BOARD OF DIRECTORS meeting papers...BOARD OF DIRECTORS Agenda for the meeting to be held on Wednesday 9th March 2011 at 2.00pm in the Education Centre, 1st Floor West Wing, 250 Euston

BOARD OF DIRECTORS

9th MARCH 2011

BOARD OF DIRECTORS

Agenda for the meeting to be held on Wednesday 9th March 2011 at 2.00pm in the Education Centre, 1st Floor West Wing,

250 Euston Road, London NW1 2PG 1. Apologies for Absence 2. Minutes of the Meeting held on 9th February 2011 Attachment A 3. Matters Arising Report Attachment B 4. Other urgent matters not appearing on the Matters Arising Report 5. Presentation: Cancer Services

Mark Emberton, Divisional Clinical Director, Cancer 6. Chairman’s Report Attachment C 7. Chief Executive’s Report Attachment D 8. Executive Board Report Attachment E 9. Performance Report Attachment F 10. Quality & Safety Committee Report Attachment G 11. Finance & Contracting Committee Report Attachment H 12. Entries in the Seal Register Attachment I 13. Register of Board Members Interests – Annual Review Attachment J 14. Any Other Business 15. Date of Next Meeting: The next meeting will be held on Wednesday 11th May 2011

A

Agenda Item 2

Minutes of the Meeting held on 9th February 2011

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

BOARD OF DIRECTORS

Minutes of the Meeting held on 9th February 2011

Present: Richard Murley, Chairman Richard Delbridge, Non-Executive Director Nick Monck, Non-Executive Director Jane Ramsey, Non-Executive Director Richard Alexander, Finance Director Geoff Bellingan, Medical Director, Surgery & Cancer Katherine Fenton, Chief Nurse Mike Foster, Deputy Chief Executive Gill Gaskin, Medical Director, Specialist Hospitals Paul Glynne, Medical Director, Medicine Tony Mundy, Corporate Medical Director Robert Naylor, Chief Executive In attendance: Tonia Ramsden, Director of Corporate Services (Board Secretary) David Wherrett, Director of Workforce Simon Knight, Interim Director of Performance & Partnerships Sandra Hallett, Director of Quality & Safety (for item 5) Jocelyn Laws, Trust Administrator (Minutes) 2/1 Apologies for Absence Apologies were received from Sue Atkinson and John Tooke. 2/2 Minutes of the Meeting held on 8th December 2010 The minutes were agreed to be a correct record. 2/3 Matters Arising Report The report was noted. 2/4 Other Urgent Matters Arising There were no other matters arising. 2/5 Presentation: National Patient Experience Surveys 2010 Sandra Hallett attended to present the outcomes of three patient surveys which had recently been published:- the National Inpatient Survey, a Cancer Survey commissioned by the Department of Health and a Maternity Survey undertaken by the Care Quality Commission (CQC).

Inpatient Survey: Sandra Hallett advised that the Picker results were available but not the national

benchmarking results. She outlined the methodology and key outcomes. In 2010 UCLH had retained the gains made in 2009 and had also made progress on other questions. The Trust had scored significantly better than average on 26 questions (18 in 2009), significantly worse than average on 7 questions (1 in 2009) and achieved average scores on 55 questions (69 in 2009). Performance in comparison with our peer group of acute London teaching hospitals was good, having done significantly better than the peer average on 40 questions, which was more than half of the total, and worse on one.

The seven areas that had scored less well included patients feeling they should

have been admitted sooner, printed information about their condition, nurses not knowing enough about patients’ conditions or treatment, unavailability of hand gel and quality of food. Sandra Hallett advised that for some of these questions our performance had not deteriorated but the average score had risen. We had shown an improvement on all the 2009 low scoring results.

The key areas where our results were better than the Picker average included all

questions related to doctors, explanations about condition, surgery, anaesthetic and results, overall rating of care and whether patients would recommend UCLH to family and friends.

The next steps would involve more analysis at specialty level, an assessment of

priorities for improvements for this year and continued focus on actions identified through frequent feedback surveys. The national benchmarking results would be analysed when they were available.

Cancer Survey: Sandra Hallett advised that this survey was not part of the CQC’s suite of

surveys but had been undertaken by Quality Health on behalf of the DoH. Adult day case and inpatients at 158 trusts had been surveyed between January and March 2010, although the results had been published only two weeks previously. Of the 1290 eligible UCLH patients, 722 had responded – a response rate of 59%.

Performance was RAG (red, amber, green) rated in a similar way to the inpatient

survey but no information was provided on rankings, nor comparisons with other trusts’ performance given. However, it was possible to view reports on individual trusts. The survey had revealed differences between London and non-London trusts, with over half the trusts in the lower scoring 20% being in London, and London patients being significantly more critical of cancer services. Sandra Hallett had produced a table comparing our performance with peer London trusts. UCLH was in the middle of the group, but overall our performance had been disappointing.

The positive and negative themes arising from the survey were listed. Negative

outcomes included explanation at all parts of the pathway not adequate or understandable, incomplete or difficult to understand information, waiting in cancer outpatients, ward nursing staff and emotional support. There had been positive comments about specialist nurses, and doctors were considered to be

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highly qualified and excellent. It was noted that the survey was very different from the Inpatient Survey as it covered areas outside the control of UCLH about choice and the pathway.

National Maternity Survey: Sandra Hallett advised that this survey was conducted every three years and

had last been done in February 2010. At UCLH 360 women had been included and 162 had responded. The overall result compared with the 2007 outcome showed improvement in five areas, deterioration in 5 others and no change in the remaining 43. A comparison of the peer group showed UCLH was significantly better in giving women a choice of where to have their babies; encouraging women to make a birth plan, cleanliness of facilities and food choice. In addition fewer women rated their care during pregnancy as fair of poor.

We had performed significantly worse than peers on partner/companion not

being made to feel welcome, not treating women with respect and dignity during labour, not always having a staff member available in postnatal, provision of postnatal and infant feeding information.

Sandra Hallett reminded the Board that the maternity survey had been

conducted a year ago and since then a number of projects aimed at improving the service had been implemented, so it was anticipated that the next set of results would be better.

The Chairman thanked Sandra Hallett for the presentation. He said the Trust had

performed well in the national inpatient survey in three of the last four years and the staff should be congratulated. He felt the results of the cancer survey suggested that staff were not spending sufficient time with patients or taking a holistic approach to their care. Geoff Bellingan agreed that the results were disappointing. He had analysed them in detail to identify the issues we should focus on and there was a need to address these across the full range of cancer services. He reminded the Board that patients were not treated only within the Cancer Division, but the establishment of the Cancer Centre Project Team would enable all multidisciplinary teams to become involved in bringing about improvements.

The Chairman asked whether we had improved significantly in the maternity

survey. Gill Gaskin said the results were still not good enough but she was confident that the comprehensive action plan which had been developed would lead to further improvements. Sandra Hallett advised that we would be commissioning a further survey next year, rather than waiting for three years.

2/7 Chairman’s Report The report was noted.

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2/8 Chief Executive’s Report 2/8.1 Monitor Q2 Summary and Q3 Governance Declaration The report advised that the Trust was on plan to achieve a financial risk

rating of 4 and a governance rating of amber/red owing to the failure to achieve the 62 day cancer target and risk to the MRSA target.

The Q3 declarations had recently been submitted and the report advised

that the Chief Executive had signed declaration 2 due to the breach of the MRSA threshold and the continued difficulty in achieving the 62 day cancer wait target. The Chief Executive explained that this was partly out of our control and was due to late referrals of patients from other hospitals. However, meetings were taking place at Medical Director level to try to address this issue. It was noted that the National Cancer Team did not intend to amend the targets and the Trust would continue to be at risk of breaching the governance standards if this was not resolved.

