standard of cleanliness. This high standard must be closely linked to our achievement of lower hospital acquired infection control rates this year. We had a threshold of 9 for our C.diff trajectory and we have managed to have no more than 9, and of those only 3 would be considered attributed to our hospitals care. We have also passed our one year anniversary since our last MRSA bacteraemia which the whole nursing, medical and support teams should take credit for.

Patient Experience

We continue to receive very positive feedback from the patient experience team front of house project. This has in some way led to an increase in our PALs enquires. However, we are completely happy that this is the right thing to do to ensure that we have open timely feedback from patients and visitors. The work by this team to pre-empt concerns has also led to a reduction in our formal complaints. We look forward to the Team continuing this improvement. Linda Hann our lead for the Patient Experience Team is leading on this and is working closely with Sophie Sennett the lead for the Contact Centre, to ensure that our written and telephone communications are at the highest possible standard.

Staffing Levels

We are on target to have a system in place for publishing staffing levels at the entrance to each ward and also on the Trust website. This is an area of work that Liz Jagleman will be leading on and we are planning to have electronic display boards at the entrance to each

ward, which will not only include the staffing levels but useful information such as the sister in charge, how to contact the matron, visiting times and patient safety information, which will include falls and pressure ulcer levels. I have discussed this with both Somerset and Dorset CCG quality leads and they are pleased with the progress with have made so far.

Helen Ryan Director of Nursing and Clinical Governance 19 March 2014

APPENDIX 6

BOARD OF DIRECTORS 19 MARCH 2014

Report to: Board of Directors

Report from: Chief Finance and Commercial Officer Subject: Chief Finance and Commercial Officer’s Report

Date: 19 March 2014

Estates Update Consultation work regarding the master plan continues with council planners. A briefing meeting was held with local residents in February. The meeting was well attended (circa 30 residents, 2 councillors and the planning officer) and while residents were generally supportive, a number of clarifications were sought which are being addressed. I would expect a final draft master plan to come to the Board in the next couple of months. Cheverton demolition is due to start later this month with removal of the building interior. We are appointing a project manager to work up the costs of the multi-storey car park so that we may consider the business case. The combined heat and power (boiler) project continues and is on schedule. The upgrade of Ward 6A is almost complete with all patient facilities now done. Works to the ground floor of the Women’s hospital are nearing completion and we are working up the detailed proposals for the upgrade of the Special Care Baby Unit and Freya Ward. The restaurant is being upgraded to improve the catering offer for patients, staff and visitors. Finally, there is a continued focus on fixing visible routine maintenance issues and a programme of urgent repairs and decoration is being undertaken. Cost Improvement Programme Currently the PMO Team continues to forecast a £1.3m shortfall of cost savings programmes vs. £3.5m plan. An update will be provided at the Board meeting. The forecast assumes delays on some material programmes. While the saving in the current year will be lower than planned, the expectation is that the full year effect next year will be substantial. Financial Position At the time of writing, February results have not been finalised. An update will be provided at the Board. Staff Final appointments have been made in the information team and Natalie Kemp has been appointed as Head of Information after a competitive recruitment process. We are

shortlisting candidates for the Head of Estates role and interviews will be held in early April. We have also started the search for the Commercial Director. Strategic Estates Partner The OJEU notice was published in February and a bidders day was held on 25 February 2014 and was well attended. The deadline for PQQ submissions is 20 March, following which we expect a shortlist of bidders to enter into the competitive dialogue stage. Assuming the traditional timetable, the partnership would be operational by October 2014. Tim Newman Chief Finance and Commercial Officer 19 March 2014

Page 1

APPENDIX 7 BOARD OF DIRECTORS

19 MARCH 2014 --------------------------------------------------------------------------------------------------------------------------- Report to: Board of Directors Report from: Director of Finance Subject: Going Concern Assessment Date: 19 March 2014 --------------------------------------------------------------------------------------------------------------------------- The Board of Director’s are requested to APPROVE whether it is suitable that the Annual Accounts are prepared under the going concern basis. Introduction: The going concern assumption is a fundamental principle in the preparation of the year end accounts, under which the Trust is ordinarily viewed as continuing in the business of healthcare provision for the foreseeable future. The term ‘going concern’ refers to the basis of measurement of an organisation’s assets and liabilities and hence how they are included in the accounts. An organisation operating under the going concern principle will record these assets and liabilities as being able to be realised in the normal course of business. An organisation that does not prepare accounts under the going concern principle may have to record assets at a much lower break-up value and reclassify liabilities to being short term. The Trust must include within the Annual Report a disclosure detailing the judgement it has taken regarding going concern and this in turn will be subject to audit examination.

It is requested that the Board of Director’s CONSIDER whether they think it suitable that the accounts are prepared under the going concern basis. Going Concern Assessment: In making the going concern assessment, the Board of Director’s are required to take into account all the information available about the future prospects of the Trust, taking a forward look for a minimum of twelve months. The extent and nature of this assessment will be driven by the historical financial position of the organisation and the knowledge of the challenges it faces. The Audit Commission suggests that the assessment should consider the wider risks used by Monitor in its risk ratings: • Financial risks • Operational risks • Governance risks

Page 2

Table 1 refers to these risks, identifying key indicators for each and giving an appropriate management comment. These indicators attempt to cover a broad spectrum of areas; however the Board of Director’s may wish to discuss other areas before they are able to come to a decision. GOING CONCERN INDICATOR MANAGEMENT COMMENT

1 Financial Risk

The Trust has an excess of liabilities over assets

As at 31 December 2013 the excess of current assets over liabilities was £5,451k. The Trust plans to maintain positive net current assets for the remainder of 13/14 and all of 14/15.

2 Financial Risk

Borrowing – the Trust defaults on loan repayments or has had to restructure its debt profile.

The Trust has one loan agreement with Salix Finance Ltd under their Energy Efficiency Loan programme. At 31 December 2013 the balance outstanding stood at £128k with a repayment of £64k due in March 2014. The installation of the CHP plant during 2011 is currently achieving savings of £108k per annum.

3 Financial Risk

Creditors – normal credit terms are reduced or cash-on-delivery is demanded. Performance against the better payment policy code decreases, indicating an inability to pay our creditors.

The Trust continues to perform satisfactorily against the Public Sector Payment Policy (currently 96.98% of all invoices paid have been paid within 30 days), building good relationships with its creditors. There are sufficient assets to pay all creditors on a timely basis.

4 Financial Risk

Are any areas of concern identified when analysing the Trust’s projected performance against Monitor’s risk rating?

Under the continuity of service risk rating, which Monitor introduced from 1st October 2013, the Trust is planning to achieve a rating of ‘4’ for 13/14 and the plan for 14/15 is to achieve a rating of ‘3’.

5 Operational

Is there sufficient staff in post, with appropriate skills and experiences to ensure the delivery of the organisation’s objectives?

At 31 December 2013, total staff in post compared with funded full time equivalent establishment is 93%. This represents a total of 121 vacancies across all staff groups, which is considered to be manageable and not to represent a risk to operational delivery. There are no significant concerns relating to gaps in skill and experience that will impact upon the organisation’s key objectives.

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6 Operational

Are there pending or ongoing legal actions.

The NHS Litigation Authority (NHSLA) manages ongoing legal action relating to insured events on the Trusts behalf. There are no other material ongoing legal actions outside of the NHSLA arrangements.

7 Operational

Are there any indications that commissioners are reviewing their commissioning arrangements such that income streams and activity levels could be adversely affected?

The Trust is currently negotiating the contract for 2014/15 with commissioners. It is envisaged that the income levels for 2014/15 will remain relatively static for our Clinical Commissioning organisations.

8 Operational

Have there been any significant issues raised to the Board which could cast doubts on the assumptions made in the plans?

There have been no significant control issues raised by internal / external audit which might disqualify the plans made.

9 Operational

Has the Board been notified of any proposals, either from the DOH, NHS England or Monitor that could have implications for the future operation of the organisation?

No such notification or proposals have been received from these organisations.

10 Governance

Is there a possibility of a red governance risk rating?

In the quarter 3 2013/14 Governance Declaration to Monitor, the Trust was able to make the following declaration: “Plans in place are sufficient to ensure ongoing compliance with all existing targets as set out in the Risk Assessment Framework”.

Conclusion: It is asked that the Board of Directors consider which of the following scenarios is most appropriate for the Trust:

1. The Trust is clearly a going concern and it is appropriate for the accounts to be prepared on the going concern basis;

2. The Trust is a going concern but there are uncertainties regarding future issues which should be disclosed in the accounts to ensure the true and fair view;

3. The Trust is not a going concern and the accounts will need to be prepared on an appropriate alternative basis.

If the Board of Directors believes the accounts can be produced under a going concern basis the following disclosure will be made in the Annual Accounts: ‘After making enquiries, the Board of Directors has reasonable expectations that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts’.

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If the Board of Directors has uncertainty over the going concern basis or if it is deemed inappropriate, the Board of Directors will need to disclose the relevant circumstances and should discuss these with the external auditors. It is RECOMMENDED that the Board of Directors discuss the issues arising and declare the Trust as a going concern.

APPENDIX 8

BOARD OF DIRECTORS 19 MARCH 2014

BOARD OF DIRECTORS PAPER

TITLE: Ernst & Young Board Evaluation Report DATE: 19 March 2014 PRESENTED BY: Chairman What is this item about? This paper provides a summary of the recommendations of an external review undertaken by Ernst & Young LLP into the performance and effectiveness of the Board and its committees. Why is this item necessary? The Trust is subject to the recommendations of the NHS Foundation Trust Code of Governance (‘NHS Code’). This closely follows the UK Corporate Governance Code and encourages Boards to conduct a formal evaluation of its own performance and that of its committees and directors. What is the Board asked to do? To RECEIVE the report and to DISCUSS any actions arising, noting that an action plan will be put in place in response to the recommendations, which will include plans for the following: - enhancing communication with stakeholders, patients and staff - establishing a professional development programme for the Board of Directors - clarifying the roles, responsibilities and reporting structures of the committees of the Board

and revising their terms of reference if required 1. How does this paper improve patient care? 2. How does this paper advance the Annual Plan? 3. How does this advance our strategic objectives? The recommendations set out in the report and the resulting action plan will support the Board and its committees to improve their effectiveness, increase appropriate levels of scrutiny and ensure clear and concise decision making. This will enable the Board and its committees to ensure that the Trust’s strategic and operational objectives are being met, ultimately resulting in improved patient care. 4. Is further information available? NHS Foundation Trust Code of Governance Are there implications for the Trust? • Legally? No Financially? No Regarding Workforce? Yes - establishment of a

professional development programme for the Board of Directors

• Is this paper clear for release under Freedom of Information? Yes

Yeovil District Hospital NHS Foundation Trust (the ‘Trust’)

Board Evaluation

27 January 2014

Contents

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Contents

1. Scope and Methodology of the Review ........................................................................ 1 2. Executive Summary ........................................................................................................ 3 3. Findings of the Review ................................................................................................... 7

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1. Scope and Methodology of the Review

The review was initiated by the Trust’s Chairman, Peter Wyman, who wished to engage an external provider to facilitate a Board evaluation exercise in order to review the performance of a recently reconstituted Board. The Trust is subject to the recommendations of the NHS Foundation Trust Code of Governance (‘NHS Code’). This closely follows the UK Corporate Governance Code and encourages Boards to conduct a formal annual evaluation of its own performance and that of its committees and directors.

Methodology

The methodology for conducting the review was discussed with Peter Wyman and it was agreed that it would be conducted in four stages as follows:

Preparation and approval of questionnaire

A questionnaire was designed, aligned to the Trust and based on its constitution and the recommendations of the NHS Code. This was reviewed by Simon Chase, then secretary of the Trust and finalised based on comments received. The questions focussed around the operation, performance and dynamics of the Board as a whole and included sections on each of the Board committees. Individual director performance and contribution was not considered, as we understood that this has already been covered under a separate internal process conducted by the Trust.

Completion of questionnaire by directors and return to EY

Each of the 13 directors was provided with a soft copy of the questionnaire to complete and these were then returned to EY.

Follow-up individual interviews conducted by EY

Following receipt of the completed questionnaires, Keith Hawkins, a Senior Manager within EY’s Corporate Secretarial Services team, conducted interviews with the directors to provide verification and/or further detail on the responses given and to elicit further comment where appropriate. It should be noted that Keith was unable to undertake an interview with Jonathan Higman as an appropriate time slot could not be agreed with him. However, interviews took place with each of the other 12 directors.

Collation of results of review

The results of the review were collated and are summarised in the remaining sections of this report.

The focus of the report is, naturally, on those areas where there is a consensus view on the need for improvement. However, the report also identifies areas where a strong positive consensus response was received, but doesn’t look to analysis these in any great detail. Finally, the report identifies areas where there is a divergence of opinion between directors.

The results are presented within the report so as to provide an average grading for each of the questions. This is achieved by allocating a score of 1 to 5 for each of the responses from strongly disagree (1), through disagree (2), neutral (3), Agree (4), to strongly agree (5). Unsure/Don’t Know responses are not allocated a score and so are not included in the average. In addition to a total average score for each question, an average is also given for the executive and non-executive director responses, together with the variance between these two averages.

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Limitation of scope

As highlighted above, the review focussed on the operation of the Board as opposed to the operation and performance of the Trust in general. As such, the report does not seek to address in any way the adequacy of the wider performance, clinical or otherwise, of the Trust or of its systems of internal control and risk management.

It should also be noted that the comments recorded reflect those made by the directors of the Trust and do not represent the opinions of Ernst & Young LLP. However, where applicable, we have made reference in the report to areas of standard boardroom practice.

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2. Executive Summary

As indicated on the previous page, a score of 1 to 5 was given for each of the question responses in order that an average score could be provided. In order then to provide a framework for determining areas that could benefit from some improvement, the following ‘traffic light’ scoring system was devised:

Average score Outcome

1 ≤ 3.00 Statement not strongly or consistently supported and so some improvement may be required

> 3.00 ≤ 4.00 Statement broadly supported but not considered an area of strength

> 4.00 Statement consistently supported and so an area of strength

It is accepted that these gradings are somewhat arbitrary, but the overall gradings for each section as recorded below reveal that the overriding feeling amongst executive and non-executive directors is that the Board is functioning well and meeting the majority of its objectives. The averaged gradings do, however, mask some individual issues where improvements could be considered.

Section heading Average score

Executive Director (‘ED’) average score

Non-Executive Director (‘NED’) average score

THE BOARD

Board Composition 3.94 3.90 3.91

Board Focus & Priorities 4.06 3.94 4.19

Board Operation 4.22 4.28 4.15

Board Information 4.09 4.13 4.03

Professional Development 3.42 3.20 3.56

Stakeholder Communication 4.18 4.13 4.24

COMMITTEES

General comments 3.60 3.31 3.96

Clinical Governance Assurance Committee 3.84 3.62 3.97

Non-Clinical Risk Assurance Committee 3.85 2.96 4.16

Commercial Assurance Committee 3.79 3.37 4.07

Audit Committee 4.13 3.87 4.31

Patient Experience Committee 3.42 3.42 3.33

Remuneration Committee 3.64 3.97 3.47

THE BOARD OF TRUSTEES 3.54 3.60 3.50

3.84 3.69 3.92

The questionnaire also provided an opportunity to give an overall grading for the Board. This grading was 7.85 for the director population as a whole, with a score of 7.43 for the executive director population and 8.33 for the non-executives. The scale that directors were asked to rate the Board against was 1 – 10 (1 being very poor, 10 being excellent). The grading, therefore, reflects the general tone of the responses, which was that the Board and its committees are functioning well, but there are certainly opportunities for improvement. The higher score

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for non-executives directors on the Board summary question also reflects the generally higher grading given by non-executives throughout the questionnaire responses. It is only possible to speculate on the reasons for this. One explanation might be that the executives are living the issues discussed by the Board on a day to day basis and so feel these more acutely than the non-executive directors, who largely only see these at Board level.