The Board endorsed the approach to the Q3 submission outlined in the

report. 2/8.2 Quality, Efficiency & Productivity December Position The appendix providing a summary report on the QEP position was noted. 2/8.3 Health &Social Care Bill – Second Reading A briefing provided by the Nuffield Trust, summarising aspects of the draft

legislation, was attached to the report. The Chief Executive said the briefing accurately reflected our own views.

2/8.4 Health Round Table The Board was advised that the Trust had decided to join the Health

Round Table, which was a group of leading teaching hospitals which would meet periodically to undertake service benchmarking and provide expert advice on political and strategic NHS-related matters.

2/8.5 VIP Visits The report advised that two VIP visits had been planned. The first, by the

Prime Minister’s Health Advisor, had taken place on 2nd February and had included a tour of the Trust and a discussion on the new legislation. The second visit by Stephen Dorrell had been cancelled but would be rearranged.

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2/9 Executive Board Report 2/9.1 Monitor Compliance Framework 2011/2 The report advised of a number of proposed changes to the Compliance

Framework, the most significant of which was the introduction of five new A&E quality indicators.

2/9.2 Improving Outpatient Processes The Chief Executive advised that the Trust had established an Outpatient

Efficiency QEP group, chaired by Gill Gaskin, to lead on improving the quality and efficiency of outpatient services across all sites. A paper, which had been considered by the EB, was attached to the report and listed the achievements in 2010 and plans for 2011. Gill Gaskin said the work complemented the administrative systems workstream. The local outpatient surveys conducted in November would be repeated. A significant improvement in the outpatient clinic environment would be achieved following the closure of the Rosenheim Building and the relocation of clinics to UCH.

2/9.3 MRSA The Chief Executive provided an oral report on a presentation and lengthy

discussion at the EB that morning. To date this year there had been 11 cases of hospital acquired MRSA bacteraemias, of which eight were considered to be avoidable. A package of measures had been introduced but the EB had been informed that it was difficult to know whether any of these measures were more effective than others. The measures included the development of a screening dashboard which provided ward staff with daily real-time data about which patients had or had not been screened. Consideration would be given to expanding the dashboard to include other infections.

Following a focus of infection control resources in the UCH ITU and the

NNU, these two areas had been successful in reducing the incidence of MRSA and consideration was being given to extending the focus to the rest of the Trust. There was recognition of the need for cultural change and to embed a zero tolerance approach. The EB had agreed that a high profile event should be arranged to raise awareness and the Infection Control team had been challenged to come up with proposals for an event that would facilitate a step change.

The Chief Executive emphasised that the incidence of MRSA was now

only around 10% of the number of cases five years ago, and he felt that staff should be congratulated on this achievement. However, there must be a continued focus on further reducing MRSA. The threshold for next year was likely to be five.

Jane Ramsey queried how other trusts had managed to achieve zero.

The Chief Executive said there was no simple answer as this was a multi-

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factorial issue. However, he believed that we could achieve it too if sufficient resources were made available. A starting point was to look at the causes of avoidable cases and strengthen procedures.

The Chairman said he had been taking a personal interest in this issue

and had discussed it with Annette Jeanes on a number of occasions. He was proposing to visit the Royal Free which was one of the trusts that had achieved zero MRSA. He agreed that a cultural change was required and said the Board should support the management focus on this issue.

2/9.4 Capital and Estates Issues The issues were noted. 2/9.5 Management Development The report advised that the EB had approved the implementation of a

management development programme designed to complement the professional training and development that was already in place for clinical staff.

2/9.6 Senior Information and Risk Owner (SIRO) Report The biannual SIRO report was attached to the EB report and presented

by Mike Foster who drew attention to the challenges of demonstrating compliance with level 2 of the Information Governance Toolkit.

2/9.7 Requests under the Freedom of Information Act The report was noted. 2/9.8 Policy Approvals The Board noted a number of new policies that had been approved. 2/10 Performance Report Simon Knight presented the report and said a number of the issues had already

been referred to by the Chief Executive. He emphasised that if the Trust was red rated in Q4 for either of the cancer indicators, our overall governance rating would be red. The key action was prospective reporting on waiting times and Urology was leading the way on this. The 62 day screening target, although met in December, was still an issue in Q3 and some breaches were due to patient choice.

Performance on VTE risk assessments had remained stable. With regard to

CQUIN target on nutrition an action plan was being put in place to ensure the Trust complied with the necessary NICE/CQUIN requirements.

Richard Delbridge asked whether the threshold in the Workforce section related

to percentage of monthly absence forms returned should be 100% rather than

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80%. David Wherrett said the threshold related to the proportion of staff using an electronic system for reporting staff absences. He anticipated that performance would improve when we moved to the Electronic Staff Record.

The Chairman asked about the reasons for the lower referrals. The Chief

Executive said this was partly due to limitations being put in place by commissioners and we would have to carry out analysis to assess the impact on income, which would depend on the proportion of outpatient activity that translated to inpatient work. In response to a question from Jane Ramsey, Simon Knight said analysis of market share demonstrated that although referrals were down, we were retaining our proportion of market share. Mike Foster said there was anecdotal evidence that commissioners’ policy was not to allow patients to choose UCLH because of our comparatively high costs. The Chief Executive said that as a central London-based trust our costs were inevitably higher but the problem had been exacerbated by the fact that the market forces factor had been included in tariff prices. As a result patients were being denied the choice of attending top quality teaching hospitals. All central London teaching hospitals were experiencing the same problem and the Chief Executive said we may have to be prepared to challenge this.

Jane Ramsey referred to the cancer access targets and asked whether there

was a link between the performance against the 31 day wait from diagnosis to first treatment and the 62 day wait for first treatment from GP referral. The Chairman proposed that Geoff Bellingan should discuss this further with Jane outside the meeting.

Action: Medical Director, Surgery & Cancer

2/11 Quality and Safety Committee The reports of the meetings held in December and January were noted. Tony

Mundy highlighted the focus on infection control and Annette Jeanes’ attendance at the January meeting. With reference to the comment in the report that level one child safeguarding training required improvement, Gill Gaskin advised that the training data had proved to be inaccurate and had under-recorded the number of staff who had been trained. The QSC would be discussing this further. Tony Mundy emphasised that child safeguarding arrangements in the Trust were very good.

2/12 HR & Communications Committee The report was presented by David Wherrett and the key issues were noted.

The Chairman commented that the report provided no information on the outcome of the benchmarking exercise on various workforce metrics. David Wherrett noted the comment and advised that this would be covered in the presentation in Part 2 of the meeting.

2/13 Finance & Contracting Committee The report was noted. The Board endorsed the view of the FCC and EB that

the Trust should declare it believed it would retain a Financial Risk Rating of at

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least 3 for the next 12 month period, based on the assumptions as set out in the report.

Richard Delbridge noted the references to budgetary pressure due to the

increase in the RPI and asked whether there was any scope to renegotiate the RPI clause as prescribed within the PFI contract, particularly given other changes that had been made by the Government regarding a move from RPI to CPI (for example pension indexation). Mike Foster expressed doubt whether this was possible; however, he would contact the DoH Private Finance Unit to make further enquiries.

Action: Deputy Chief Executive

2/14 Report of the Audit Committee Meeting held on 27th January 2011 The report was noted. 2/15 Minutes of the Audit Committee Meeting held on 25th November 2010 The minutes were noted. 2/16 Any Other Business There was none. 2/17 Date of Next Meeting The next meeting would be held on Wednesday 9th March 2011. The Board of Directors resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

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B

Agenda Item 3

Matters Arising Report


BOARD OF DIRECTORS

REPORT ON MATTERS ARISING FROM THE MEETING HELD ON 9th FEBRUARY 2011

Minute no.

Issue Outcome

2/10 Performance report: link between performance on 31 day wait from diagnosis to first treatment and 62 day wait from GP referral to first treatment to be discussed between Geoff Bellingan and Jane Ramsey

Geoff Bellingan has communicated with Jane Ramsey on the issue. Action completed.

2/13 FCC report: Contact DoH Private Finance Unit on the question of scope to renegotiate the RPI clause of the PFI contract

Mike Foster is due to meet with the PFU on 4th March to discuss this issue. An oral update will be given at the meeting.

Items from previous meetings brought forward

Date of Meeting

Minute ref.no.

Issue Action

August 2010

8/9 Quality & Safety Committee report: Develop proposals for revised complaints-handling system

A report on the outcome of a pilot of the new complaints process was due to be presented to the QSC in February and the Board in March. The review is still

ongoing and a report will come to the May Board meeting.

Items from previous meetings carried forward to future meetings

Date of Meeting

Minute ref.no.

Issue Action

December 2010

12/6.2 Dr. Foster Good Hospital Guide – analyse report and produce action plan

An action plan to address areas for improvement will be developed and presented to the May Board.

October 2010

10/10 Submit report to the Board on processes for providing assurance on clinical audit/quality and safety issues

This work is still in progress. A report will be submitted to the Audit Committee in March and the Board in May

explaining current processes for providing assurance on quality and safety issues. It will also address how the processes might be strengthened to improve effectiveness.

Cancer experience at UCLH

Cancer at UCLH

Understand the Pathways

Discuss the cancer centrewhy this will be different

Managing all of cancer across UCLH

Services in Cancer Centre 1

Self managed follow up

Specialist follow up

More treatment

Diagnosis Treatment agreed Treatment

GP

Referral

Screened

RadiotherapySurgery

in main tower

Specialist diagnostics

in main tower

Cancer pathway managed by Cancer Centre from

initial GP referral

Examples: breast, prostate, lungReason for GP referral is suspected Cancer

Reassurance




More treatment

Diagnosis Treatment agreed

More treatment

RadiotherapySurgery

in main tower


in main tower

Examples: colorectal, acute leukemia

Cancer pathway managed by Cancer Centre after urgent treatment

Inpatient treatment provided after

initial diagnosis

Pathways not involving Cancer Centre much or at all


Diagnosis surgery Treatment

Radiotherapyin main tower


in main tower

Examples: referrals from A&E or other hospitals to UCLH specialist cancer teams, eg. Brain

Referral after fit

Treatment

Surgery At Queens

Square

Follow-up At Queens

Square

The Cancer Pathway



More treatment


RadiotherapySurgery

in main tower


in main tower

Populationat risk




More treatment


GP

Referral

Screened

RadiotherapySurgery

in main tower


in main tower


initial GP referral

Examples: breast, prostate, lungReason for GP referral is suspected Cancer

Reassurance




More treatment


RadiotherapySurgery

in main tower


in main tower


suspected Cancer referral

Examples: referrals from other hospitals to UCLH specialist cancer teams, urology, gynae, upper GI

Referral after initial diagnostic test




More treatment

Diagnosis Treatment agreed

More treatment

RadiotherapySurgery

in main tower


in main tower

Examples: colorectal, acute leukemia

Cancer pathway managed by Cancer Centre after urgent treatment

Inpatient treatment provided after

initial diagnosis

Macmillan Cancer Support



More treatment


RadiotherapySurgery

in main tower


in main tower

Name for support service to be agreed

Stratifying care

Pathway support

1. Scheduling

2. No wait appointments

3. Electronic booking

4. CDR upgrade

5. Check and track

6. Patient portal

7. Volunteers / admin team

8. Pathway co-ordinators

9. Communication

10. Culture

NanoKnife® IRE System

MLC 375 US Rev A

No Electroporation

+ -

Irreversible Electroporation

+ -

New therapies

Established by Board to provide clinical leadership to cancer across UCLH

Chair: Geoff BellinganMembership: All three clinical boards,

UCL Macmillan

Met first 17th Feb 2011Established proposed work programme for 2011

Cancer Clinical Steering Group

Improve cancer patient experience:QH: MDTs presented their relevant results from cancer surveyAgree action plans to respond – MDT, nursing, CCSG…Clinical and operational policies embedded:

Design and feel, waiting times, cancer centre and beyond…Regular pt feedback Macmillan: experience, organisational and patient user group

Agree criteria to judge MDT performance(and their pathways)

Collect, review, respond, improve…Working relationship with primary providers and network

Cancer Clinical Steering Group

Open Cancer Centre on time and in budgetEmbed new ways of working outlinedWork with the sector:

Pathway DirectorsNHS London plans:

Commissioners will engage with <5 networks

Challenges

Clinical leadership

Jane Maher

Medical Director

Macmillan

Mark Emberton

Cancer Centre

Clinical Champion

Geoff Bellingan

Medical Director

UCLH

Tumour leads

Patient experience and effective MDTs

Clinical leads

Driving new models of care

Pathway Directors

Working across UCLP

C

Agenda Item 6

Chairman’s Report


CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS

9 MARCH 2011

1. REVIEW OF THE TRUST CONSTITUTION

Following the Governing Body in November I established a small working group to review the Constitution. Since it was last revised in 2008 it became apparent that a small number of areas would benefit from review including our narrow public area and the composition of the Board. I endorse the conclusions and recommendations of the group which are attached in a paper at Appendix A for consideration by the Board. The Governing Body will receive a similar paper to consider at its meeting on the 30th March. If supported, the revisions will be submitted for a final review to our legal advisors and a revised Constitution will subsequently be submitted to Monitor. I would also like to record my thanks to both governors and board members who contributed to this piece of work.

2. LONG SERVICE AWARDS

On 22nd February, I was very pleased to be able to present the Long Service Awards to members of staff who have worked for the Trust or its predecessors for over 25 years. It was particularly striking to see the range of NHS professionals who have shown such loyalty. As ever, we are very grateful to the UCLH Charities for sponsoring the awards. The following were the recipients: Beverley Astley, EDH Consultant Anaesthetist Rina Bonaventura, Diabetes and Endocrine support administrator Siew-Peng Crevel, EGA Senior Staff Midwife Libby David, UCH site manager Sharon Davis, Ophthalmology Clinic Coordinator Nenita Enriquez, NHNN Staff Nurse Norma Facey, Outpatients Sister Aurea Fenty, Rosenheim Department Administrator Ellen Gregory, A&E Angela Hawkins, Heart Hospital Senior Chief Cardiac Physiologist Kamlu Jeswani, EGA Alison Johns, EGA Transitional Care Sister Steven Jones, EDH Consultant in Orthodontics Marios Karseras, UCH Mortuary Service Manager Marcellous Lewis, NHNN Porter Lesley Morton, NHNN Senior Nurse Chandra Mubaiwa, UCH Acute Medical Ward Christopher North, UCH Clinical Nurse Specialist Been Teen Ooi, UCH Clinical Site coordinator Damiantee Ramdoo, EGA Healthcare Assistant Rebecca Ridge, Rosenheim Rheumatology Infusion Clinic Cheryl Roberts, Workforce Information Advisor Pete Robbins, Surgical Admissions Officer Christopher Tims, Chief Biomedical Scientist Amanda Todd, EDH Office Manager Kate Welford, UCH Clinical Nurse specialist Pow Ling Wong, UCH Theatre Sister and team leader Indranee Wood, UCH Staff Nurse

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3. QEP WEEK

The week commencing 28th February was QEP Week in the Trust. It was a chance for departments and wards to celebrate the successes they have achieved this year and an opportunity to prepare for the second year of this very challenging programme. A number of Board members have visited the Trust’s hospitals to understand better what has been achieved. I went to the Heart Hospital on 28th February. I was very interested to learn more about the programme there and to talk about its implications with a number of members of staff.

4. MOLLY LANE FOX BRAIN TUMOUR UNIT

At the time of writing I am due to attend on 3rd March the formal opening of the Molly Lane Fox Brain Tumour Unit at the NHNN. This ceremony follows on from the visit by Boris Johnson, Mayor of London, last summer when he unveiled an inaugural plaque outside the unit. I am looking forward to meeting again Molly’s family and to be able to express the gratitude of the Trust to them and to the National Brain Appeal for funding this splendid new facility, the first of its kind in the UK.