There are very few areas where more than one director agreed on a question whilst more than one director disagreed, reflecting that there is a general consensus of views. Where differences of opinion do exist, they are recorded in the pages that follow.

At this point, it is worth providing some context to the findings that follow. Although these indicate some areas for improvement, the comments received reveal that the Board is generally functioning well and has made significant progress in the previous 12 months. It would appear, then, that it is incremental improvements that are required, as opposed to resolution of any fundamental issues. The findings indicated that there are open channels of communication between the executive and non-executive directors and between the directors in general and management and that challenge and debate in Board discussions is encouraged. This is a fundamental building block of a successful Board, without which it would be difficult to address issues in its operation. Finally, the governance standards by which the Board has been assessed in this review are based largely on those that operate within the private sector. The environment in which the Trust operates is complex, highly regulated and political, which is not the case in many private business sectors. This should be borne in mind when considering the overall performance of the Board.

The main findings of the review, broken down into the same headings used for the questionnaire, are detailed in the next section of this report. However, the main themes are summarised below for ease of reference.

The Board

The composition of the Board is appropriate in terms of the mix of skills represented. Consideration of diversity (both in terms of gender and ethnicity), together with addition of a wider skill base (such as clinical governance, property and IT) to be considered for future Board roles. Development of senior management to create a pipeline of future Board members and to underpin the work of the executive directors was identified as an area of current weakness, although relevant programmes are in the process of being introduced.

Meeting length and the ambitious nature of Board agendas should be explored, although it is recognised that the Board has ‘a lot on its plate’. There was some support for holding some Board meetings offsite. Broadly speaking, the Board focusses on the right issues and splits its time between them appropriately. There was, however, the feeling that there is too great a focus on the consideration of operational data at the expense of strategy and forward planning. There is also insufficient focus on risk. A number of respondents felt that the Board could be better at pushing through agreed actions.

The interaction and communication between executive directors, non-executive directors and management is an area of strength, with challenge and debate in the boardroom being encouraged and no barriers existing to non-executives seeking the further information and clarification that they require. The non-executive directors would, however, welcome greater opportunity to meet separately as a group. There is also support for scheduled offsite / strategy sessions held separately to Board meetings.

The quality of board papers and other presentations to the Board is an area that has improved greatly over the last 12 months, but there is a call for there to be no complacency on this. Reporting between meetings takes place, but informally. There is some support for greater formalisation in this regard. This could also provide a separate medium for disseminating operating data outside of Board meetings, freeing up meeting time for more discussions on strategy and risk. Alternatives to the current meeting timetable and structure could also be considered to allow greater time for discussion of the key issues facing the Trust. For example, is it set in stone that public/private meetings are held every month? Could these alternate with expanded seminar sessions?

Professional development was an area that elicited a wide range of comments, reflecting its very personal nature. There does, however, appear to be a need for greater formalisation and structure around the induction process. In addition, whilst there is clearly support from the Trust for the concept of continuing professional development for directors, there could be greater structure here.

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Stakeholder communications are an area of strength, with acknowledgment of the effort put into this particularly by the Chairman and CEO. The spread of focus around the various stakeholder groups is considered to be broadly appropriate, although patient engagement and staff communications are the areas identified where perhaps more could be done.

Committees

There is not universal acceptance of the statement that there is duplication between the four assurance committees, but there is sufficient agreement with this statement to justify the review of the committee structure, which is already underway. Rationalisation of the assurance committee structure could also encourage greater attendance of clinicians at meetings.

Much of the rejection of the statement of duplication comes from the belief that this is avoided by cross committee membership and other forms of communication between the non-executive directors. However, this appears to mask some issues with the linkage of the committees into the Board. A significant minority of directors felt that they were not sufficiently aware of the responsibilities and/or forward work plan of each of the Board’s committees. In addition, there was some support for a more formal process of committee reporting into the Board. The impression gained was that at least some of the committees were operating with a degree of separation from the Board.

Although not always appropriate, some committees appear to lack rolling agenda / forward work plans.

A question was raised over the appropriateness of the Clinical Governance Assurance Committee not having any executive director membership. It was also noted that there is duplication between this committee and the Clinical Governance Delivery Committee that reports into it. Could these committees be combined?

The creation of a Commercial Assurance Committee was praised, although with a membership of only two directors it was questioned whether this was a full Board committee as opposed to a sub-committee.

There was broad support for the idea of the Audit Committee becoming the senior assurance committee, to which the other assurance committees would report into. This would give it oversight of risk throughout the organisation, whereas it currently only focusses on financial risk.

Although very much in its infancy, there was support for the existence and purpose of the Patient Experience Committee. If not already included in the committee review process, consideration should be given to the question of whether there is any overlap with the Clinical Governance Assurance Committee that needs to be addressed.

Consideration could be given to providing a more formal structure to the holding of Remuneration Committee meetings, perhaps rolling into it responsibility for personal development and succession planning to justify a rolling calendar of meetings. Separating meetings from the Board would also support its separate identity. Connected to the last point, there was some feeling that the committee was only really ‘rubber stamping’ decisions made by the executive team, which was not considered to be satisfactory. There was also questioning of whether the Trust Chairman should chair this committee.

The Board of Trustees

It is widely accepted that this board would operate more effectively if separated from the main Board in order that it could focus purely on the appropriate use of trust funds. Such separation cannot currently take place as regulation requires trustees to be drawn from the Board membership. Any change to the structure of the Board of Trustees will, therefore, need to wait until the ongoing consultation on this matter is concluded.

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In the meantime, separating trustee meetings from Board meetings (to provide greater focus) and/or increasing the limit beyond which trustee approval is needed for management to spend trust funds, may result in greater use of available funds.

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3. Findings of the Review

THE BOARD

Board Composition

Overall Average

ED Average

NED Average

Variance

The Board is effectively organised as to the:

i) appropriate number of Directors 4.38 4.43 4.33 0.10

ii) right balance of Executive and Non-Executive Directors (‘NEDs’) 4.38 4.43 4.33 0.10

iii) right balance of skills, experiences and backgrounds of Directors 4.31 4.29 4.33 0.04

iv) diversity (including gender) of its membership 3.08 2.71 3.50 0.79

There are clear terms of reference for the Board 4.25 4.14 4.40 0.26

There is a clear division of responsibilities between the Chairman and CEO 4.31 4.43 4.17 0.26

The commitment of time given by the NEDs to their role is sufficient to enable them to effectively fulfil their duties 4.08 4.14 4.00 0.14

The Board gives regular and appropriate consideration to its make-up and to refreshing the Board 3.75 3.71 3.80 0.09

The Board considers programmes to develop senior management to provide a future pipeline for Executive Director roles 2.92 2.83 3.00 0.17

There is broad agreement that the Board has an appropriate balance in terms of the number and experience of its directors and the split between executive and non-executive directors. One respondent felt, however, that there could be more diversity of skills on the Board, noting that although the Board is well served by those with an accounting and HR background, there are no non-executive directors with a clinical governance background. The absence of property and IT specialisms on the Board was also noted, although these areas are underpinned by the use of external consultants. A wider skill base could, therefore, be considered when making future Board appointments. The low score on diversity largely reflects the fact that only 3 of the 13 directors are female (23%). It was noted that this is not representative of the wider NHS staffing population, which is predominantly female. This fact may explain why the executive director population, who operate within the NHS on a day to day basis, tended to disagree with the statement on diversity, whereas the non-executive directors where largely neutral on the subject. One respondent also noted that there was no ethnic representation on the Board. The overwhelming consensus was that diversity needed to be borne in mind for future appointments, but that the key criteria should always be finding the right person, with the right skills set. Tokenism or positive discrimination was not supported.

Although there was agreement that there is a separation of the roles of CEO and Chairman, two directors were neutral on this question. This reflected comments that the Chairman could sometimes become a little too involved in operational detail. However, this was not considered a major issue and it was acknowledged that it was at least in part a result of the Chairman having had to reconstruct the Board over a short period of time.

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The non-executive directors were felt to be committing the appropriate level of time to their roles, although one respondent noted that a further two days a month would be needed to really do it justice. This is clearly a difficult balance to achieve in what is by its nature a part time role. However, the key, as noted by one respondent, is to organise the Board and its committees in such a way as to get the most out of the limited time that is available from the non-executives. It should be noted also, that it appears that there is no expected time commitment recorded in the non-executive director appointment letters. It is standard practice for such a clause to be included so that both the Trust and the directors concerned are clear as to the expectation of the time commitment for the role.

The lower score on refreshing of the Board reflects that a number of respondents were neutral on this question as the Board had only recently been reconstituted.

The development of senior management stands out in this section as an area where further work needs to be undertaken, with only four directors agreeing with the statement and six disagreeing. We understand, however, that efforts are being made to address this, with the Trust shortly to embark on a management development programme. It was also noted that the FD had undertaken a programme to reduce the number but increase the quality of senior managers in his team. This process could be replicated in other functional areas of the Trust. Other initiatives being considered, such as leadership programmes and secondments, should also increase the quality of the senior management team. Given that a number of senior managers are female, this may also, in due course, lead to a greater level of gender diversity on the Board.

Board Focus & Priorities

Overall Average

ED Average

NED Average

Variance

The Board has:

i) the appropriate number of meetings 4.31 4.29 4.33 0.04

ii) meetings of an appropriate length 3.46 3.14 3.83 0.69

iii) meetings at appropriate locations 3.85 3.71 4.00 0.29

iv) sufficient attendance at meetings 4.69 4.57 4.83 0.26

Board meetings are sufficiently focussed on the following matters of concern to the Trust:

i) long term strategic aims and objectives 3.85 3.71 4.00 0.29

ii) quality of patient service and care 4.69 4.57 4.83 0.26

iii) performance and motivation of staff 3.69 3.71 3.67 0.04

iv) workforce planning, to meet local healthcare requirements 3.69 3.43 4.00 0.57

v) identification and mitigation of risks 3.46 3.00 4.00 1.00

vi) internal control and management information systems 3.54 3.57 3.50 0.07

vii) financial planning and budgets 4.38 4.57 4.17 0.40

viii) financial performance and efficiency 4.31 4.29 4.33 0.04

ix) operational issues and performance targets 4.31 4.29 4.33 0.04

x) leadership of the Trust 4.23 4.14 4.33 0.19

The Board has identified, prioritised and scheduled those issues that it believes should be considered on a regular basis 4.15 4.00 4.33 0.33

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Board agendas cover appropriate issues 4.23 4.00 4.50 0.50

The Board directs the senior management team to ensure that the Trust operates within any applicable laws and regulations and to the highest ethical standards 4.23 4.29 4.17 0.12

The Board monitors the Trust’s progress towards its goals and revises and alters its direction through the senior management team in light of changing circumstances 3.92 3.71 4.17 0.46

Meeting length was identified as an area to be reviewed, with three out of the seven executive directors feeling that meetings are too long. This is, of course, a difficult balancing act, as the Board has a number of matters to juggle and a constantly evolving set of issues to discuss. Sufficient time needs to be allocated to give due consideration to all of these issues. Specific concerns raised included the length of afternoon seminar sessions (raising issues of concentration and focus), ambitious agendas and ensuring that only key issues are focussed on. This is clearly an issue for the Board to debate and a difficult one to get right to ensure an appropriate balance between coverage of issues and focus on those that are most important at any given time. Suggestions for improvement put forward by respondents included:

i. introducing greater rigor in the finalisation of the agenda to sense check that topics need to be discussed by the Board as opposed to being communicated to the directors outside of the meeting,

ii. having some agenda items dealt with every other meeting, and iii. altering the agenda order so that key strategic issues are dealt with at the start of the meeting when

attendees are fresh.

The slight reticence to fully endorse the statement on meeting locations reflects that some respondents felt that the Board could benefit from occasionally holding meetings away from the hospital. This could assist with focus on the matters being discussed, as executives would be taken away from their day-to-day responsibilities and would also allow non-executives to visit some of the ‘outlier’ sites.

On Board focus areas, one or more directors disagreed that sufficient focus was being given to the following areas: strategy, performance and motivation of staff, identification and mitigation of risks and internal control. A majority of executive directors were also neutral on the subject of workforce planning. Common themes in the supporting comments are that, historically, the Board had spent a disproportionate amount of time looking at backward looking data at the expense of forward looking strategy and linking items being discussed at Board level to strategic objectives. Insufficient time had also been devoted to regular scrutiny of critical risks. It is widely acknowledged, however, that changes introduced to the format and content of meeting papers is changing the bias from backward to forward looking. It was also noted that work is underway to address the assurance framework and the consideration of risk. Comments related to staff and workforce issues suggest that the neutrality on this issue reflected the fact that these issues are lower down the priority list for the Board. One respondent noted, however, that the Board had perhaps not talked sufficiently about the shape of the workforce going forward.

The one neutral grading on ‘agendas covering appropriate issues’ reflects their deemed ambitiousness. One respondent also noted that the agenda covers all areas that it should do, but some areas can be rushed, particularly towards the end of the meeting. The one ‘disagree’ grading on the ‘Board monitoring progress towards its goals’ reflects the comment that the Board could be better at ‘closing the loop’, i.e. making progress on agreed actions. This sentiment is reflected in other comments given in the Board summary section of the questionnaire.