5. GP VISITS

I have continued with the programme of GP visits, accompanied by Paul Glynne, Medical Director for Medicine and Daniel Wallis, Clinical Director for Emergency Services. Since the last Board meeting, we have visited two more practices – The Caversham Group and The Amwell Group Practice - and attended the NHS Islington Locality Group meeting. In each case it was as ever helpful to be able to understand how GPs view the Trust’s performance and exchange views as to how we could work better together in future.

RICHARD MURLEY CHAIRMAN

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CHAIRMAN’S REPORT TO THE BOARD OF DIRECTORS – PART 1 – APPENDIX ‘A’


Report to the Board - 9th March 2011

Revision of the Trust’s Constitution

A Paper for Decision

1. Introduction Since the Trust was authorised as a Foundation Trust in 2004 it has revised its Constitution on two occasions.

The Chairman established a small review group comprising five governors and one non-executive director, supported by the Trust Secretary, to consider changes to the Constitution. The group met on two occasions between January and February. It considered a report on aspects of the Constitution that might benefit from review and concluded that a number of areas warranted revision; the issues under consideration were also circulated to governors for comment. As a group a degree of consensus was achieved, the group endorsed the recommendations outlined in the report and no fundamental concerns or issues were raised by governors.

The Trust may amend its Constitution following a process outlined at paragraph 22.2 of the Constitution which states; No proposal for the amendment of [UCLH’s] Constitution shall be submitted to the Independent Regulator unless it has first been approved by the Board of Directors who shall have consulted with the Governing Body before doing so.

However, in order to ensure that the Trust meets its 2011 election timetable amendments need to be submitted to Monitor in early April. This can be achieved if the Board of Directors approves the revisions at its meeting on 9th March 2011 subject to considering any comments from the Governing Body following its meeting on 30th March 2011.

The Board should note that; • the Trust’s legal advisors have been asked to review the proposed changes; the

group considered all the issues they raised; • the legal advisors have been asked to make any typographical or other minor

corrections; • the Governing Body Standing Orders will require revision; these will be presented

for approval at the Governing Body meeting on 4th July 2011.

This report sets out the proposed changes to the Constitution (Schedule 1 of the Trust’s Terms of Authorisation); the amendments are listed below and where more detail is required this is provided in Appendix A.

2. Specific Amendments The group reviewed the overall composition of the Governing Body; it looked at both the membership constituencies and the allocation of stakeholder positions. In reviewing the seats the group did not consider changing the overall balance of the Governing Body.

2.1 Membership Constituencies Board members will recall that in 2008 changes were made to the staff classes; the Governing Body agreed to return to the membership constituencies at a later date.

The group reviewed the three membership constituencies and the distribution of governor seats. The review concluded that the public geographical area should be expanded and the number of patient classes reduced. Proposals to amend the staff constituency were considered; it was agreed there should be no further changes at this time.

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The proposal It was agreed that there was greater public interest in the Trust than when it was first authorised in 2004. It had established itself as a leading London Trust; was part of the largest AHSC in Europe conducting research delivering benefit to both patients and the wider population; and had developed partnerships with other health organisations e.g. the Christie for PBT. The group proposed that the public area be extended to include inner London as listed in Appendix A. The group proposed the patient constituency be subdivided into three rather than the current four classes; this would be achieved through the merger of the local and regional groups into one class covering the same geographical area. Governors elected to patient seats would all be referred to as patient governors in the same way as staff are called staff governors. However, for the purpose of providing a definition in the Constitution the new combined class would be called Patients – London; the current National class would be renamed Patients – Elsewhere. There would be no change to the Patient- Carer class.

To support the change it is proposed the seats are distributed as outlined in the table below. Transition arrangements will be incorporated in the Constitution to ensure that all current elected governors retain a position on the Governing Body for the remainder of their tenure. See Appendix A for new paragraph.

Constituency / Class Number of seats

Public – Inner London 4

Patient – London 9

Patient – Elsewhere 3

Patient - Carer 1

Staff (no change) 6 seats in total

Table1 – Distribution of 23 elected seats

2.2 Patient Constituency Two specific changes were proposed to the Patient section.

(i) Although parents of young patients can currently join the Trust it was agreed that this should be made explicit in the relevant section. However, it was noted that this could only be given to the parent of a patient under 14 as at age 14 a patient could become a member in their own right – Appendix A.

(ii) To avoid the cost of a by-election when an elected governor leaves office mid term it was agreed that the Trust should introduce a reserve governor position. This provision already exists for staff. However in the case of patient governors this will be limited to two reserve positions only. This new reserve clause would also apply to public candidates. However, to ensure public and patient governors are in the majority the paragraph will include a provision to hold an election if one is required. - Appendix A.

2.3 Staff Constituency It was agreed the position of the Trust’s volunteers should be clarified. Generally the volunteers do not consider themselves staff and many have applied to join the Trust as patient or public members. The act states staff employed by a voluntary organisation qualify under the staff rule. Voluntary organisations in this context mean for example the Red Cross or WRVS. On this basis the group agreed that Trust volunteers should not be considered staff.

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2.4 Stakeholder Governors

The group considered the composition of stakeholder seats. The Chairman had suggested that the Trust should strengthen its engagement with GPs to recognise the emerging health reforms. The group also considered that the Trust should seek a representative from UCL Partners who were considered to be a key stakeholder of the Trust.

A Trust is only required to have one PCT governor; it was therefore proposed that a GP governor replace the Westminster PCT representative. The WPCT position is due for review at the end of March 2011; when the new bill is passed all PCT positions will need to be reviewed.

To accommodate UCL Partners it is proposed that the seat assigned to the UCLP Research Group is transferred to UCL Partners. UCL Partners is Europe’s largest AHSC and through this governor the Trust will ensure it has a partner with a research interest on the Governing Body. The distribution of stakeholder seats is outlined in table 2 below.

Governor Seats PCT – Camden and Islington 2 Local Authority – Camden and Islington 2 University – UCL 1 Friends of UCLH 1 UCL Partners 1 UCLH Charities Committee 1 London South Bank 1 GP representative 1

Table 2 - Distribution of 10 appointed seats

The Trust was advised by its legal advisors that it could future proof its Constitution. In the unlikely event that either Local Authority failed to nominate a representative the provision exists to approach an alternate organisation without referral to Monitor subject to the organisations being named in the Constitution. It is therefore proposed that the City of Westminster and the City of London are named as alternate qualifying local authorities. Both authorities fall within the public area.

2.4 Board of Directors The Chairman suggested that the Trust increase the number of non-executive directors to six. The group considered this and agreed that an additional NED on the Board would increase the number of independent non-executive directors and create a more suitable balance of power; this would enable the Trust to better comply with the Monitor FT Code of Governance. In addition the Chairman had indicated that an additional NED would help to cover the increasing workload.

The group also considered the appointment process for non-executive directors (including the Chairman). While the power to make the decisions about these matters sits with the Governing Body and this should be reflected in the Constitution it was agreed that the detailed processes currently described in section 9.6 and 9.7 of the Constitution should be transferred into Standing Orders. This would allow the Governing Body to make changes to its procedures should it wish to without having to refer to Monitor. The revision would refer to the role of the Nomination and Remuneration Committee and the statutory responsibilities of the Governing Body regarding appointments, remuneration and Chairman’s appraisal.

3. General Amendments A number of other amendments were discussed which would assist with procedure or correct errors in the current Constitution. These are listed below.

3.1 Staff Membership The requirement to be at least age 14 before you can qualify as a Staff member will be removed.

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3.2 Disputes Procedure

The current procedure requires the Governing Body to resolve all issues; it has been redrafted to set out a clear procedure for dealing with disputes - Appendix A.

3.3 Code of Conduct The group were advised that Board members were asked to comply with a Code of Conduct which included the Nolan Principles. Monitor’s reference guide for governors advises that these principles should also apply to governors. Having a code would also assist the Governing Body should it need to consider terminating a governor’s position. It was therefore agreed that a succinct Code of Conduct should be included as an Annex to the Constitution. The draft code is attached at Appendix B.

3.4 Declaration of Interests The Constitution will refer to the requirement to make a declaration of interest; the detail will be transferred into the Standing Orders of both the Governing Body and Board of Directors.

3.5 Eligibility Certificate Governors are required to annually declare that they are eligible to be a governor. An eligibility certificate has been developed for this purpose and will be included as an Annex to the Constitution.

4. Recommendation The Board is asked to approve the following amendments subject to consultation with the Governing Body in order that the variations can be submitted to Monitor.

(a) The proposed revisions set out in Appendix A including the extension of the Public Area;

(b) The proposal to reduce the patient constituency to three classes;

(c) The redistribution of elected seats as outlined in table 1 and table 2 of the report;

(d) That volunteers are no longer classified as staff members;

(e) That the City of Westminster and the City of London are named as alternate Local Authorities;

(f) That the number of non-executive directors is increased by one and the detailed appointment process is incorporated into Standing Orders; and

(g) The amendments set out in section 3 of the report, including the Code of Conduct attached as Appendix B.

If following consultation with the Governing Body at its meeting on 30th March 2011 further changes are proposed the Board is asked to delegate the decision to consider and accept any changes to the Chairman and Chief Executive.

Tonia Ramsden Trust Secretary 4th March 2011

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Appendix A Proposed Amendment to the Constitution Public Area Section Annex A - Area of qualification Current provision London Borough of Camden

London Borough of Islington The following wards in the City of Westminster: • Marylebone High Street • West End • St James The following wards in the City of London: • Farringdon Without • Farringdon Within • Aldersgate • Cripplegate • Bassishaw • Cheap • Cordwainer • Walbrook • Vintry • Queenhithe • Castle Baynard • Bread Street • Coleman Street • Dowgate

Revised draft provision London Borough of Camden London Borough of Greenwich London Borough of Hackney London Borough of Hammersmith and Fulham London Borough of Islington London Borough of Royal Borough of Kensington and Chelsea London Borough of Lambeth London Borough of Lewisham London Borough of Southwark London Borough of Tower Hamlets London Borough of Wandsworth London Borough of Westminster City of London

Reason for change Increase public engagement and involvement; reduce incidence of membership disqualification by postcode within specific streets of Westminster and city of London.

Transition arrangements Section New section Current provision No provision Revised draft provision No amendments to this Constitution shall affect the validity of appointments

made, action taken or processes followed prior to the adoption of the amendment.

Upon the adoption of amendments to this Constitution, the posts within the Trust and procedures to be followed shall be reorganised accordingly to give effect to the amendments and, to the greatest extent possible, such persons appointed prior to the amendment shall be deemed to be appointed to positions stipulated in the Constitution, as amended.

Reason for change To provide a clause to accommodate changes to the Governing Body from time to time

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Patient Carers Section Patient Constituency paragraphs 7.4.6.1 Current provision provide care on a regular basis for a Patient Revised draft provision provide care on a regular basis for a Patient who has not attained the age of

14 years or who is by reason of mental or physical capacity unable to discharge the functions of a Member; and

Reason for change To enable parents of patients under 14 to join as members. Board members should note that the carer and the patient cannot both be members this is unconstitutional – the patient constituency is one constituency; if both the parent and patient are members they are considered as having two votes.

Reserve list Section New section Current provision No provision New draft provision Where the office of a Public Governor or Patient Governor falls vacant for

any reason the Trust shall offer the candidate who secured the second highest number of votes in the last election for the constituency (or Class of constituency, as the case may be) in which the vacancy has arisen the opportunity to assume the vacant office for the unexpired balance of the retiring Governor’s term of office. If that candidate does not agree to fill the vacancy it will then be offered to that candidate who secured the third highest number of votes. If no reserve candidate is available or willing to fill the vacancy, an election will then be held in accordance with the Election Scheme at Annex 2 save that, if an election is due to be held within twelve months of the vacancy having arisen, the office will stand vacant until the next scheduled election unless by so doing this causes the aggregate number of Governors who are Public Governors or Patient Governors to be less than half the total membership of the Governing Body. In that event an election will be held in accordance with the Election Scheme as soon as reasonably practicable.

Reason for change To avoid the unnecessary expense of a by-election should a governor no longer qualify as a governor or choose to resign from their position. The position would be filled for the unexpired term of office.

A similar clause was successfully used to fill a staff vacancy when a governor left UCLH to take up a new post.

Disputes Procedure Section Dispute resolution procedures – paragraph 22 Current provision Dispute resolution procedures shall operate in the following circumstance:

for disputes involving Members in relation to matters of eligibility and disqualifications, the dispute shall be referred to a committee of the Governing Body composition of which is determined by the Chairman.

for disputes with Governors in relation to matters of eligibility, disqualifications and termination of tenure, the dispute shall be referred to the Governing Body; andfor other disputes, such as between the Governors and the Board of Directors, the parties may resolve the same by agreement or by such other means as are appropriate and available.

New draft provision Dispute resolution procedures shall operate in the following circumstance:

In the event of any dispute about entitlement to membership a member or prospective member shall be invited to an informal meeting with the Trust Secretary to discuss the matter in dispute. If not resolved, the individual may refer the dispute in writing within 14 days of the decision of the Secretary to a panel of the Chairman and Lead Governor or another elected governor if lead governor has an interest or is not able to attend. The decision of the panel shall be final.

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In the event of any dispute relating to eligibility, disqualification or termination a governor or prospective governor shall refer the dispute to the Chairman who shall make a determination on the point at issue. If the dispute is not resolved the individual may appeal in writing within 14 days of the decision to a panel of the Chairman and lead governor or another elected governor if lead governor has an interest or is not able to attend. The decision of the panel shall be final.

If through informal efforts the Chairman is unable to resolve a dispute between the Governing Body and the Board of Directors the Chairman shall set up a special ad hoc committee (a resolution committee) comprising no more than eight members of which three will be board directors including the Chairman and Chief Executive and five will be governors including the Lead Governor to consider the circumstances and make a recommendation to the Governing Body and the Board of Directors with a view to resolving the dispute. The aim of the meeting will be to achieve resolution. The Chairman will have the right to appoint an independent facilitator to assist the process. The recommendations (if any) of the resolution committee are unsuccessful in resolving the dispute the Chairman may refer the dispute back to the Board of Directors to decide on the matter. A clause will be included to ensure that if there is a conflict of interest in relation to the business being discussed that individual will not be invited to be a member of the ad-hoc committee.

Reason for change To ensure a written process is agreed and can be enacted should it be required.

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(Draft) Code of Conduct for Governors Appendix B

Governors at UCLH Foundation Trust are required to:

1. Uphold the Nolan principles* of public life; 2. Attend Governing Body meetings; 3. Attend induction, seminars and training events as required; 4. Declare political affiliations; 5. Comply with the Trust’s Constitution and Governing Body Standing Orders; 6. Comply with the confidentiality requirements of the Trust; 7. Follow the Trust’s Guidelines for Governors in dealing with the media; 8. Treat colleagues, staff and patients equally and comply with equality legislation^.

* The Seven Principles of Public Life (Nolan)

Selflessness: Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends. Integrity: Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties. Objectivity: In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability: Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness: Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty: Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership: Holders of public office should promote and support these principles by leadership and example. These principles apply to all aspects of public life. The Nolan Committee has set them out here for the benefit of all who serve the public in any way.

^Equality legislation covers age, disability, gender, race, religion and belief and sexual orientation.