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Board Operation

Overall Average

ED Average

NED Average

Variance

Board practices allow:

i) meaningful participation by Directors in open and comprehensive discussions 4.54 4.57 4.50 0.07

ii) timely resolution of issues 4.08 4.29 3.83 0.46

Board meetings:

i) use Directors’ time productively 3.85 3.86 3.83 0.02

ii) allow sufficient and appropriate allocation of time for proper consideration of all agenda items 3.46 3.43 3.50 0.07

iii) incorporate sessions without Executive Directors being present 3.30 3.25 3.33 0.08

Directors are prepared for meetings 4.38 4.57 4.17 0.40

Directors are encouraged to provide their opinions and input at meetings

4.77 4.86 4.67 0.19

The quality of Executive Director participation in meetings is satisfactory, including debate and decision making, providing support and informed challenge

4.50 4.50 4.50 0

The quality of NED participation in meetings is satisfactory, including debate and decision making, providing support and informed challenge

4.31 4.43 4.17 0.26

NEDs are allowed the freedom to challenge and scrutinise the performance and recommendations of the senior management team and/or Executive Directors

4.62 4.71 4.50 0.21

Appropriate levels of ongoing dialogue are maintained between Executive and Non-Executive directors, between NEDs and the senior management team and between the Board and the Council of Governors

4.31 4.43 4.17 0.26

The Chairman runs Board meetings effectively, including consideration of all opinions and promoting constructive debate

4.50 4.43 4.60 0.17

The actual running of Board meetings is clearly an area of strength, with the overwhelming majority of directors agreeing or strongly agreeing that both executive and non-executive directors participate fully in meetings and that challenge and debate is encouraged. There is also freedom for non-executives to follow-up directly with executive directors or management on issues of concern, so there are no barriers to communication. This is a key aspect of a functioning Board and is an encouraging aspect of the survey results. There are two comments to note that may otherwise be lost in the overwhelmingly positive responses relating to director participation in meetings. Firstly, two respondents suggested that greater levels of challenge from the non-executive directors would be welcomed, although it was acknowledged that a certain reticence on their part may be a result of the relative infancy of the current Board. One respondent also referred to an element of ‘silo thinking’ in the contribution of executive directors. This may be driven in part by the climate of ever changing operational issues

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and regulatory scrutiny that exists within the NHS and also the fact that many of the executive directors are undertaking their first Board roles. Two directors were neutral on the question of preparedness for meetings, but this appears to relate to the conciseness of papers (which has improved) rather than the commitment of directors to undertake the necessary reading in order to be prepared for meetings.

The lower scores on ‘use of directors’ time’ and ‘proper consideration of all agenda items’ reflects issues noted in the previous section on the ambitiousness of the agenda, that some items can be rushed and the feeling that focus on forward looking strategic issues can sometimes be lost with too much time being taken up with consideration of statistics and data. This is, of course, a balancing act, as day to day operational issues must be considered fully. The Chairman noted that some reports are taken as read or by exception and that meetings would overrun if necessary to ensure that big decisions were not rushed. It would certainly appear, though, that a review of the agenda structure and how time is allocated between operational and strategic issues would be of benefit.

The holding of meetings between the non-executives, without the executive team being present is a key plank of good corporate governance as it encourages fresh thinking, challenge and the consideration of strategic issues without the interruption of day to day operational priorities. It is clear that such meetings do take place informally, with short sessions taking place before each Board meeting and one dinner having been held previously with the Chairman. It was also noted that other informal meetings take place between smaller groups of non-executive directors from time to time, focussing on areas of interest to their respective committees (which aids committee chairs in understanding what other Board committees are focussing on). Although there is, therefore, no shortage of dialogue between the non-executives, there was support for formalising the holding of such meetings, perhaps offsite, two or three times a year. There is also support for scheduled offsite / strategy sessions to enhance dialogue between the executive and non-executive directors and to allow the Board to focus on the forward planning agenda away from day to day operational considerations.

Board Information

Overall Average

ED Average

NED Average

Variance

Board material is distributed long enough in advance of meetings to allow adequate preparation 4.15 4.43 3.83 0.60

The Board has the information necessary to:

i) discuss agenda items with confidence 4.31 4.43 4.17 0.26

ii) monitor the performance of the senior management team and the Trust in general 4.23 4.43 4.00 0.43

Management follows up with any information requested by the Board/individual Directors in a timely fashion 4.38 4.57 4.17 0.40

Directors have access to the senior management team and other employees, where appropriate, to obtain further information on matters of relevance to the Board 4.67 4.71 4.60 0.11

There is a sufficient and timely distribution of information to Directors outside of Board meetings, e.g. reporting of KPIs and other updates 4.08 4.14 4.00 0.14

Directors are given adequate and timely information about significant issues, changes and/or problems that affect the Trust’s operations 4.00 4.29 3.67 0.62

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Reporting to the Board/Directors represents what is actually happening in the Trust 4.46 4.57 4.33 0.24

Oral presentations to the Board are:

i) of an appropriate length 3.62 3.43 3.83 0.40

ii) focused on the right issues 4.00 4.00 4.00 0

iii) not repetitive 3.62 3.43 3.83 0.40

Information included in meeting papers is:

i) accurate and concise 3.85 3.71 4.00 0.29

ii) in an appropriate format 3.85 4.00 3.67 0.33

iii) focussed on the right issues 4.00 4.00 4.00 0

Minutes of meetings are accurate and circulated to Directors in a timely manner 4.08 3.86 4.33 0.47

This is an area which is clearly moving in the right direction and has been much improved over the past 12 months. We understand that papers have been slimmed down and that the operating and financial review report has been refined and incorporates elements of reports that were previously dealt with separately, such as the HR and nursing reports. More thought is going into what information should be included in papers. The use of iPads for distribution of papers has also been a positive change. Caution was raised by some respondents, however, that complacency needs to be avoided and although progress has been made there were still room for improvement. One respondent felt that some papers were still too long, whilst another felt that the level of detail had crept up again in the last two months. Another respondent noted that he would like to see more forward looking/planning elements to papers produced by the Medical, Nursing and Elective Care Directors.

The length and quality or oral presentations is also trending in the right direction as a result of coaching and experience. Presentations had tended in the past to be too long and/or had merely been a repetition of information contained in the written reports. There are a number of possible causes for this, including that clinicians lacked previous experience of presenting to Boards. It was acknowledged also, however, that lack of clear instructions on what was expected from the presentation had contributed to the issues experienced. For example, one respondent noted that it had not been uncommon for individuals to be invited to attend and talk at a meeting without being given a clear indication as to what they should talk about. It appears that some presentations continue to overrun and it is, therefore, incumbent on the Board to ensure that those being asked to present are given clear guidance on how long they have to present and on what their presentation should focus. Such pre-planning, together with appropriate coaching where required, should ensure that the trend of improvement in this area continues. Presentation templates could also be used to enhance the consistency of content structure.

Reporting to directors between meetings and updates on significant issues affecting the Trust are both considered to be sound, but perhaps not surprisingly, the executive directors are more positive in this regard than the non-executive directors. On ‘reporting between meetings’, it is evident that this takes place informally, via e-mails and accessing information via the intranet. The Board could, however, consider whether the production and distribution of more formal reporting between meetings could lessen the time spent on operational matters in Board meetings and hence free up time for more forward looking and strategic discussions. With regard to ‘updates regarding significant issues’, one non-executive recorded a neutral grading, whilst one other disagreed with the questionnaire statement. The disagree grading resulted from specific examples where the director concerned felt that information of relevance had not been communicated in a timely manner and that matters were sometimes agreed upon before coming before the Board. The respondent recognised that there was a balance between the executive team being able to run the Trust on a day to day basis and matters being considered by the full Board (and we would note here that reference should always be made to the Board matters reserved and delegated authority schedules to determine if the matter concerned is one which does or does not require approval by the Board). Albeit that this was an isolated comment, it was felt that it should be flagged here as a potentially material matter.

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Professional Development

Overall Average

ED Average

NED Average

Variance

There are appropriate processes for the induction and orientation of new Directors 3.55 3.17 4.00 0.83

There are appropriate processes for on-going Director education 3.08 3.00 3.20 0.20

Directors are provided with sufficient information on the Trust and its policies and practices in order to undertake their responsibilities in full 3.69 3.29 4.17 0.88

Directors have sufficient information and training provided such that there are no gaps in their knowledge and understanding of the Trust and the healthcare environment in general that could impact on their performance as Directors 3.36 3.33 3.40 0.07

This is an area in which there was a wide range of opinions given, with there being two or more directors agreeing with the statement and two or more disagreeing with the statement in each of the first three questions. There is also a wide variance of opinions between executive and non-executive directors on the questions relating to induction and provision of information on the Trust, with the executives being less positive in their responses (as they are, although more marginally, in the other two questions). The comments received indicate that this variance of opinions results from induction and ongoing professional development being a very personal experience. Some directors feel that it is their responsibility more than the Trust’s to ensure that their continuing professional development is adequate. In addition, there are two main elements of induction and ongoing development that are relevant in the context of the Trust. These are NHS induction and training for those non-executives that are drawn from outside the NHS (all of the current non-executives) and Board induction and training for the executives for which this is their first Board role.

It is clear that there are resources available for directors to stay informed about industry issues, such as the Foundation Trust Network and NHS seminars, information available via the intranet and the support that directors provide each other. There is a Trust staff induction that all new joiners, including directors, attend, although this is of course not directed specifically at new Board members. It does not appear, however, that there is a formal induction process for members of the Board and consideration should be given to developing one. This is typically a task undertaken by the Company Secretary and the new incumbent of this post could use the comments received in this survey as a starting point for developing appropriate documentation. As a minimum, it is recommended that a schedule of induction materials and resources is drawn up so that new joiners can decide which items they would have use for.

With regard to ongoing professional development, the Chairman felt that informal discussions were held with directors. He may, however, wish to consider formalising an annual meeting with each director to discuss their performance and ongoing professional education requirements.

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Stakeholder Communication

Overall Average

ED Average

NED Average

Variance

The Board takes reasonable steps to ensure that it maintains effective communication with and is aware of the views and opinions of:

i) patients and patient groups 4.08 3.86 4.33 0.47

ii) Trust staff 4.08 4.00 4.17 0.17

iii) the Council of Governors 4.54 4.57 4.50 0.07

iv) members 3.91 4.00 3.75 0.25

v) commissioners 4.46 4.43 4.50 0.07

vi) the public 3.62 3.43 3.83 0.40

vii) local authorities 3.77 3.71 3.83 0.12

viii) regulators 4.46 4.43 4.50 0.07

ix) other stakeholders (including third parties with which the Trust transacts) 4.00 3.86 4.17 0.31

NEDs are updated as to the views and opinions of the above 4.08 4.14 4.00 0.14

The Board takes reasonable steps to ensure the Trust’s financial, clinical and operational performance is adequately reported to the relevant stakeholders and regulators on a timely and regular basis 4.38 4.29 4.50 0.21

The Board takes reasonable steps to ensure financial results are reported fairly and in accordance with generally accepted accounting principles 4.62 4.71 4.50 0.21

The Board takes reasonable steps to ensure the timely reporting of other developments that have a significant material impact on the operations of the Trust to the Council of Governors and other stakeholders 4.38 4.29 4.50 0.21

This is clearly an area of strength for the Trust, with more than one neutral or disagree grading being found only in response to the questions on the Board taking steps to communicate effectively with patients and patient groups (two neutral gradings), trust staff (two neutral gradings), members (two neutral gradings), the public (one disagree grading and four neutral), local authorities (one disagree grading and three neutral) and other stakeholders (two neutral gradings) . The results indicate broad agreement in this area between executive and non-executive directors, with little variance between their gradings. The comments received also make it clear that this is an area taken very seriously by the Chairman and CEO.

Taking each of the groups mentioned in turn, it is worth highlighting the following comments:

i. patients and patient groups – could do more with regard to patient engagement. Previous engagement was based on too narrow a demographic. Now setting up patient councils and associations to engage with a wider group of patients

ii. trust staff – need to take more opportunities to get into the organisation and ‘take the temperature’ of staff (this is backed up by recent staff surveys which suggests that staff feel that they don’t receive

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sufficient internal communications). Appointment of new Director of Communications is assisting with this. Strain currently taken by Chairman in this area, so could be an area for non-executive directors to get more involved with

iii. members and the public – some neutral comments reflect belief that lower priority than some other stakeholders. Relations with wider public are, however, getting a higher profile with new Director of Communications. Public engagement could be enhanced by allowing questions to be asked in the open section of Board meetings or giving the public the opportunity to post questions in advance of meetings

iv. local authorities – lower priority and current engagement adequate, e.g. probably represented through communication with Council of Governors

v. other stakeholders – are invited to attend some seminar sessions where appropriate. One respondent noted that the chairman and CEO are good at keeping regulators and other stakeholders not listed in the questionnaire, such as MPs and Ministers, informed.

COMMITTEES

General comments

Overall Average

ED Average

NED Average

Variance

The Board has established the appropriate committees to undertake the mandate of the Board 3.67 3.29 4.20 0.91

The responsibilities delegated to Board Committees are appropriate and clear 3.54 3.29 3.83 0.54

Excessive duplication between the Board and its Committees is avoided 3.85 3.57 4.17 0.60

The four assurance committees (reviewed in this section) operate together effectively and efficiently without material duplication or gaps in responsibilities 3.15 2.71 3.67 0.96

The information provided to the Board by its committees is timely and complete 3.85 3.86 3.83 0.03

The Directors are aware of the function and responsibilities of each of the Trust’s Board Committees 3.46 2.86 4.17 1.31

The terms of reference of the Board Committees are reviewed periodically to ensure that they remain fit for purpose 3.69 3.57 3.83 0.26

Specific comments on each of the committees is given in the following pages. Views on the function and effectiveness of the committee structure are clouded by two elements at play. Firstly, there is awareness that the structure is being looked at as part of a separate exercise, which has tended to lead to neutral gradings. Secondly, some of the committees have only recently been formed, which again tends to lead to naturally guarded comments. The figures above reveal that there is a range of opinions on the operation of the committees, with the executive directors being more critical of the committee structure than the non-executive directors. The range of opinions also makes drawing conclusions from the responses difficult as there is no real consensus on the way forward, other than a general acceptance that the current review of the structure is an appropriate and worthwhile exercise. Also, the responses for the questions relating to the appropriateness of the matters delegated to the committees as a whole suggest that this is not the issue. Rather, it is in the interaction between the committees and their respective responsibilities where there is concern; i.e. the Board is delegating the right things to the committees but the spread of responsibilities between committees is not always appropriate and aligned. Examples of the range of opinions can be seen in the questions relating to duplication between the four assurance committees and awareness of the function of each of the Board committees. On the

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former question, four directors (all executive) felt that there was duplication, whilst four directors felt that there was not. On the latter question, three directors (again, all executive) felt that directors were not aware, whilst seven said that they were.

Even with the range of views given, it is possible to make the following observations from the comments received:

i. The two areas identified by the response gradings as the main areas for improvement are duplication between the assurance committees and awareness of the work of committees by directors who do not sit on the committees concerned

ii. Accepting that there is overlap between the four assurance committees, suggestions for improvement include combining the Non-Clinical Risk Assurance committee with the Clinical Governance Assurance Committee or combining the Non-Clinical Risk Assurance Committee with the Audit Committee. Another option is to give the Audit Committee some form of oversight of the activities of the other assurance committees to ensure that no issues are missed

iii. A number of comments suggest that duplication between assurance committees is avoided through informal means, such as non-executive directors having cross membership of committees and communicating regularly with each other. This, together with the minutes of each committee meeting being tabled at Board meetings and committee chairmen being given the opportunity to report on their committee’s activities at Board meetings, is the means through which awareness of committee activity is made available. There is some support, however, for creating a more formal process for reporting from the committees. One suggestion, for example, is for quarterly presentations from the committees to the Board. It should be noted here that committees are bodies of the Board and as such should not operate in isolation of the Board. It is important, therefore, that the Board as a whole is fully cognisant of the activities of each of its committees and is given the opportunity, where appropriate under the terms of reference of the committee concerned, to consider the recommendations made by such committee

iv. A significant minority of directors stated that they were not fully aware of the responsibilities and/or forward work plan of each of the Board committees. An initial step for quarterly presentations to the Board, after revision of the committee structure, could be for each committee chairman to present the new terms of reference of the committee to the Board and report on its proposed areas of focus for the coming 12 months

v. One comment in support of the rationalisation of the assurance committee structure is that it would encourage greater attendance at meetings by clinicians. It was felt that a smaller number of assurance committees with rolling agendas of specific matters of focus would allow clinicians to attend meetings of particular relevance to them. It was noted that multiple meetings, many of which did not cover their particular areas of specialism, did not encourage attendance.