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D

Agenda Item 7

Chief Executive’s Report


CHIEF EXECUTIVE’S REPORT TO THE BOARD OF DIRECTORS

9 MARCH 2011

1. CHAIR OF MONITOR

The Board may be aware that David Bennett has been appointed as Non-Executive Chair of Monitor. I attach a letter (Appendix A) sent to Foundation Trusts setting out his immediate priorities. An early task will be to recruit a permanent Chief Executive – he will continue as Interim Chief Executive in the meantime. He states that the Government has said that it has no intention of asking Monitor to lower its assessment bar and this is something that he is equally clear about. He expresses the intention for Monitor to become an exemplary economic regulator, promoting competition where appropriate and regulating effectively where necessary. His main duty is ‘to protect and promote the interests of people who use healthcare services’.

2. MRSA ESCALATION I attach as Appendix B, a letter from the Senior Compliance Manager at Monitor in connection with our breach of the MRSA target. In the light of the circumstances, described in the letter, Monitor has decided that the Trust will not be formally escalated at this stage. The automatic override resulting in a red governance risk rating will not be applied at Q3 and the Trust’s risk rating will reflect its underlying service performance score.

3. CO-OPERATION AND COMPETITION PANEL (CCP) – ‘ANY WILLING PROVIDER’

I should like to bring to the Board’s attention an interim assessment of the CCPs review of the operation of ‘any willing provider’ for the provision of routine elective care. This report was issued at the same time as Mike Foster and I met with the Chief Executive of the CCP when we expressed concern about the emerging plans of a number of commissioners. The report deals with two main issues, the problems in transferring independent sector providers of NHS funded care to PCT-based contracts and broader concerns that a significant number of PCTs are engaging in behaviours that could raise issues of consistency with the principles and rules for co-operation and competition. It is this latter aspect which is of particular concern to the Trust. The report expresses concern about a pattern of behaviour by PCTs (and SHAs acting on behalf of PCTs) that could breach the principles and rules, as well as obligations arising under the NHS constitution. In particular the alleged behaviour includes:

• Restricting Patient Choice of provider for routine elective care through directions to GPs, waiting list requirements and referral processes which direct patients to particular providers.

• Inserting provisions into contracts with providers that restrict Patient Choice including, for example, activity caps and reductions in the type of procedures that providers can offer.

• Creating incentives that undermine Patient Choice, for example, setting different prices for different providers, local price negotiations and block contracts.

1

Lord Carter of Coles, the Chairman of CCP, comments ‘our interim report highlights that some parts of the NHS have yet to fully embrace the role of choice and competition. Both NHS and independent sector providers are being hampered in their efforts to deliver the kind of choice that is expected by patients. Through our review, we aim to better understand the motivation for this restrictive behaviour and how it might be addressed’.

At the time of writing this report, the Health Service Journal has reported on a statement made by the Secretary of State, that he will amend the Health Bill to ensure his policy of tariff as ‘a maximum’ price will not introduce competition on price. He is quoted as saying that the Government wants the tariff to be a nationally regulated price, not a starting point for price competition.

4. FOUNDATION TRUST NETWORK AND ITS SUBMISSION TO THE DEPARTMENT OF

HEALTH

The Board will recollect, from previous reports, that members of the NHS Confederation, including the Foundation Trust Network, were balloted on the issue of FTN independence from the NHS Confederation. The ballot concluded that 77% were in favour of independence for the FTN. This matter is now being taken forward with the NHS Confederation Trustees who will want to ensure that independence for the FTN is closely tied in to solving the ‘going concern’ issue for the NHS Confederation. In its role as representing the interests of Foundation Trusts, the FTN has written to the Deputy Chief Executive of the NHS (a copy of which I attached as Appendix C). The letter covers a number of issues of significant importance to UCLH. It provides evidence that the mean average cost improvement programme (CIP) that Foundation Trusts are facing is 6.33%. The FTN suggests that for many organisations this means serious financial stress that will lead to the loss of many thousands of jobs and will seriously endanger waiting times and services for vulnerable patients, as well as threatening organisational survival. The FTN comments that it does not believe that this is the policy intention. A second issue concerns the policy on emergency readmissions and argues that they are largely caused by patients with conditions unrelated to the original treatment, or are entirely justifiable in the interests of patients. A third issue, which was particularly raised by UCLH, concerns the timescales in which providers are expected to agree contracts this year. The failure to agree contracts by 31st March may result in Trusts being reimbursed on a ‘pay as you go’ basis which could result in a delay in payments (perhaps up to three months) with severe liquidity implications. The letter concludes that there is a growing sense of frustration that whilst there is money in the system, it is just not getting to the front line of patient services and even the most efficient Foundation Trusts will be pushed into failure. This view reflects the discussions at the Finance & Contracting Committee.

5. TRUST-WIDE IT INCIDENT

On 2nd February we experienced a Trust-wide network performance problem such that PCs across the Trust were unable to access most of our systems. The problem was caused by a faulty network switch. The network management tools at UCLH had reported the irregularity on the data network, but the origin was unidentifiable. The impact on hospital services was extensive and resulted in the closure of A&E to blue light traffic, and the cancellation of operations at the Heart Hospital and UCH. Due to the nature of the problem the ICT team together with external IT experts were forced to systematically disable individual sections of the trust network including connection to our

2

primary data centre in order to isolate the faulty component, this was extremely complex and took a considerable time. As designed, some systems automatically switched over to the backup systems located in our disaster recovery centre however this made no difference to their availability as PCs were still unable to gain access as a result of the severe network performance issue. It should be stressed therefore that the data centre itself worked as intended as was not part of the problem. Following this incident we are undertaking a full investigation of the network design and components, to verify if there are any design issues to be addressed, and to establish if we have any remaining equipment of the same age and configuration. An external lead investigator is being appointed from RSM Tenon to take this forward and in order to identify lessons for the future.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

3

22 February 2011

Sir Robert Naylor Chief Executive University College London Hospitals NHS Foundation Trust Trust Headquarters 2nd Floor Central 250 Euston Road London SW1H 9NP

Dear Robert,

MRSA escalation – University College London Hospitals NHS Foundation Trust (the

“Trust”)

1. The Trust has declared as part of its Q3 2010/11 submission to Monitor that it has

breached its full year MRSA target with 10 cases versus a full year target of 8.

2. The purpose of this letter is to set out:

a. Monitor’s concerns in relation to the Trust’s MRSA performance;

b. the process adopted in considering whether the Trust should be formally escalated to

determine whether or not it is in significant breach of its terms of Authorisation; and

c. the next steps.

3. Monitor’s concerns

3.1 The Trust has breached its full year MRSA target with 10 cases reported at Q3 2010/11

versus a full year target of 8.

4 Matthew Parker Street

London

SW1H 9NP

T: 020 7340 2400

F: 020 7340 2401

W: www.monitor-nhsft.gov.uk

http://www.monitor-nhsft.gov.uk/

Monitor views the achievement of targets and service performance as an indicator of

governance and the Compliance Framework sets out the significance Monitor attaches

to a failure to comply.

4. Consideration for escalation

4.1 Monitor’s approach to escalating HCAI breaches of trajectories and full year targets is

set out in the 2010/11 Compliance Framework at Appendix C (as amended on 2 July

2010). If during the year, an NHS foundation trust breaches the target in three

successive quarters, Monitor will triple the service performance score associated with

the breach, the NHS foundation trust will be red-rated for governance risk and Monitor

will then determine whether or not the NHS foundation trust is in significant breach of its

Authorisation. In making this determination, Monitor will assess each breach of an NHS

foundation trust’s Authorisation in light of the specific facts and circumstances of the

case.

4.2. Monitor’s approach was further clarified in the FT Bulletin (issue 40) dated 17 December

2010. Where it is clear that a trust has failed a full-year governance trigger in-year,

Monitor will consider at that point in time whether the Trust should be escalated to

determine if it is in significant breach of its terms of Authorisation.