Clinical Governance Assurance Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 4.11 3.67 4.33 0.66

The Committee is effective in carrying out its mandate 3.89 3.33 4.17 0.84

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 4.00 4.00 4.00 0

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues

3.33 3.00

3.50 0.50

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The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 3.00 3.00 3.00 0

Meetings are sufficiently focussed on the following matters of concern to the Committee:  

i) Identifying risks and control gaps in the Trust’s framework of clinical governance and reviewing progress in resolving these 3.50 3.33 3.60 0.27

ii) oversight of clinical aspects of outsourced functions 3.13 3.00 3.20 0.20

iii) monitoring regulatory updates issued by the Care Quality Commission and their impact on the Trust 4.17 4.00 4.33 0.33

The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 3.89 3.67 4.00 0.33

The Committee allocates the right amount of time for its work 4.29 4.00 4.50 0.50

The Committee has available to it the necessary resources and information to fulfil its mandate 4.13 4.00 4.20 0.20

Committee meetings are productive 3.88 3.67 4.00 0.33

The Committee is able to pursue and successfully resolve any issues that it identifies 3.67 3.33 3.83 0.50

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 4.50 4.33 4.67 0.34

Minutes are circulated to members in a timely manner 4.14 4.00 4.25 0.25

As referenced in the section on committees in general, the function of this committee is being reviewed as part of the review of the committee structure and the assurance committee structure in particular. Again, it can be seen from the gradings that the executive directors are more critical of the role and operation of this committee than the non-executive directors. Conclusions are difficult to draw from the gradings as a significant minority of directors did not give an opinion on the questions posed, as they do not attend the meetings concerned. This in itself supports the perception we have that the directors as a whole are not fully aware of the function of all the committees, perhaps reflecting the lack of formal reporting to the Board. As with some of the other committees, there is some support for introducing a rolling agenda or forward plan for committee meetings, so that there is comfort that governance in each clinical area will be considered at appropriate regular intervals. In this regard, the chairman of this committee noted that a draft 12 month framework was in the process of being prepared.

Another comment worth noting here is that there is duplication between this committee and the Clinical Governance Delivery Committee that reports into it (not reviewed as part of this survey). One suggestion is that the activities of the Delivery Committee be rolled up into its parent committee to remove this duplication.

One director raised a specific concern about the membership of the committee consisting solely of non-executive directors. It was felt that this was at odds with the joint executive/non-executive Board.

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Non-Clinical Risk Assurance Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 4.20 4.00 4.25 0.25

The Committee is effective in carrying out its mandate 3.67 2.50 4.25 1.75

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 4.17 4.00 4.25 0.25

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues 3.67 3.00 4.00 1.00

The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 3.50 0 3.50 3.50

Meetings are sufficiently focussed on the following matters of concern to the Committee:

i) identifying risks and control gaps in the Trust’s framework of non-clinical governance and reviewing progress in resolving these 3.50 2.50 4.00 1.50

ii) reviewing actions of sub-committees to ensure strategic overview of non-clinical risk management 3.50 2.50 4.00 1.50

The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 4.17 3.50 4.50 1.00

The Committee allocates the right amount of time for its work 3.83 3.00 4.25 1.25

The Committee has available to it the necessary resources and information to fulfil its mandate 3.83 3.00 4.25 1.25

Committee meetings are productive 3.83 3.00 4.25 1.25

The Committee is able to pursue and successfully resolve any issues that it identifies 4.00 3.50 4.25 0.75

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 3.83 3.00 4.25 1.25

Minutes are circulated to members in a timely manner 4.17 4.00 4.25 0.25

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As with the Clinical Governance Assurance Committee, executive directors are more critical of the role and operation of the Non-Clinical Risk Assurance Committee than the non-executive directors, but conclusions are difficult to draw from the gradings as a majority of directors did not give an opinion on the questions posed. The general view, though, was that there were areas of overlap between this committee and the Clinical Governance Assurance Committee, but some felt that the duplication was managed by cross membership. Another respondent felt that although there was overlap, there were sufficient subjects to be discussed to justify there being separate committees. Opinion was split on whether there was a rolling agenda/annual work programme for the committee. Added to this the comment from one respondent that he felt he needed a better understanding of the areas of overlap and interaction with the Clinical Governance Assurance Committee, suggests that the areas of focus for the committee going forward are not entirely clear.

Commercial Assurance Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 4.00 3.00 4.50 1.50

The Committee is effective in carrying out its mandate 3.50 3.00 3.75 0.75

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 3.80 3.50 4.00 0.50

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues 3.80 3.50 4.00 0.50

The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 4.00 3.00 5.00 2.00

Meetings are sufficiently focussed on the following matters of concern to the Committee:

i) reviewing commercial opportunities for and threats to the Trust 4.00 4.00 4.00 0

ii) ensuring that satisfactory due diligence is undertaken on strategic contracts and strategic contract renewal 3.80 3.50 4.00 0.50

iii) ensuring that the Trust’s commercial activities deliver improved patient care and benefits 4.00 3.50 4.33 0.83

The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 3.67 3.50 3.75 0.25

The Committee allocates the right amount of time for its work 3.80 3.50 4.00 0.50

The Committee has available to it the necessary resources and information to fulfil its mandate 3.60 3.50 3.67 0.17

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Committee meetings are productive

3.60 3.00 4.00 1.00

The Committee is able to pursue and successfully resolve any issues that it identifies 3.60 3.00 4.00 1.00

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 3.80 3.50 4.00 0.50

Minutes are circulated to members in a timely manner 3.83 3.50 40 0.50

This is a new committee with limited membership and, accordingly, the majority of directors did not provide gradings or comments. Comments received did, however, indicate that the existence of a separate committee to focus on the Trust’s commercial operations was valid. One respondent felt, though, that with only two directors on the committee, it was more of a sub-committee than a full assurance committee. Another respondent noted that the meetings had been good so far but felt that the committee’s terms of reference should be reviewed. The concern raised was with regard to the respective roles of the committee and management in commercial matters. It was felt, for example, that commercial strategy should be set by management rather than the committee.

Audit Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 4.00 3.50 4.33 0.83

The Committee is effective in carrying out its mandate 4.20 4.00 4.33 0.33

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 4.20 4.00 4.33 0.33

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues 4.20 4.00 4.33 0.33

The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 4.00 4.00 4.00 0

Meetings are sufficiently focussed on the following matters of concern to the Committee:  

i) the operation of the internal audit function 4.40 4.50 4.33 0.17

ii) monitoring the work of the external auditors 4.20 4.00 4.33 0.33

iii) reviewing all aspects of the Trust’s financial reporting

4.17 4.00 4.25 0.25

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The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 4.20 4.00 4.33 0.33

The Committee allocates the right amount of time for its work 4.20 4.00 4.33 0.33

The Committee has available to it the necessary resources and information to fulfil its mandate 4.00 3.50 4.33 0.83

Committee meetings are productive 4.00 3.50 4.33 0.83

The Committee is able to pursue and successfully resolve any issues that it identifies 4.20 4.00 4.33 0.33

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 4.00 3.50 4.50 1.00

Minutes are circulated to members in a timely manner 4.00 3.50 4.25 0.75

The gradings reveal that there are no particular areas of concern with this committee. However, the majority of directors did not provide gradings or constructive comments, which makes drawing conclusions from the survey responses difficult. Two respondents question the committee’s focus on financial risk, as opposed to risk to the Trust as a whole. This is clearly an area to explore in conjunction with the wider review of the interaction of the assurance committees. Should, for example, the Audit Committee be the senior assurance committee into which the other assurance committees report? There is support for this concept from a number of respondents. For example, one respondent felt that the committee should have a greater focus on overall risk through a regular review of the Trust risk register. On the question of a rolling agenda, it was not felt that there was currently a need for this as most of the committee’s activities are driven by the statutory financial calendar. However, more structure might be needed if the role of the Audit Committee is more closely aligned with those of the other assurance committees.

Patient Experience Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 3.75 3.50 4.00 0.50

The Committee is effective in carrying out its mandate 3.25 3.00 3.50 0.50

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 3.00 3.00 0 3.00

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues 3.00 3.00 0 3.00

The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 2.00 2.00 0 2.00

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Meetings are sufficiently focussed on the following matters of concern to the Committee:

i) reviewing information on patient experience and the arrangements in place to understand and improve this 3.00 3.00 3.00 0

ii) identifying gaps in control and assurance with regard to patient care and reviewing progress in addressing them 3.00 3.00 0 3.00

The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 3.75 4.00 3.50 0.50

The Committee allocates the right amount of time for its work 3.50 3.50 0 3.50

The Committee has available to it the necessary resources and information to fulfil its mandate 3.33 3.50 3.00 0.50

Committee meetings are productive 3.00 3.00 3.00 0

The Committee is able to pursue and successfully resolve any issues that it identifies 3.00 3.00 3.00 0

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 3.33 3.50 3.00 0.50

Minutes are circulated to members in a timely manner 3.67 3.50 4.00 0.50

It is very difficult to draw any conclusions from the responses relating to this committee, as only four respondents offered gradings to the questions posed and many of these were neutral on the basis that they had insufficient experience of the committee to give a reasoned response. One respondent noted that he did not even know the committee existed, which brings into question whether this is truly speaking a committee of the Board as opposed to a working group of management into which some directors input. It is worth noting here, though, that only one meeting of the committee has been held to date, so it is very much in its infancy. There was support in the comments for the existence and purpose of the committee. It was felt that it brought together all the meetings which have an interest in the patient experience and allowed a central focus on patient issues. One respondent questioned what overlap there was with the Clinical Governance Assurance Committee. Accordingly, it is suggested that this be considered as part of the ongoing review of the assurance committees (if this is not already the case).

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Remuneration Committee

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Committee are appropriate 3.89 4.00 3.83 0.17

The Committee is effective in carrying out its mandate 3.89 4.00 3.83 0.17

Members of the Committee receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 3.44 4.00 3.17 0.83

Information presented to the Committee is accurate, of an appropriate length and focussed on the right issues 3.38 3.33 3.40 0.07

The Committee has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting the Committee’s mandate 2.57 2.67 2.50 0.17

Meetings are sufficiently focussed on the following matters of concern to the Committee:  

i) making recommendations with regard to appropriate remuneration and terms of service for the CEO, Executive Directors and certain other senior employees 4.00 4.50 3.83 0.67

ii) ensuring that an appropriate process is in place for the annual appraisal of and setting of objectives for the CEO and other Executive Directors 3.83 4.00 3.75 0.25

iii) reviewing staff opinion surveys before these are submitted to the Board of Directors 2.33 2.00 2.40 0.40

The composition of the Committee is appropriate (i.e. it has the appropriate mix of skills and experience to fulfil its responsibilities) 4.25 4.67 4.00 0.67

The Committee allocates the right amount of time for its work 3.75 4.33 3.40 0.93

The Committee has available to it the necessary resources and information to fulfil its mandate 3.88 4.67 3.40 1.27

Committee meetings are productive 3.78 4.00 3.67 0.33

The Committee is able to pursue and successfully resolve any issues that it identifies 3.78 4.00 3.67 0.33

The Committee chairman runs meetings effectively, including consideration of all opinions and promoting constructive debate 4.22 4.67 4.00 0.67

Minutes are circulated to members in a timely manner 3.67 4.67 3.17 1.50

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This committee is not currently playing a leading role in supporting the Board as public sector pay remains mostly static. As such, the committee does not currently sit separately and is convened to follow Board meetings as and when an issue arises which requires its attention. The negative response on the committee having a rolling agenda, therefore, largely reflects the fact that the majority of respondents felt that this was not needed. There was some support, however, for a fixed schedule of two or three meetings a year to consider recurring topics such as annual performance reviews. Other topics that could be rolled into this committee could be consideration of personal development and succession planning (both for the Board and senior management). A formal meeting schedule might also allow the committee to be separated from Board meetings. This would provide more time for meetings to fully discuss the issues it is considering, as opposed to these being possibly rushed at the end of Board meetings when attendees are running out of steam.

There is some dissatisfaction with the operation of the committee, particularly from the non-executive directors. The feeling is that the meetings are called at short notice with little opportunity to explore the background of the issues to be discussed. There was also the suggestion that the committee sometimes ‘rubber-stamps’ decisions already made by the executive team, which is unsatisfactory. Finally, there was questioning by some respondents of whether the Chairman of the Trust should chair the committee, with one suggesting that permitting another non-executive director to chair the committee would facilitate a more effective separation of the committee from the executive team.

One final point to note on this committee is that it does not currently review staff opinions before these are presented to the Board. Accordingly, this item should be removed from the terms of reference unless it is considered appropriate for the committee to retain this responsibility under a revised wider scope of activity.

THE BOARD OF TRUSTEES

Overall Average

ED Average

NED Average

Variance

The terms of reference of the Board of Trustees are appropriate 3.88 3.67 4.00 0.33

The Board of Trustees is effective in carrying out its mandate 3.78 3.75 3.80 0.05

Members of the Board of Trustees receive adequate material in advance of meetings, in sufficient time and detail to permit members to effectively consider issues to be dealt with 3.44 4.00 3.00 1.00

Information presented to the Board of Trustees is accurate, of an appropriate length and focussed on the right issues 3.56 4.00 3.20 0.80

The Board of Trustees has established a full year’s rolling agenda of matters to be considered, which is appropriate in supporting its mandate 2.78 2.25 3.20 0.95

Meetings are sufficiently focussed on the following matters of concern to the Board of Trustees:

i) consideration of updates on Trust Fund balances 3.44 3.25 3.60 0.35

ii) ensuring that the Trust Fund is managed in accordance with the terms of reference and delegated powers that apply to it 3.86 4.00 3.80 0.20

iii) reviewing applications for expenditure from Trust Funds exceeding £5,000 3.89 4.00 3.80 0.20

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The Board of Trustees allocates the right amount of time for its work 3.11 3.00 3.20 0.20

The Board of Trustees has available to it the necessary resources and information to fulfil its mandate 3.50 3.75 3.33 0.42

Board of Trustees meetings are productive 3.30 3.50 3.17 0.33

The Board of Trustees is able to pursue and successfully resolve any issues that it identifies 3.50 3.50 3.50 0

The chairman of the Board of Trustees runs meetings effectively, including consideration of all opinions and promoting constructive debate 3.70 3.75 3.67 0.08

Minutes are circulated to members in a timely manner 3.80 4.00 3.67 0.33

There is widespread agreement amongst both the executive and non-executive directors that the Board of Trustees is not operating effectively at present. Current legislation requires that the trustees are drawn from the membership of the Board. This position is currently under review by regulators. The chairman is firmly of the view that a Board of Trustees separated from the Board would operate more effectively as it would have the time and focus to make effective use of funds. Currently, this time and focus is lacking as it is a secondary consideration for the Board relative to the running of the hospital. The outcome of this lack of focus is that available funds are not being spent, for example to improve the hospital environment for patients and staff. A Board of Trustees separated from the main Board, should legislation ultimately allow this, is supported by an overwhelming majority of directors. As with the Remuneration Committee, there is frustration from some respondents at the meetings being rushed as a result of these being held at the end of Board meetings.