4.3. The Trust’s MRSA performance at Q3 2010/11 falls within the situation described

above. As a result, Monitor has considered whether the Trust should be formally

escalated to determine whether or not it is in significant breach of its terms

Authorisation.

4.1. In making its decision, Monitor has considered the following:

The Trust had a target of 25 cases in 2009/10 and achieved 22 cases. The 2010/11

target represents a 64% reduction compared to the actual number of cases over

2009/10.

The Trust had 3 cases in Q1 and hence no breach was scored. The Trust had 7

cases YTD at Q2, and consequently declared a risk to breaching its full year target of

8 cases.

The Trust wrote to Monitor in October 2010 to advise of the potential risk to achieving

the 2010/11 threshold of 8 cases. The Trust emphasised that reducing MRSA is a

key objective and priority and set out the steps being taken to achieve this.

The Trust has provided assurance that it has had an action plan in place since April

2010. While Monitor has not required sight of the action plan, we have been

provided with assurance that the Trust is doing everything it can to reduce MRSA.

4.2. In light of the above, Monitor has decided that the Trust will not be formally escalated at

this stage. The automatic override resulting in a Red governance risk rating will not be

applied at Q3 and the Trust’s risk rating will reflect its underlying service performance

score.

5. Next Steps

5.1. Compliance with targets and national priorities is a requirement of the Trust’s terms of

Authorisation. Monitor expects the Trust to have plans in place and to deliver them

effectively to reduce the incidence of MRSA cases during the remainder of the year

2010/11 and to ensure a return to compliance with the target on a sustainable basis in

2011/12.

5.2. As a result, at the conclusion of Q4 2010/11, Monitor will consider further the Trust’s

position with regards to MRSA cases and decide whether the Trust should be formally

escalated at that stage to determine whether or not it is in significant breach of its terms

of Authorisation and if so, what further regulatory actions would be appropriate.

If you have any queries relating to the above, please contact me by telephone on 020

7340 2429 or by email [email protected]

Yours sincerely,

Will Rowberry

Senior Compliance Manager

Direct line: 020 7340 2429

1

Foundation Trust Network 29 Bressenden Place

London SW1E 5DD

www.foundationtrustnetwork.org

David Flory Deputy NHS Chief Executive Department of Health Richmond House 79 Whitehall London SW1A 2NS 3 March 2011 Dear David, The FTN Board wanted to thank you for the very helpful contribution you made at the recent FTN Chairs and Chief Executives meeting where you made it clear you want to hear about the issues that are concerning providers. I am writing to you following that meeting to raise a number of issues of concern and to share with you the results of our analyses of the current risks facing providers. The first issue concerns the unprecedented levels of CIP that members will confront. At the meeting it was clear that members are facing a much steeper CIP than the 4% suggested within the tariff settlement. The additional factors compounding risk are retaining activity caps at outturn 2008/09 coupled with 30% marginal pricing above the cap, the impact of re-admission policy, estimated at an overall loss of £789 millions and de-commissioning plans on the part of commissioners. We surveyed the FTN membership and in two weeks received a response rate of 38%. This evidence suggests that the mean average CIP members are facing is 6.33%. This is modelled without having taken into account any de-commissioning plans. For many organisations this means serious financial stress that will lead to the loss of many thousands of jobs and will seriously endanger waiting times and services for vulnerable patients, as well as threatening organisational survival. FTN members do not believe that this is the policy intention. A summary of the survey information is attached as an appendix to this letter. The FTN Board believes that the policy goal should be to restrict the financial impact to the 4% CIP that ministers have sanctioned and which all organisations are committed to delivering. The second issue concerns the policy on emergency re-admissions following elective work. Many members are examining the reasons for re-admissions and it is clear that the vast majority are not as a result of mistakes on the part of the hospital in the original elective treatment. No one disputes that these should be the responsibility of the organisation at

2

fault. But most re-admissions seem to be either of patients with conditions unrelated to the original treatment, or entirely justifiable and in the interests of the patient. We were pleased to see paragraph 60 of the PBR Guidance: “Commissioners should continue to reimburse providers for readmitted patients when any of these exclusions apply. Where commissioners accept that a readmission is clearly unrelated, they may also continue to reimburse providers” We believe this paragraph should get greater emphasis in communications with commissioners and that some sensible rules should be designed to facilitate rapid agreement. Our concern is that in the current financial climate this provision will provide ground for dispute where commissioners’ main goal is to save money. Whilst mental health providers are not subject to some of the policy pressures on the acute sector, it is clear they are faring no better in terms of the risks they face. They are subject to the pressures of the additional resources that have gone into the acute sector over the past few years in terms of the budget limitations being imposed upon them by commissioners. Additionally, they are facing sharp pressures without even having the protection of tariff. We have written to you previously about the need to accelerate tariff for mental health providers and would like to reiterate that request. The third issue concerns the timescales in which providers are being expected to agree contracts this year, in contrast with the rolling basis that has applied in previous years. We are aware that commissioners are insisting on providers signing contracts for 2011-12 by 31 March, otherwise activity will be reimbursed on a “pay as you go” basis, with its associated high transaction costs. Members report that this approach will require significant working capital to cover any lag in resolution, of perhaps up to three months, putting providers under further. They report that they do not feel that the position in the contract is sufficiently balanced between the rights of providers and commissioners, echoing previous comments the FTN has made about the importance of this balance being fairly struck. We would welcome any clarification you can provide on this matter given that the problem will start having effect in a matter of weeks. The fourth issue is acute foundation trusts’ concern about the implementation of the new outcome measures for emergency departments. Whilst there is full support for the principles of the approach, there is concern that there was no lead-in time permitted to enable the right information collection mechanisms to be put in place. In the recent FTN benchmarking study of accident and emergency services which used the A & E outcome measures as the benchmark for quality, none of the 17 participant organisations were able to achieve all of the indicators. Some were not yet able to collect the information required. We are mindful of the fact that when the 98% A&E target was first introduced there was sufficient lead in time to make proper investment in achieving it. With the introduction of the outcome measures trust have been given three months, making it an impossible task. Acute foundation trusts are very concerned that as Monitor will integrate the outcome measures into the risk compliance framework there will be unintended consequences for the risk ratings for foundation trusts and further knock on impacts for acute NHS Trusts seeking foundation trust authorisation. This is not a problem that Monitor can solve, but it could be solved if the Department of Health allowed adequate lead in time for the achievement of the policy The final issue that members will be concerned about is the strategy in relation to GP commissioned pathology services under the QIPP agenda, recognising that this will be yet another measure, being pushed through rapidly that can severely destabilise trusts. FTN members would urge that, at the least, the provider risk tool that was developed with the Department of Health last year should be used by commissioners to understand what impact their commissioning decisions on pathology will add to an already fragile situation.

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4

Appendix

FTN monitoring of financial pressures – update 1 March 2011 1. There follows a report of member returns to a FTN survey investigating the extent

of the financial challenge being faced by FTN members. This updates the data circulated with the Board papers.

2. A further request for data was circulated following the Chairs and Chief Executives meeting on 17 February. This elicited a significant number of additional responses.

3. The member response rate is now 76 of a possible 199, a response rate of 38%.

4. The number of authorised respondents was 60, representing 44% of the newly

expanded FT sector (136 authorised FTs as of 1 March 2011).

5. Cost improvement plans are reported as follows:

6. This confirms our initial assumption following anecdotal reports that the efficiency requirement faced by providers in the service was about 6%. There is significant clustering in the 6 – 9% range.

7. The impact of the readmissions policy was hard to quantify as members were

often still in negotiation with local commissioners. However, the survey yielded the following information.