Assuming that the status quo needs to be maintained at least for the immediate future, a number of suggestions were put forward for improving the functioning of the committee as follows:

i. A refresher on the role and purpose of the trust and of the roles and responsibilities of the trustees. The latter would help meeting attendees frame the decisions to be made. Some respondents were also unclear as to the membership of the Board of Trustees

ii. Separate meetings from that of the Board to allow greater focus. It should be noted, however, that some respondents were comfortable with the current timing of meetings

iii. Smaller membership to promote more effective decision making. Raising the limit at which executives need trustee approval to spend funds (currently £5,000) would also, it was hoped, raise the level of funds being put to use.

Operating & Financial

Performance Overview

January 2014 – Month 10

2

Section Title Page

CONTENTS

1 Operational Performance

2 Financial Performance Summary

3 Appendix - Financial Detail

Mortality

3

HSMR in December 13 was 89.6 (9.1 higher than December 12).

Actual number of deaths in February 14 was 48, (Feb 13 52)

0

20

40

60

80

100

120

140

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Hospital Standardised Mortality Ratio (HSMR)

6 month moving average

0

10

20

30

40

50

60

70

80

90

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Actual number of deaths

6 month moving average

RTT [1/2]

4

In January 2014 94.9% (target 90%) of admitted patients and 96.9% (target 95%) of non-admitted patients started consultant-led treatment within 18 weeks of referral.

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

RTT completed pathways - 18 week - admitted

6 month moving average RTT target

75%

80%

85%

90%

95%

100%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

RTT completed pathways - 18 week - non admitted

6 month moving average RTT target

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

RTT incompleted pathways - 18 week - admitted

6 month moving average RTT target

75%

80%

85%

90%

95%

100%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

RTT incompleted pathways - 18 week - non admitted

6 month moving average RTT target

RTT [2/2]

5

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

RTT incomplete pathways

RTT incomplete pathways

0

50

100

150

200

250

300

350

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

RTT incomplete pathways > 18 weeks

RTT incomplete pathways > 18 weeks

Patients that delay treatment through choice are counted as an incomplete pathways until they receive their treatment, or it is decided that they don’t need treatment. Patient choice only changes things once they have received an admitted treatment (non-admitted stops aren’t adjusted for patient choice)

0

20

40

60

80

100

120

140

160

19

we

eks

20

we

eks

21

we

eks

22

we

eks

23

we

eks

24

we

eks

25

we

eks

26

+ w

eeks

RTT Incomplete pathways - Aging

Non Admitted Admitted

0

50

100

150

200

250

300

350

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

RTT incomplete pathways

RTT incomplete pathways > 18 weeks

123 admitted patients and 138 non-admitted patients were waiting longer than 18 weeks as at the end of January 2014, 83 of these patients were waiting over 26 weeks. Only Neurology had more than the 7% target of patients waiting over 18 weeks, at 14.2%, though when only admitted pathways are considered, General Surgery, Orthopaedics, ENT, Ophthalmology, Oral Surgery, and Gynaecology all exceed this target.

Waiting lists

6

0

500

1000

1500

2000

2500

3000

3500

4000

4500A

pr-

10

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Waiting Lists

OP Waiting List Size IP/DC Waiting List Size

At the end of February 14, the inpatient and day case waiting list has increased by 1% compared to January 14 (1429), +2.4% vs prior year. The outpatient waiting list in on a increasing trend and reached 3983 (+51.9% vs prior year)

Numbers above are live waiting list patients, they include patients that have chosen to delay their treatment. Currently it is difficult to identify these patients due to the booking methods i.e. this information is only in the form of a “comment”. Previously we used a separate waiting list code, which enabled us to exclude these patients from our reports. This was stopped in order to increase visibility of all patients. The above numbers do not include planned or suspended patients i.e. medically unfit or regular future bookings i.e. five year endoscopies.

Outpatients waiting list - patients that have been referred but not yet seen.Inpatients/Day cases – patients that have been referred for elective admissions but not yet treated.

Day Case Admissions

7

Day case admissions (1,314) were 83% of total elective admissions in February 2014. This mix has remained stable between 80% and 86% since April 2010.

60% of all day cases this financial year to date were in 4 specialities –Gastroenterology (18.0%), General Surgery (17.7%), Oncology (16.1%) and Ophthalmology (8.2%).

0

500

1,000

1,500

2,000

2,500

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Day Case admissions

Total Elective admissions Day Case admissions

0

500

1000

1500

2000

2500

3000

Ga

stro

en

tero

logy

Ge

ne

ral S

urg

ery

Me

dic

al O

nco

logy

Op

hth

alm

olo

gy

Ort

ho

pae

dic

s

Ha

emat

olo

gy

Gyn

aec

olo

gy

De

rma

tolo

gy

Ge

ne

ral M

ed

icin

e

Ora

l Su

rge

ry

Pla

stic

Su

rger

y

Uro

log

y

Rh

eu

mat

olo

gy

Neu

rolo

gy

EN

T

Car

e o

f th

e E

lder

ly

Car

dio

log

y

Pae

dia

tric

s

Th

ora

cic

Me

dic

ine

YTD day cases April 2013 - January 2014

A&E [1/2]

8

In February 95.3% (target 95%) of patients were seen and discharged within 4 hours from A&E. The 6 months rolling average trend has started to increase after a decrease in 4 hour breaches.

Average A&E overall attendances are concurrent with November and December. Ambulance arrivals averaging 42 YTD.

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

A&E 4 hour performance - All Attendances

6 month moving average

100

110

120

130

140

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Avg A&E attendance per day

0

20

40

60A

pr-

12

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Avg A&E ambulance arrivals per day

Day Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

Monday 142 132 145 146 125 145 129 128 135 117 130

Tuesday 122 124 121 132 127 119 113 117 114 107 119

Wednesday 119 118 127 129 120 128 120 115 125 116 115

Thursday 125 119 121 135 123 121 117 115 123 115 123

Friday 116 120 117 121 126 111 115 116 119 107 112

Saturday 125 127 131 136 127 123 123 121 127 108 119

Sunday 143 126 136 138 146 134 128 135 133 108 127

Grand Total 128 123 128 134 128 127 120 121 125 111 121

A&E [2/2]

9

A&E activity increased by 5% in 12/13 vs 11/12, mainly due to spikes in June (+7.2%), August (8.8%), September (7.3%) and December (+13.1%).

February 14 activity is down compared to January by -2.1% (3,380 vs. 3,450) and lower than previous year by -4.8%.

YTD, activity is down on last year by -1.3%.

3000

3200

3400

3600

3800

4000

4200

4400

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

A&E Activity

6 month moving average

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

% increase/decrease vs LY

80

90

100

110

120

130

140

150

160

01/1

2/2

013

15/1

2/2

013

29/1

2/2

013

12/0

1/2

014

26/0

1/2

014

09/0

2/2

014

23/0

2/2

014

A&E Attendances by day

Ambulance targets

10

We have achieved the 30 minute handover target (98%) for the last 10 months running.

YTD fines total £31,800 , mainly due to spike in April of £16,800, the same period last year fines were £31,490.

NOTES:Ambulance fines for over 30mins only began in April 2011Imposed Fines have changed each year but have always been based on breaching 30 mins or more

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

£0£2,000£4,000£6,000£8,000

£10,000£12,000£14,000£16,000£18,000

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Ambulance handovers - Fines Ambulance Handover <30mins

Cancer 2 week waits

11

In January 2014 we failed to achieve the 93% target for 2 Week Waits in suspected cancers for the first time since October 2011, achieving only 90.8%. All breaches for 2 Week Waits were due to patient choice.

The 2 week wait target for exhibited breast referrals was met comfortably at 96.5%.

0

10

20

30

40

50

60

70

80

0

100

200

300

400

500

600

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14 no

. ref

erra

ls -

bre

ast

sym

pto

ns

no

. ref

erra

ls -

susp

ecte

d c

an

cer

Number of referrals

2 week wait suspected cancer 2 week wait exhibited breast symptoms

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

2 week cancer targets

2 wk wait suspected cancer 2 wk wait Breast

Cancer 31 day and 62 day targets

12

We continue to achieve the target of delivering treatment within 31 days of the decision to treat.

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

31 day treatment first

Achievement % Target % 6 month rolling %

85.0%

87.0%

89.0%

91.0%

93.0%

95.0%

97.0%

99.0%

101.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

31 day treatment first subsequent drugs

Monthly data Target % 6 month rolling %

75.0%77.0%79.0%81.0%83.0%85.0%87.0%89.0%91.0%93.0%95.0%97.0%99.0%

101.0%103.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

31 day treatment subsequent surgery

Monthly data Target % 6 month rolling %

0

1

2

3

4

5

6

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

62 day treatment screening

Achievement % Target % Number of referrals

0

10

20

30

40

50

60

70

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

62 day treatment standard

Achievement % Target % Number of referrals

0

5

10

15

20

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

62 day treatment upgrades

Achievement % Target % Number of referrals

We are currently achieving all 62 day targets.

DNA - Outpatients

13

In January 14 we had a DNA ratio of 8.1%, remaining steady in comparison to December 13.

In February 14, 176 patients did not attend their first appointment, 601 did not attend their follow up appointment.

£0

£20

£40

£60

£80

£100

£120

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Ap

r-1

0Ju

n-1

0A

ug-

10

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1Ju

n-1

1A

ug-

11

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Tho

usa

nd

s

DNA rate

Overall DNA rate First DNA rate

Follow up DNA rate DNA Cost

DNA rate has been excluded in February as data not available

0

0.2

0.4

0.6

0.8

1

1.2

0

200

400

600

800

1000

1200

1400

1600

T&

O

Pae

dia

tric

s

Op

hth

alm

olo

gy

Ge

ne

ral S

urg

ery

De

rma

tolo

gy

Ob

stet

rics

/Mid

wif

e

EN

T

Ge

ne

ral M

ed

icin

e

Gyn

aec

olo

gy

Ga

stro

en

tero

logy

Ort

ho

do

nti

cs

Car

dio

log

y

Uro

log

y

Rh

eu

mat

olo

gy

OM

F

Th

ora

cic

Me

dic

ine

Neu

rolo

gy

He

pat

olo

gy

On

colo

gy

Ha

emat

olo

gy

Pla

stic

Su

rger

y

Car

e o

f th

e E

lder

ly

Re

hab

ilita

tio

n

An

aeth

eti

cs

Apr 2013 - Feb 2014 DNAs by speciality

DNAs Rate

First to follow up

14

1st to follow up ratio in January 2014 remains steady at 1:2.1, matching the 6 month rolling average 1st to follow-up ratio.

Orthodontics and Ophthalmology have the highest first to follow up ratios

- 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0

0100020003000400050006000700080009000

10000

Ort

ho

pae

dics

Op

htha

lmol

ogy

Gen

eral

Sur

gery

ENT

Uro

logy

Ort

ho

dont

ics

Ora

l Sur

gery

Pla

stic

Su

rge

ry

An

aes/

Pai

n

rate

att

end

an

ces

Apr 2013 - Jan 2014 1st to follow up ratio by speciality

1st Follow Up Rate

1.5

1.7

1.9

2.1

2.3

2.5

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

New:Follow ratio

6 month moving average

Stroke

15

In January we achieved the 80% target for the sixth month in a row for stroke patients spending >90% of their time on the stroke ward. 68% of patients were admitted directly to the stroke ward within 4 hours, this is below target of 90%.

86% of high risk Transient Ischaemic Attack (TIA) patients were treated within 24 hours. 35% of patients that were subsequently diagnosed with a stroke had a CT scan within 1 hour of arrival. Please note that the underlying data includes all patients, whether a CT scan is needed within 1 hour or not, therefore our achievement maybe understated

0%

20%

40%

60%

80%

100%

120%

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Stroke Unit Stay >90%

Stroke Unit Stay >90% Target

0%

20%

40%

60%

80%

100%

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-12

Jan

-13

Feb

-13

Ma

r-13

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

4Hr Direct Admission

4Hr Direct Admission Target

0%

20%

40%

60%

80%

100%

120%

Apr

-10

Jul-1

0

Oct

-10

Jan-

11

Apr

-11

Jul-1

1

Oct

-11

Jan-

12

Apr

-12

Jul-1

2

Oct

-12

Jan-

13

Apr

-13

Jul-1

3

Oct

-13

Jan-

14

High Risk TIA <24Hrs

0%

10%

20%

30%

40%

50%

60%

Apr

-12

Jun-

12

Aug

-12

Oct

-12

Dec

-12

Feb-

13

Apr

-13

Jun-

13

Aug

-13

Oct

-13

Dec

-13

Achievement 1HrCTScan

Discharges

16

39.1% of inpatients had an EDD (estimated discharge date) recorded, of these only 37.8% were actually discharged by the estimated due date.

Top 4 largest specialities (% discharged by EDD) - General medicine 29%, Paediatrics 41%, General Surgery 49%, Orthopaedics 43%

0

500

1000

1500

2000

2500

3000

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Discharges by Day of the Week (Excluding Day Cases) YTD (Apr 13 - Feb 14)

Elective Emergency

0

500

1000

1500

2000

2500

3000

3500

GeneralMedicine

Paediatrics General Surgery Orthopaedics Gynaecology Care of theElderly

Urology Cardiology

Inpatient Discharges with EDD Status - Top 8 Specialties (Excluding EAU and Maternity)(YTD April 13 - Feb 14)

disch on EDD no EDD recorded not disch on EDD

Cancelled operations

17

For any elective operation cancelled by the trust on the day of the operation/admission, an offer of a new date must be made within 5 calendar days, and the newly offered date must be within 28 days of the cancelled operation date.

YTD to Feb 14, 152 operations have been cancelled by the trust on the day for non-clinical reasons, 148 were contacted within 5 days to be offered a new date and 147 were rebooked within 28 days.

Most common reason of cancelling operation is “patient cancellation”

For Hospital Cancellations – 30% are cancelled on the day, while 51% give at least 8 days notice

Patient Cancellations – 62% on the day, 24% give at least 8 days notice.

0 50 100 150 200 250 300 350 400

PATIENT CANCELLED - TCI / APPOINTMENT…

TCI / APPOINTMENT RESCHEDULED - DATE…

PATIENT FAILED TO ARRIVE / DNA

PATIENT CANCELLED - UNFIT FOR…

TCI / APPOINTMENT RESCHEDULED -…

CONSULTANT / CLINICIAN UNAVAILABLE

PATIENT UNFIT FOR SURGERY (PRE-…

MORE URGENT CASE TOOK PRIORITY -…

PATIENT UNFIT FOR SURGERY (ACUTE…

SURGERY / APPOINTMENT NOT REQUIRED

Top 10 Reasons for Cancellation of Elective Operations Apr 13 - Feb 14

0

100

200

300

400

500

600

On the day 1 day before 2-7 days before 8 or more daysbefore

Timing of Hospital Clinical and Non Clinical Cancelled OperationsApr 13 - Feb 14

Safety

18

Patient falls in October were 75 with spikes in Feb and Mar 13. The last reported case of MRSA was in Mar 13 with only 4 cases in the last 3 years. Pressure ulcers are on a decreasing trend

0

1

2

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

MRSA

Monthly data 6 month moving average

0

20

40

60

80

100

120

140

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Patient falls

Monthly data 6 month moving average

0

1

2

3

4

5

6

7

8A

pr-

10

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

C difficile cases

Monthly data 6 month moving average

0

5

10

15

20

25

30

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Pressure ulcers +2

Monthly data 6 month moving average

Friends and Family Test

19

YTD response rate 22.0%, low A&E response rate of 9.2%.

A&E IP TOTAL

Apr-13 30 368 398

May-13 50 318 368

Jun-13 133 362 495

Jul-13 85 383 468

Aug-13 81 456 537

Sep-13 144 437 581

Oct-13 166 467 633

Nov-13 98 377 475

Dec-13 121 330 451

Jan-14 135 388 523

Feb-14 149 383 532

TOTAL 1,192 4,269 5,461

No of Respondants

A&E IP TOTAL

1,815 991 2,806

1,642 923 2,565

1,631 928 2,559

1,894 950 2,844

1,828 901 2,729

1,705 845 2,550

1,815 950 2,765

1,700 914 2,614

1,657 873 2,530

1,657 971 2,628

1,612 802 2,414

15,687 8,275 23,962

No of eligible Patients

A&E IP TOTAL

1.7% 37.1% 14.2%

3.0% 34.5% 14.3%

8.2% 39.0% 19.3%

4.5% 40.3% 16.5%

4.4% 50.6% 19.7%

8.4% 51.7% 22.8%

9.1% 49.2% 22.9%

5.8% 41.2% 18.2%

7.3% 37.8% 17.8%

8.1% 40.0% 19.9%

9.2% 47.8% 22.0%

7.6% 51.6% 22.8%

% of Responses

76%

69% 68%72% 71% 73%

76% 76%71% 73%

67%

20%26%

23% 21% 23% 22% 20% 21% 23% 21%27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

Friends and Family Test Inpatient and ED Response to 'extremely

likely' and 'likely' to recommend YDH

Extremely Likely Likely

398 368 495 468 537 581 633 475 451 523 532

2,8062,565

2,5592,844 2,729 2,550

2,7652,614 2,530

2,628 2,414

0%

5%

10%

15%

20%

25%

0

500

1000

1500

2000

2500

3000

3500

4000

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14

Friends and Family Test % of Responses

No of Respondants No of eligible Patients % of Responses

Patient complaints and compliments

20

YTD there have been 1071 compliments to Clinical Departments and Medical Staff and 648 complaints

There has been an increase in number of PALs contacts, Sep (72), Oct (85) compared to average Apr-Aug (57)

0 10 20 30 40 50 60

Emergency Department

Out-Patient Department

Kingston Wing

EAU - Emergency Admissions Uni

Ward 9B - Merriott

Ward 6A - Charlton

Ward 9A - Sparkford

Radiology

Ward 8B - Montacute

Orthopaedic Outpatients

Complaints - Highest 10 Departments Apr - Dec 2013

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%

Out-Patient Department

Orthopaedic Outpatients

Emergency Department

EAU - Emergency Admissions Uni

Ward 8B - Montacute

Ward 9A - Sparkford

Kingston Wing

Ward 9B - Merriott

Ward 6A - Charlton

Complaints - Rate Apr - Dec 2013

0

200

400

600

800

1000

1200

YTD complaints & PALS YTD compliments

April to December 2013

Under Investigation

Patient complaints and compliments

21

YTD there have been 1071 compliments to Clinical Departments and Medical Staff and 648 complaints

There has been an increase in number of PALs contacts, Sep (72), Oct (85) compared to average Apr-Aug (57)

0 10 20 30 40 50 60

Emergency Department

Out-Patient Department

Kingston Wing

EAU - Emergency Admissions Uni

Ward 9B - Merriott

Ward 6A - Charlton

Ward 9A - Sparkford

Radiology

Ward 8B - Montacute

Orthopaedic Outpatients

Complaints - Highest 10 Departments Apr - Dec 2013

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% 3.50%

Out-Patient Department

Orthopaedic Outpatients

Emergency Department

EAU - Emergency Admissions Uni

Ward 8B - Montacute

Ward 9A - Sparkford

Kingston Wing

Ward 9B - Merriott

Ward 6A - Charlton

Complaints - Rate Apr - Dec 2013

0

200

400

600

800

1000

1200

YTD complaints & PALS YTD compliments

April to December 2013

Data updated to Dec 13 – further investigation needed

Incidents

22

0 50 100 150 200

South Devon Healthcare

Yeovil District

Dorset County

Poole Hospital

* National Acute Avg *

Taunton and Somerset

Royal Devon and Exeter

Northern Devon Healthcare

Reported Physical Assualts - FY 12/13

Involving Medical Factors Not Involving Medical Factors

0

0

0

2

2

2

3.49

4

0 1 2 3 4 5

South Devon Healthcare

Yeovil District

Poole Hospital

Dorset County

Royal Devon and Exeter

Northern Devon Healthcare

* National Acute Avg *

Taunton and Somerset

Declared Sanctions 12/13

12

21

22

23

29

32

32

38

0 5 10 15 20 25 30 35 40

South Devon Healthcare

* National Acute Avg *

Royal Devon and Exeter

Poole Hospital

Dorset County

Yeovil District

Taunton and Somerset

Northern Devon Healthcare

Assaults Per 1000 staff 12/13

0 5 10 15 20 25 30 35 40 45

Ward 10

Ward 7B EAU

Ward 6B

Ward 8A

Emergency Department

Ward 9A

Ward 9B

Depts < 5 incidents

Reported Incidents July 13 - Nov 13

Physical Abuse Verbal Abuse Non Violent incidents

FY 12/13 YDH has reported 72 assaults (32 / 1000 staff), which is above the national average of 21 / 1000 staff. YDH have reported 150 incidents between the period Jul 13 –Nov 13, 87 of these were violent incidents.

Admissions

23

Total elective admissions in February 14 were 1,577compared to non-elective 1,471. For the last 12 months the mix has remained at approximately a 50:50 equal split, compared to prior year which was 54% Elective to 46% Non Elective admissions.

Average length of stay is 3.0 days for Elective Division and 5.1 days for UCLTC Division.

In November we are carrying out further analysis to

determine relevant and accurate criteria for LOS vs accurate

targets

6mth avg

Elective

Non Elective

LOS

Elective

Non Elective0

500

1,000

1,500

2,000

2,500

3,000

3,500

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Admissions

Total Elective admissions Non Elective admissions

Total admissions (6 mths avg)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Ap

r-1

0

Jun

-10

Au

g-1

0

Oct

-10

De

c-10

Feb

-11

Ap

r-1

1

Jun

-11

Au

g-1

1

Oct

-11

De

c-11

Feb

-12

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Average Length of Stay (days)

LOS Elective LOS Non Elective

Average LOS Feb-11 Feb-12 Feb-13 Feb-14

Elective 3.3 2.6 3.3 3.0

Non Elective 6.2 5.2 5.7 5.1

Length of stay – long stayers

24

As of 13/03/14, the current longest staying inpatient is 84 days, but they are not medically fit for discharge. The longest staying inpatient fit for discharge has been an inpatient for 76 days, and is yet to be discharged due to social service delays.

0 1 2 3 4 5 6

Not Medically Fit

Not Medically Fit

Not Medically Fit

Patient or Family Choice

Social Service Delay

Community Hospitals Delay

Equipment Delay

Not Medically Fit

Social Service Delay

Community Hospitals Delay

Not Medically Fit

Community Hospitals Delay

Not Medically Fit

Social Service Delay

Not Medically Fit

Not Medically Fit

Patient or Family Choice

Community Hospitals Delay

Not Medically Fit

Social Service Delay

Community Hospitals Delay

ICU

JAS

MI

NE

WA

RD 6

AW

AR

D 6

BW

ARD

7AW

ARD

8A

WA

RD

8B

WA

RD 9

AW

ARD

9B

60-100

30-60

15-30

Re-admissions within 30 days (YTD February 2014)

25

General Medicine has a high rate of readmissions post electively from other specialties, and post-emergency generally, because General Medicine has a large portion of all emergency admissions.

General Surgery has a high rate of post-elective same-specialty readmissions due to the high rate of elective admissions for general surgery (all endoscopies are managed as day cases, and therefore count as admissions)

0 50 100 150 200 250 300 350 400 450 500

Gastroenterology

Obstetrics

Cardiology

Urology

Paediatrics

Gynaecology

Trauma & Orthopaedics

A&E

Care of the Elderly

General Surgery

General Medicine

Post Emergency Readmissions by Specialty

different speciality same speciality

0 20 40 60 80 100 120

Urology

Paediatrics

Care of the Elderly

A&E

Gynaecology

Trauma & Orthopaedics

General Surgery

General Medicine

Post Elective Readmissions by Specialty

different speciality same speciality

Theatre utilisation(YTD December 2013)

26

ENT, Ophthalmology, Oral Surgery, Plastic Surgery, and Urology are the areas most prone to theatre lists ending at least 45 minutes earlier than scheduled

Conversely, private endoscopy sessions and paediatric sessions have overrun in 38% of cases and 20% of cases respectively, and never ended early.

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

100%

END

OSC

OP

Y

GA

STR

OEN

TER

OLO

GY

DER

MA

TOLO

GY

PLA

STIC

SU

RG

ERY

GYN

AEC

OLO

GY

UR

OLO

GY

OR

AL

SURG

ERY

PRI

VA

TE S

ESSI

ON

…

GEN

ERA

L M

EDIC

INE

OP

THA

LMO

LOG

Y

PRI

VA

TE S

ESSI

ON

…

OR

THO

PAE

DIC

S &

…

ENT

GEN

ERA

L SU

RGER

Y

PA

EDIA

TRI

CS

AN

AES

TH

ETIC

S

CA

RD

IOLO

GY

Theatre Utilisation by Speciality (Jan 13 - Feb 14)

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

Jan

Feb

Ma

r

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Theatre Utilisation by Month (Jan 13 - Feb 14)

-6%-11%

-43%

-10%

-27%

-18% -21%

-53%

-43%

-22%0%

-33%

0% 0%

-37%

20%13%

3%

15%22% 24% 24%

6% 5%

23% 20%

8%

39%

0%

13%

-100.00%

-80.00%

-60.00%

-40.00%

-20.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

DER

MA

TOLO

GY

END

OSC

OPY

ENT

GA

STRO

ENTE

ROLO

GY

GEN

ERA

L M

EDIC

INE

GEN

ERA

L SU

RG

ERY

GYN

AEC

OLO

GY

OPT

HA

LMO

LOG

Y

ORA

L SU

RG

ERY

ORT

HO

PAED

ICS

& T

RAU

MA

PAED

IAT

RIC

S

PLA

STIC

SU

RGER

Y

PRIV

ATE

SESS

ION

(EN

DO

SCO

PY)

PRIV

ATE

SESS

ION

(FLE

XIB

LE C

YSTO

SCO

PY)

URO

LOG

Y

UnderRuns are only Calculated if they end over 45 minutes early. OverRuns are only calculated if they are over 30 minutes

. %Overrun

. %UnderRun

Monitor

27

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

RTT 18 week RTT admitted wait - All specialties 90% M 97.5% 97.3% 95.7% 94.9% 0 0 0 0

RTT 18 week RTT non-admitted wait - All specialties 95% M 98.8% 98.8% 97.2% 96.9% 0 0 0 0

RTT 18 week RTT Incomplete pathways - All Specialties 92% M 97.6% 97.6% 95.4% 95.4% 0 0 0 0

A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 96.0% 96.0% 95.9% 96.1% 0 0 0 0

Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 94.0% 95.6% 94.4% 90.8%

Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 95.5% 94.0% 91.4% 96.5%

Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 99.5% 98.6% 98.7% 98.2% 0 0 0 0

Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100.0% 100.0% 100.0% 100.0% 0 0 0 0

Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 95.9% 100.0% 100.0% 100.0% 0 0 0 0

Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 92.4% 91.7% 93.5% 91.8% 0 0 0 0

Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 100.0% 100.0% 100.0% N/A 0 0 0 0

SafetyC.Diff year on year reduction

(DH target - Post 72hrs only)9 pa Q 2 3 2 1 0 0 0 0

Safety Access to health care for people with a learning disability 9 pa Q

0 0 1 1MONITOR SCORE

MonitorResults

TH Period

0 0 1

Monitor Score

1

Workforce Performance

January 2014 - Month 10

FTEs

29

Total Workforce Capacity outturn for month 10 was 1,767 full time equivalent (FTE).

Temporary Staff Capacity decreased by the equivalent of 7 FTE.

Temporary Capacity accounted for 6% of the Total Workforce Capacity (the same as month 9)

FTEsYTD avg

PY YTD avg

var

Nursing and Midwifery Registered 502 508 -1.3%

Administrative and Clerical 375 381 -1.6%

Additional Clinical Services 253 261 -2.9%

Medical and Dental 212 218 -2.6%

Estates and Ancillary 161 163 -0.9%

Allied Health Professionals 82 75 8.9%

Add Prof Scientific and Technic 41 39 6.4%

Healthcare Scientists 5 9 -40.6%

Total 1,633 1,654 -1.3%

Substantive Workforce Capacity Movement

30

The number of Substantive Staff (i.e. directly employed staff) increased by 3 FTE against Month 9.

Registered Nursing (+3 FTE), Medical and Dental (+1 FTE), Additional Clinical Services (+5 FTE),

Admin and Clerical (-3 FTE), Prof Scientific and Technical (-1 FTE), Allied Health Prof (-2 FTE).

-50 -40 -30 -20 -10 0 10 20 30 40

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

FTEs - Variance to Prior Month by Staff Group

Nursing and Midwifery Registered Medical and Dental Healthcare Scientists

Estates and Ancillary Allied Health Professionals Administrative and Clerical

Additional Clinical Services Add Prof Scientific and Technic

Mandatory Training

31

The percentage of staff remaining in date for all elements of their Mandatory Training remained at 80%, against a target of 80%

Appraisal

32

The percentage of staff remaining in date for their Annual Appraisal remained the same at 80%, against a target of 90%.

Sickness Absence

33

The Sickness Absence Rate for Month 9 was 3.8%, (0.3% higher than the Month 8 performance) representing an adverse variance of 0.8% against target. All areas with high levels of sickness absence have action plans in place to improve attendance.

0.0% 2.0% 4.0% 6.0% 8.0% 10.0%12.0%

Nursing and Midwifery…

Medical and Dental

Healthcare Scientists

Estates and Ancillary

Allied Health Professionals

Administrative and Clerical

Additional Clinical Services

Add Prof Scientific and…

Sickness Absence by Staff Group - Last 3 months

Dec-13 Nov-13 Oct-13

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-1

2

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-1

3

Sickness Absence vs Target

Total for YDH Target

Staff Turnover

34

Between Month 9 and Month 10, Staff Turnover remained at 13.0% (against a target upper limit of 15%). The 13 month rolling twelve-month average is 12.9%.

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Staff Turnover

Actual Target Lower Limit Target Upper Limit

Recruitment Efficiency

35

The average time from advert to ‘ready to start’ has reduced in Month 10 to 47 days against a target of 60 days.

The average time taken to send a letter of confirmation has reduced in Month 10 to 8 hours against a target of 48.

0

10

20

30

40

50

60

70

80

90

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Average time taken from advert to ready to start (Days)

Actual Target

0

20

40

60

80

100

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Average time taken to send a letter of confirmation

(Hours)

Actual Target

Financial Overview

January 2014 – Month 10

Finance

37

YTD surplus £634k, £216k favourable against budget, Monitor risk rating of 4, YTD capital expenditure £3,453k, Cash balance £7.4m

Variance: Favourable/(Adverse)

Financial Summary

Actual Variance Actual Variance

Income 10,099 261 96,418 226

Pay (6,517) (444) (61,484) (220)

Non Pay (3,192) (6) (30,050) 197

EBITDA 391 (189) 4,884 203

Other (423) 2 (4,250) 13

Surplus (33) (187) 634 216

EBITDA Margin % 3.7% -2.2% 4.9% 0.2%

Surplus % -0.3% -1.9% 0.7% 0.2%

Year to DateIn Month

38

APPENDIX

Financial Detail

Summary (£’000)

39

YTD: £634k surplus, £216k favourable against budget

Variance: Favourable/(Adverse)

Financial Summary

November December Actual Variance Actual Variance

Income

Clinical Income 8,338 8,386 8,853 331 83,577 (31)

Non NHS Clinical Income 220 149 209 (121) 2,271 (386)

Other Income 1,155 1,028 1,037 51 10,570 643

Total Income 9,713 9,563 10,099 261 96,418 226

Pay

Nursing (2,198) (2,201) (2,367) (87) (21,971) 368

Medical Staff (1,955) (1,941) (2,131) (114) (19,790) 323

Estates, Admin & Clerical (1,087) (1,081) (1,084) (13) (10,662) 183

Pay - Scientific, Therapeutic & Technical (591) (613) (609) (37) (5,931) (134)

Pay - Ancillary (320) (306) (326) (13) (3,130) (77)

CIP 0 0 0 (180) 0 (883)

Total Pay Expenditure (6,151) (6,142) (6,517) (444) (61,484) (220)

Non Pay

Drugs (890) (874) (954) (71) (8,665) (379)

Consumable M&SE (615) (645) (589) 24 (6,032) (56)

High Cost M&SE (277) (251) (236) 67 (2,470) 206

Other (1,216) (1,371) (1,413) (138) (12,883) (348)

Central Budgets 0 0 0 112 0 774

Total Non Pay Expenditure (2,998) (3,141) (3,192) (6) (30,050) 197

EBITDA 564 281 391 (189) 4,884 203

Other (415) (415) (423) 2 (4,250) 13

Surplus 149 (135) (33) (187) 634 216

EBITDA Margin % 4.9% 2.9% 3.7% -2.2% 4.9% 0.2%

Surplus % 1.5% -1.4% -0.3% -1.9% 0.7% 0.2%

In Month - January Year to DatePrior Months Actuals

Monitor Risk Ratings

40

The Trust is achieving a continuity of service risk rating of 4

In Month YTD In Month YTD

130 1367 130 1237

378 4,739 283 4,361

2.9 3.5 2.2 3.5

4 4 4 4

3119 3119 3163 3163

-9,709 -91,534 -9,283 -81,825

9.6 10.2 10.2 10.4

4 4 4 4

4 4 4 4

* Calculation is based on Cash for Continuity of Service divided by Operating Expenses x 30 days per month

Month 9

Liquidty Rating

Month 10

Continuity of Service Risk Rating

Debt Service Cover

Debt Service

Debt Service Cover Rating

Revenue available for Debt Service

Debt Service Cover Metric

Liquidity

Cash for Continuity of Service

Operating Expenses

Liquidty Metric *

Income (£’000)

41

Income in month £10,099k; YTD £96,418k (£226k favourable to budget)

Clinical Income - There is a favourable variance of £331k in month. Of this £130k is as a result of higher than planned Cancer Drug Fund income (for pass through drug payments) & reduction in deferred income relating to Somerset CCG transitional funding.

Non NHS Clinical Income - There is an adverse variance of £121k in

month. This is due to £128k under achievement of private patient

income. Partially offset by an overachievement of injury benefit income

of £7K.

Other Income – There is a favourable variance in month of £51k. This is

in relation to over achievement in R&D and Education and Training. This

is offset by Donated Asset Income due to timing differences, and

Pathology recharges.

N.B. Main components of Other Income include Research & Development, Education & Training funding and Donated Asset Income. Other significant income streams include services provided to external organisations for pharmacy & facilities contracts.

Summary of Clinical Activity Performance

42

• Underperformance in General Surgery is the main reason for both the Elective admissions and Elective same-day activity variance.

• We have improved our data capture for procedures carried out in outpatient settings, particularly in Trauma and Orthopaedics. This is seen in the Outpatient Procedure over-performance, and partially explains the underperformance seen in Outpatient Attendances.

• The ‘Other’ category includes the Pathology activity, which includes a high volume of low-cost items.

Patient Type Annual Plan

Year to

date

plan

Year to

date

actuals Variance

%

variance

Elective inpatients 3,399 2,850 2,562 (288) -10%

Elective day case patients (Same day) 17,689 14,834 13,496 (1,338) -9%

Emergency inpatients 16,965 14,223 13,584 (639) -4%

Outpatient Attendances 145,503 122,016 120,458 (1,557) -1%

Outpatient Procedures 14,350 12,034 14,384 2,350 20%

A and E Attendances 47,098 39,485 38,387 (1,098) -3%

Maternity 5,004 4,195 4,557 362 9%

Direct Access 29,229 24,504 24,646 141 1%

Other 819,045 686,652 711,144 24,492 4%

TOTAL 1,098,282 920,793 943,218 22,425 2.44%

43

Clinical Activity Performance against Plan by Activity Type and Commissioner

*The biggest activity % variances are on the Specialist Commissioning baselines: however, these are relatively small in ‘real’ terms and have a

negligible financial value compared to the underperforming activity on the Somerset CCG baselines.

*These graphs exclude ‘non PbR’ and ‘Other’ elements such as High Cost Drugs, Critical Care and SCBU. These are shown on the following slide.

*Maternity under-performance is at least partly due to inconsistent capturing of data in the first half of the year, though this has since improved.

Although we are showing an underperformance in terms of activity, we are seeing a more ‘Intensive’ mix of patients than planned under the new

currency, hence the financial over-performance.

*‘Other’ commissioners include Local Authority, Out-of-Area work and Public Health and Military work (the latter are both commissioned by NHS

England)

44

Best Practice Tariffs – We are under-performing for both

our Stroke and Fragility of Hip Best Practice Tariffs.

Critical Care– Our under-performance on Somerset’s planned activity is offset by over-performance in specialist commissioning.

High Cost / Chemo Drugs– The SWSCG (NHS England

South West Specialist Commissioning Group) over-

performance is funded through a pass-through

arrangement with NHS England.

Non Tariff Performance against Plan by Activity Type and Commissioner

45

Activity Comparison, Year on Year

This graph shows the difference between this year to date

activity with the same period in 12-13. The bars are in % terms,

with the numbers of additional or lesser activity described on the

chart.

Outpatients– The biggest increase is in outpatient procedures,

although it is fair to note that this is largely a data issue in addition

to YDH performing more work in this setting.

The remaining movements are relatively consistent with the overall contract performance.

Note: Maternity is now recorded on a different tariff currency (being pathway -rather than activity- based) and so to allow for like-for-like comparison maternity work has been excluded from this graph.

Substantive &Total Pay (£’000)

46

Pay in month £6,517k; YTD £61,484k (£220k adverse variance to budget)

Nursing – Total expenditure in month is £2,367K, resulting in an adverse variance of £87K. This is due to £34K overspend in emergency medicine on

agency and bank shifts. Ward budgets were overspent by 26K due to high agency usage. There is a £17K overspend in cancer due to costs incurred

offset by non recurrent funding received.

Medical Staffing – Total expenditure in month is £2,131k, resulting in a adverse variance of £114k. This is due to £21K overspend in ophthalmology,

£15k in emergency medicine, £28K in respiratory and £19K in theatres due to locum and agency shifts. There is an adverse variance of 18K in ENT

due to contract expense incurred in month.

A&C & Estates – Total expenditure in month is £1,084k, resulting in an adverse variance of £13k. This is primarily due to delays in implementation of

the pathway support project.

Scientific, Therapeutic & Technical – Total expenditure in month is £609k, resulting in an adverse variance of £37k. This is due to agency overspends

of £9k in pharmacy and £7K in medicine, with various other overspends across the Trust.

Other CIP – This is the CIP target for total employment costs and should be measured against the savings in other categories.

Pay Non Substantive (£’000)

47

Non substantive Pay in month £599k; YTD £4,572k (£859k greater YTD than 12/13)

Locum Bank Agency Total Locum Bank Agency Total

Medical and Dental 86 125 211 587 822 1,409

Nursing and Midwifery 101 145 246 938 778 1,715

Other 38 104 142 436 1,012 1,448

Total 86 139 374 599 587 1,373 2,612 4,572

In Month YTD

Drugs (£’000)

48

Drugs spend in month £954k; YTD £8665k (£379k adverse variance to budget)

Drugs are reporting an overspend of £379k year to date. This is offset by increased income of £482k; £189k from the cancer drug fund, £331k from Specialist Commissioning . In addition Somerset and Dorset CCGs’ high cost drugs are overspent by £12k but this tends to fluctuate month to month.

Note: Any total under or over performance relating to drugs commissioned by NHS England will be paid through on a ‘pass through’basis.

Non Pay (£’000)

49

Non Pay (excl drugs) spend in month £2,238k; YTD £21,385k (£576k favourable variance to budget)

In month:

– Consumable M&SE – Favourable £24k. This is due to underspends within Orthopaedics, Surgery and Obstetrics, this is partially offset by an overspend in Main Theatres.

– High Cost M&SE – Favourable £67k due to underspends within Orthopaedics.

- Other Non Pay – Adverse £138k. The key areas are professional fees (£48k adverse) for recruitment, service transformation Capita space project

and Symphony (this is offset by income), restructuring costs (£100k adverse) and office expenses (£27k adverse) due to timing of computer purchases.

50

Overhead costs include Facilities, Energy, Maintenance, Management, HR, and Finance.

Use of Capital (£’000)

51

Site Capex Year to date favourable variance of £73k relates to the

Women’s Hospital & Fire Alarms now scheduled later in the year. In

month variance is due to catch up of costs planned earlier in the

year.

Medical Equipment The £227k year to date variance represents a

change in the phasing of orders. The budget is forecast to

underspend by £146k at year end with plans in place to purchase a

Laparoscopic Ultrasound £90k and an Operating Table £60k in

2014/15.

Radiology The year to date variance is as a result of slippage of the

X-Ray room 2 refurbishment and MRI upgrade .

Energy Project The favourable variance is due to a slight delay on

the project because of asbestos removal. The project is now due

to complete in July 2014

Information Technology – Smartcare The Trust is progressing the

Smartcare project within a consortium which includes access to

external funding.

Car Park Phase 1 (Including Demolition)

This includes costs for the site master plan and associated works.

The underspend is due to timing differences .

Other

The cumulative adverse variance includes the dementia project of £405k which has central funding and the Frail and Older Person Project of £342k which is a new project to support the ambulatory care model.

Total Capital spend in month is £434k, YTD spend is £3,453k

Capital Expenditure

Actual Variance Actual Variance

Operational Capital

Site Capex 127 (49) 974 73

Medical Equipment 190 (153) 556 227

Radiology Equipment 0 50 119 61

Other 18 (5) 263 96

Major Developments

Energy Project 0 1,402 432 970

Car Park Phase 1 36 59 152 448

IT - Smartcare 21 36 155 65

Other 29 (29) 639 (639)

Donated schemes 12 (12) 163 10

Total Annual Budget 434 1,300 3,453 1,312

In Month Year to Date

52

Cash (£’000)

Cash inflow in month is £68k, YTD Cash outflow is £2,438k

There is a cash inflow in month of £68k. This is an favourable variance of £375k in month compared to plan.

The closing cash balance is £7.4m which is in line with plan.

The main variances in month are:

Trade ReceivablesNHS Debtors have decreased significantly in month due to collection of outstanding NHS debt, particularly from NHS England..

Accrued income has increased by £377k. This is in respect of the phased income for the Somerset contract compared to the agreed cash received schedules.

Trade PayablesCreditors and accruals have decreased by £187k in month, mainly due to the payment run falling at the end of January.

Deferred income has reduced in month by £165k due to costs now being incurred against this funding.

CapitalCapital additions & accruals are lower than plan year to date due to delays in the capital programme.

StockStock is below plan by £38k. This relates to decreases in Pacemaker, Sleep and Gynae stock.

Other - EBITDA is significantly below plan ( £203k) due to the adverse position in month

Cashflow In Month Variance Year to Date Variance

Trade Receivables 938 (1,273)

Trade Payables (228) 963

Provisions (2) (23)

Capital 1,107 1,595

PDC 130 4

Stock 38 (219)

Other (202) (654)

Cash inflow/(outflow) Variance 1,782 392

53

Statement of Financial Position (£’000)

Key Variances

Current AssetsStock has decreased by £39k in month. This relates to decreases in Pacemaker, Sleep and Gynae stock.

NHS Debtors have reduced by £1,064k, due to efficient collection of income.

Accrued Income has increased by £377k. This is in respect of the phased income for the Somerset contract compared to the agreed cash received schedules.

Prepayments have increased by £70k this is largely in relation to business rates being prepaid for the next two months.

Current LiabilitiesCreditors and accruals have decreased by £187k in month, mainly due to the payment run falling at the end of January.

Capital Creditors have decreased by £213k as invoices for work on Level 1, Ward 6A and FOPAS have been received and paid .

Deferred Income has decreased by £165k. This is a third of the total deferred last month, the remaining two thirds will be phased in over the remaining two months of the financial year.

December 2013 January 2014 Mvt In Mth

Non Current Assets 52,017 52,178 161

Current Assets

Stock 2,050 2,011 (39)

NHS Trade Debtors 2,261 1,197 (1,064)

Non NHS Trade Debtors 784 855 71

Accrued Income 2,071 2,448 377

Prepaid Contracts 1,047 1,117 70

Non Current Assets Held for Sale 0 0 0

Cash in Hand and at Bank 7,366 7,434 68

Total Current assets 15,579 15,062 (517)

Current Liabilities

Trade Creditors (1,541) (1,230) 311

Other Creditors (2,602) (2,864) (262)

PDC Dividend Creditor (391) (521) (130)

Capital Creditor (692) (479) 213

Accruals (4,295) (4,157) 138

Borrowings <1yr (147) (147) 0

Deferred Income (493) (328) 165

Current Liabilities (10,161) (9,726) 435

Net Current Assets 5,418 5,336 (82)

Total Assets less Current Liabilities 57,435 57,514 79

Trade and other Payables >1yr 0 0 0

Borrowings> 1yr (413) (413) 0

Provisions >1yr (986) (966) 20

Net Assets employed 56,036 56,136 100

Financed by:

I&E Reserve Current year 666 635 (31)

Public Dividend Capital 41,030 41,160 130

I&E Reserve Previous year 6,238 6,238 0

Revaluation Reserve 8,103 8,103 0

Donation Reserve 0 0 0

Total Financed 56,037 56,136 99

Trust Level Key Ratios

54

EBITDA margin 4.9% YTD, 3.7% in month

There are no material variations for Pay and Non Pay expenditure in month compared to last year.

Return on pay has decreased slightly compared to the previous month.

Return on non pay has increased compared to the previous month.

EBITDA margin is 5.6% higher in month than achieved in 12/13.

Notes: Ratios are calculated under the current contract income value and not PbR

1.0

1.2

1.4

1.6

1.8

2.0

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Rev

enu

e/P

ay

Co

sts

(£)

Return on Pay Trend

2012/2013 2013/2014

1.0

2.0

3.0

4.0

5.0

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Ma

r

Rev

enu

e/N

on

Pa

y C

ost

s (£

)

Return on Non Pay Trend

2012/2013 2013/2014

-10%

-5%

0%

5%

10%

15%

20%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarEBIT

DA

/Rev

enu

e

EBITDA Margin Trend

2012/2013 2013/2014

Service Line Reporting Summary (£’000)

55

The Corporate income figure of £1,586k includes other income streams such as car parking and Injury Cost Recovery Schemeincome.

The £16.486m of central costs are overheads and include departments such as Facilities, Management Services, HR, Finance, and also depreciation costs.

Elective Care Urgent Care Corporate Total

Revenue 42,781 41,554 1,586 85,921

Direct Costs (19,446) (27,186) 0 (46,632)

Indirect Costs (14,612) (7,555) 0 (22,167)

Gross Contribution 8,723 6,813 1,586 17,121

Central Costs (8,602) (7,884) 0 (16,486)

Net Contribution 120 (1,071) 1,586 635

Year to Date (as of Month 10)

Service line reporting – Elective Care contribution

• Average full year budget margin for Elective Care is 22%• We have refreshed the activity data for maternity and it has

revealed that we are doing a more ‘intensive’ casemix of activity, therefore we have increased revenue in month to reflect a year-to-date correction

56

£000's % £000's %

Month 10 1,164 25% 1,140 25%

YTD 8,723 20% 9,879 22%

Full Year Budget 11,566 22%

Elective Care Strategic Business Unit Contribution

Actual Budget

Service line reporting – Urgent Care contribution

• Average full year budget margin for Urgent Care is 19%• The full year contribution of 19% is higher than the YTD plan of 17%

due to CIP savings to be made in the latter part of the year.

57

£000's % £000's %

Month 10 724 16% 817 19%

YTD 6,813 16% 7,036 17%

Full Year Budget 9,825 19%

Actual

Urgent Care Strategic Business Unit Contribution

Budget

APPENDIX 10

BOARD OF DIRECTORS 19 MARCH 2014

BOARD OF DIRECTORS PAPER

TITLE: HR and Workforce Update DATE: 19 March 2014 PRESENTED BY: Head of Workforce Performance and OD PAPER What is this item about? The purpose of this report is to: provide an update on the Management of Sickness Absence Policy provide an update on myCARE Why is this item necessary? To provide the Trust Board with information on what the Trust is doing to manage sickness absence. What is the Board asked to do? To NOTE the report 1. How does this paper improve patient care? There is a direct correlation between good sickness management and the quality of patient care. 2. How does this paper advance the Annual Plan? The maintenance of a workforce which is adequately resourced, appropriately skilled, trained and developed, and effectively managed, underpins many of the key objectives associated with the delivery of the Annual Plan. 3. How does this advance our strategic objectives? The overall performance of the workforce, at all levels of the organisation, impacts significantly on the achievement of Trust strategic objectives. There needs to be continued focus on improving the working environment and becoming an employer of choice. 4. Is further information available? Yes, upon request. Are there implications for the Trust? • Legally? Yes • Financially? Yes

• Regarding Workforce? Yes Is this paper clear for release under Freedom of Information? Yes

1. INTRODUCTION 1.1 The purpose of this paper is to set out the actions HR are currently taking to manage

sickness absence effectively and meet the Trust’ sickness target of 3%. Sickness absence performance for December (Month 9) was 3.8%.

2. MANAGEMENT OF SICKNESS ABSENCE POLICY 2.1 The Management of Sickness Absence Policy has been revised and updated and

training sessions for managers commenced in February 2014. 2.2 The new policy was developed as a result of research into best practice in the

management of sickness absence, and Heads of Department were instrumental in providing feedback during its development. Full consultation took place with Staff Side.

2.3 The policy has introduced a number of major changes to the previous policy, which

include:

Short-term Process • Trigger points are now ‘Occasions’ of sickness absence rather than Bradford Scores, as

staff and managers found the previous method complicated. • New tougher trigger points for formal action have been included. • The process for formal action has been simplified and streamlined. • The possibility of expediting the process for staff with under two years’ service has been

added.

Long-term Process • A complete revision of the long-term management process has been undertaken as the

previous version was not sufficiently clear. • A new final review meeting after four months absence has been included, to determine

whether the employee will be fit to return in the next two months – this will expedite the process and provide clarity of expectation for both managers and staff.

Other Improvements

• The volume of paperwork required following an employee’s sickness absence has been reduced.

• A new process to deal with unauthorised absence has been included. Previously, there was no process in place; therefore this provides clear steps to take in the event of employee’s absence without permission.

• Details regarding the support available to employees have been improved, including much more information regarding reasonable adjustments and redeployment.

3. myCARE 3.1 HR have developed a new myCARE programme to help staff cope with change and

stress. The programme was designed by employees, and is delivered by trained clinical and non-clinical facilitators within the Trust.

3.2 Using a series of interesting, thought-provoking and humorous DVDs, presented by

Dr Dawn Harper (the Gloucestershire GP famous for presenting Channel 4’s Embarrassing Bodies), the programme aims to help support employees improve their health and wellbeing and develop coping strategies.

3.3 The format of the programme provides the time, support and space to review work-life balance, and explore options and strategies to make improvements.

3.4 There are five myCARE modules. These are: • Making Changes - explores the process of making changes at work and home in order to

achieve goals and overcome barriers to change. • Healthy Lifestyles - covers the principles of a healthy lifestyle including diet and exercise

and provides strategies for change. • Doing Your Day - considers the workplace environment and helps staff make

improvements to their work/life balance, prioritise tasks, manage time effectively, deal with conflict, and through positive communication, be more assertive.

• Transform Your Thinking - helps staff look at the world in a more positive light. It

explores cognitive behaviour therapy and the bereavement process to provide coping strategies.

• Identifying Stress - explores what causes stress, how to recognise it and how to respond

to the symptoms. 4. Recommendation 4.1 The Board is asked to note the actions HR are taking to manage sickness absence

effectively. Paper Submitted by: Mark Appleby, Head of Workforce Performance and OD Contributor: Ali Morris, Head of Operational HR Services March 2014

All information provided must remain on this sheet only

APPENDIX 11

BOARD OF DIRECTORS 19 MARCH 2014

BOARD OF DIRECTORS PAPER

TITLE: Monitor Quarter 3 Assessment DATE: 19 March 2014 PRESENTED BY: Company Secretary PAPER What is this item about? This paper confirms Monitor’s assessment of the Trust’s performance based on an analysis of Quarter 3 of 2013-14 in light of the Trust’s own quarterly report. Why is this item necessary? This paper informs the Board of Monitor’s regulatory assessment of the Trust’s performance with the governance and continuity of services requirements of the Trust’s provider licence. What is the Board asked to do? The Board is asked to NOTE the assessment from Monitor. 1. How does this paper improve patient care? It provides external assurance on performance against the standards and targets of patient care. 2. How does this paper advance the Annual Plan? It provides external assurance on the achievement of clinical and financial aspects of the plan. 3. How does this advance our strategic objectives? It provides external assurance on the achievement of clinical and financial elements of the objectives. 4. Is further information available? Further information on the performance of all foundation trusts for Q3 is available on the Monitor website. Are there implications for the Trust? • Legally? The assessment indicates the Trust is complying with the terms of its licence. • Financially? The Trust has been assigned a Green governance risk rating but failed to

meet the target for two-week waits for breast cancer symptoms in Q3 and therefore retains a continuity of services risk rating of 4.

• Regarding Workforce? No Is this paper clear for release under Freedom of Information? Yes

5 March 2014 Mr Paul Mears Chief Executive Yeovil District Hospital NHS Foundation Trust Yeovil District Hospital Higher Kingston Yeovil Somerset BA21 4AT

Dear Paul Q3 2013/14 monitoring of NHS foundation trusts Our analysis of Q3 is now complete. Based on this work, the Trust’s current ratings are:

Continuity of services risk rating - 4

Governance risk rating - Green The Trust has been assigned a Green governance risk rating but failed to meet the target

for two-week waits for breast cancer symptoms in Q3.

Monitor uses the above target (amongst others) as indicators to assess the quality of

governance at foundation trusts. A failure by a foundation trust to achieve the targets

applicable to it could indicate that the Trust is providing health care services in breach of its

licence.

We do not intend to take any further action at this stage. We expect the Trust to address the

issues leading to the target failure and achieve sustainable compliance with the target

promptly. Should these issues not be addressed promptly and effectively, or should any

other relevant circumstances arise, Monitor will consider what if any further regulatory

action may be appropriate.

I have attached a one page executive summary (Appendix 1) of your Trust’s Q3 results for your information and a report on the aggregate performance of the NHS foundation trust sector will shortly be available on our website (in the News, events and publications section) which I hope you will find of interest. For your information, we issued a press release on 21 February 2014 setting out a summary of the key findings across the NHS foundation trust sector from the Q3 monitoring cycle.

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: enquiries@monitor.gov.uk W: www.monitor.gov.uk

If you have any queries relating to the above, please contact me by telephone on 020 3747 0167 or by email (Jayne.Rhodes@monitor.gov.uk). Yours sincerely

Jayne Rhodes Senior Regional Manager cc: Mr Peter Wyman, Chair Mr Timothy Newman, Chief Finance and Commercial Officer

Key risks Action taken / committed Gaps and residual concerns

Winter pressures

• The Trust continued to meet the 4-hour standard for A&E waits in Q3

2013/14.

• Meeting the standard in Q4 will remain a key challenge as the Trust

historically experiences its highest emergency demand this quarter.

• The Trust has agreed its 2013/14 Winter Plan with commissioners. This formalises arrangements

developed in response to pressures experienced in winter 2012/13 including block purchasing of

beds from a private nursing home provider to support prompt discharges from hospital.

• The Trust’s 4-hour wait performance in Q4 up to 23 February 2014 was just above target at 95.2%.

• The Trust may not achieve its 4-hour

wait target if its winter planning

arrangements cannot cope with

anticipated increases in emergency

demand in Q4.

Cancer wait time performance

• The Trust has met relevant waiting time targets this year with the

exception of the 93% target for 2 week breast screening waits in Q3,

against which the Trust achieved performance of 91.4%.

• The Trust has reviewed the 14 patients who breached the 2 week wait target in Q3 and confirmed

all were offered first appointments within 14 days but which they were unable to attend. The Trust

has booked alternative appointments outside 14 days and reports no significant delays where this

has occurred.

• The Trust is monitoring and responding to risks to achievement of other waiting time targets

including increasing demand for some services and addressing capacity gaps in some specialties.

• Cancer performance will continue to

require effective monitoring to

ensure risks to delivery are mitigated

by the Trust, especially as clinical

activity for the year is likely to peak

in Q4.

Five-year strategic plan

• Funding constraints will make financial and service planning over the

next five years very challenging and will require trusts to work

increasingly collaboratively with partners to bridge the financial gap.

• The Trust is preparing its two-year financial plan 2014 – 16 for submission to Monitor by 4 April

2014 and expects to sign contracts with commissioners before the start of the new financial year.

• The Trust’s Estate Master Plan, approved by the Board in November 2013, sets out how the Trust

plans to modernise its estate and improve patient experience from available capital resources.

• The Trust is working with partners across South Somerset on the ‘Project Symphony’ integrated

care model due to go live from April 2014. This aims to improve outcomes and reduce costs across

all elements of the care pathway, covering patients with diabetes and dementia initially with scope

to expand this to other comorbidities.

• The Trust is working with Dorset County Hospital FT to identify opportunities to improve services

and efficiency through collaboration.

• The Trust may not be able to

develop and agree a sustainable

five-year plan if it and key partners

are not sufficiently ambitious in

identifying and progressing

transformational change and

efficiency opportunities.

Next steps Continue quarterly monitoring.

Risk Ratings Continuity of Service Risk Rating

13/14: YTD Plan YTD Actual

13/14:

YTD Actual

4 Unchanged was col 6

Governance Risk Rating:

Declared risks at APR: None YTD Actual: Green

Declared Risks in Year: None

Breaches for Current

Period: C2wBreast

• The Trust met all relevant targets in Q3 2013/14 except for 2 week waits for breast screening referrals. This

is the first quarter this year the Trust has not achieved this target.

• The Trust remains ahead on its financial plan at Q3, delivering a surplus of 667k YTD, £445k ahead of plan.

• The Trust is progressing its two-year financial plan and healthcare contracts with commissioners in

preparation for submission to Monitor on 4 April 2014.

• Delivering efficiency savings over this period will become increasingly challenging for all NHS providers.

The Trust will need to work closely with partners to look at options to collaborate, integrate and re-design

services to remain on a sustainable footing.

Yeovil District Hospital NHS Foundation Trust

Q3 2013 - 14 Reporting Executive Summary Summary Income & Cash Flow vs Plan

£m

Plan Actual Variance Plan Actual Variance

Op. Rev for EBITDA 28.8 29.3 0.5 86.0 86.2 0.1

Employee Expenses (18.4) (18.7) (0.3) (55.7) (55.2) 0.5

PFI Op. expense 0.0 0.0 0.0 0.0 0.0 0.0

All other Op. costs (8.8) (9.1) (0.2) (26.5) (26.6) (0.2)

EBITDA 1.5 1.4 (0.1) 3.9 4.3 0.5

Surplus/(Deficit) pre exceptionals 0.7 0.7 0.0 1.5 1.9 0.4

Net Surplus/(Deficit) 0.3 0.3 0.0 0.2 0.7 0.4

EBITDA % 5.2% 4.9% (0.3%) 4.5% 5.0% 0.5%

CapEx (Accruals Basis) (1.8) (1.9) (0.1) (2.9) (3.0) (0.1)

Net cash flow 0.0 1.0 0.9 (2.5) (2.5) 0.0

Cash & Equiv 7.3 7.4 0.0 7.3 7.4 0.0

CoSRR Liquidity days 8.8 10.4 1.6 8.8 10.4 1.6

CIP % OpEx less PFI 3.7% 3.2% (0.5%) 2.3% 2.3% (0.1%)

Net current assets 4.5 5.2 0.7 4.5 5.2 0.7

Borrowing (excluding PFI) 0.1 0.1 0.0 0.1 0.1 0.0

2013/14 Q3 2013/14 YTD