‐16

‐14

‐12

‐10

‐8

‐6

‐4

‐2

0

CIP 2011‐12 %

CIP 2011‐12 %

N = 74

mean ‐6.33

mode ‐5

median ‐6

lowest ‐3.5

highest ‐15

5

8. Fewer responded on the impact of readmissions, with 44 returns. Mental Health

FTs did not return this information. The following data expresses the % impact of the implementation of the readmissions policy. Most reported an impact between 1% and 2%

N = 44

mean ‐1.86

mode ‐2

median ‐1.5

lowest ‐0.2

highest ‐8.1

9. On the impact of headline tariff, excluding readmissions and volume changes,

there were 59 returns. Some mental health members did not answer this question though others assumed a 1.5% decrease in line with tariff.

N = 59 mean ‐1.34

mode ‐1.5 median ‐1.3

lowest 0.5 highest ‐5.8

10. Three members reported an increase in tariff income (though all below 1%) and

four reported no change (0%). 11. The figures reported above are likely to understate the position because some

included QIPP challenge figures in their data, whereas some did not. In addition, others were impacted by the MFF, and in others the readmissions policy was still being locally agreed. FTN 1 March 2011

E

Agenda Item 8

Executive Board Report


Executive Board Report to

the Board of Directors, March 2011

1. Quality Improvement Programmes Board members have previously been informed about two quality

improvement initiatives which were introduced concurrently as pilot programmes - the Productive Ward and Transforming Care at the Bedside (TCAB). The Productive Ward is a programme to reduce waste, improve efficiency and increase the time spent on direct patient care, while TCAB also aims to increase time spent on care as well as improving patient safety and focusing on patient-centred care.

As both initiatives appeared to have similar work streams the Executive Board requested an assessment of their respective benefits in order that a decision could be reached about the roll-out of one or both throughout the Trust. In assessing the progress of both initiatives it became evident that, even though Productive Ward and TCAB have some common elements and have been shown to deliver benefits, they are different. It is however acknowledged that running two separate programmes that deliver similar outcomes is not sensible. The EB therefore endorsed a proposal that the TCAB and the Productive Ward programmes should be merged into a hybrid model - the UCLH Quality Improvement Framework - that uses both approaches in a planned way. This will be adopted as the overarching quality improvement methodology of choice for the Trust. All Wards and departments will be expected to implement the UCLH Quality Improvement Framework and a comprehensive communication cascade will take place, commencing with a launch event. While the overarching approach to quality improvement will allow ward teams to drive the improvements and changes that are important for their specific areas, there are some interventions that have already been proven to have positive benefits. All ward areas will therefore be expected to implement these over time. 2. The Patients’ Association Report 2010: ‘Listen to patients, speak up for change’: Key messages for healthcare professionals

Katherine Fenton advised the EB that Christine Mackenzie & Dee Carter, Governor members on the Nursing & Midwifery Advisory Board (NMAB), presented to the NMAB the Patients’ Association Report which includes accounts from patients and carers who experienced poor standards of care in a number of acute Trusts nationally. There were no cases from UCLH reported. There was agreement that compassion and human kindness are vital when dealing with patients and in many of the cases presented this was clearly missing. Carers need to be included in the patient’s pathway as much as possible because of their knowledge of the patient, and this was also not apparent in many circumstances. The NMAB considered the implications and lessons for UCLH with particular focus on ‘basic care’ training that is

offered to qualified staff and students at UCLH. The importance of leadership and role modelling was emphasised. The NMAB endorsed the use of examples from this report to educate nurses and midwives at UCLH and these are to be incorporated into the Trust-wide band 5 & 6 development days. 3. Cancer Centre Progress Report The EB considered a report from the Divisional Manager for Cancer containing a proposed work programme for the new Cancer Clinical Steering Group which met for the first time in February. The Steering Group was originally to be called the Cancer Centre Steering Group but the change of name reflects the wider remit of the group. The CCSG has set as its first priority the development of an action plan to improve the patient experience in areas identified in the national cancer survey. Geoff Bellingan and Mark Emberton will give a presentation to the Board about the clinical services in the Cancer Centre and the service changes required to make the Cancer Centre a success. This presentation will cover:

The clinical services to be provided in the cancer centre The changes involved in delivering better services to patients from the

Cancer Centre The important contribution played by our partners, Macmillan Cancer

Support The role and work programme of the new CCSG to drive forward

improvements in cancer services across all three clinical boards. Two background papers have been circulated for information to Board members. The first is the agreed work programme of the new CCSG. The second is a more detailed report about changes that are being made to clinical and support services to improve the model of care, patient experience and patient environment in the Cancer Centre, including the work with Macmillan and the programme to get the building ready for full occupation by April 2012. 4. Capital and Estates Issues On the recommendation of the Capital Investment Board, the EB approved a number of schemes from the agreed 2010/11 programme. These include:

• improvements to patient accommodation on the Neuro-rehabilitation Unit at the NHNN through improving visibility from the nursing station, modernising communal ward areas and creating en-suite shower facilities;

• protection of walls in Neuro-radiology from damage by patient trolleys, wheelchairs and goods cages as noted at PEAT inspections;

• environment improvements at the Heart Hospital to day surgery patient accommodation and areas used by relatives.

2

5. Policy Approvals

The Executive Board approved a number of revised policies which had previously been endorsed by the Policy Approval Sub-Group. The policies include a New and Expectant Mother Policy, Flexible Working Policy & Procedure, Clinical Record Keeping Procedure and Medical Equipment Management Policy.

The EB also approved a new Appraisal Policy and Procedure, the aim of which is to ensure a consistent process and approach to conducting appraisals for all employees. The document clarifies the process and sets out a timetable for the annual cycle of appraisals which commences at the start of the financial year and cascades through the workforce. The timescale will be agreed each year by the Executive Board and published by the 1st of April. The cycle will commence with the appraisal of all directors and cascade to direct reports to directors and the whole workforce.

The Knowledge & Skills Framework (KSF), which was designed to ensure that all staff covered by Agenda for Change terms and conditions have clear expectations of the skills and knowledge they would be required to demonstrate in their role, has been simplified and a more user-friendly approach has been developed. It has been designed to ensure that the key attributes of the KSF are retained but that the related process and paperwork are streamlined.

SIR ROBERT NAYLOR CHIEF EXECUTIVE

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Agenda Item 9

Performance Report

Purpose of the paper/report: This paper notifies Board of Directors of changes to the performance pack and highlights issues from the report Changes to content of performance pack: Page 23: Workforce. New chart added showing staff in post WTE and performance figures included for mandatory training completeness. Key issues from January 2011 report: The following are key issues from the current report and updates on issues previously raised: Current issues Action Month first

raised

Open pathways greater than 52 weeks

% 14-18 week pathways validated (page 15)

Central team to be funded on non-recurrent basis to address backlog >30 weeks. Team now appointed and will be in post mid-February.

Indicators tracking maintenance of clean open pathways now introduced and show that divisions validated only 21% (up from 14% last month) of pathways passing the 14 week milestone in January. Boards have reinforced requirement with divisions to ensure this validation takes priority as the above team will be in a position to support the over 52-week issues.

August 2010

January 2011

Cancer 62 day GP target (page 16)

Urology have now completed their action plan in relation to capacity and escalation issues and results will now improve. A small backlog of overdue cases however remain in the system which will cause breaches as they are treated. Reporting to EB on a weekly basis in respect of the Q4 position, which is at risk.

September 2010

Cancer 62 day screening target

Target involves small numbers and one breach resulted in being below the threshold.

August 2010

MRSA cases

(Page 18)

One case in January takes the year to date total to 11 against a threshold of 8. Improvement plan largely complete now, although some outstanding tasks relating to intravenous line audits and blood-taking policy.

August 2010

VTE risk assessment (pg 19)

Reported performance above the quarter 4 CQUIN target in January. Work continues on identify low-risk patient cohorts, alongside drive to increase performance amongst some clinicians.

October 2010

Appraisal rate (page 23)

Current appraisal rate remains below target. However, concerns have been raised over the accuracy and data recording methodology. This is being reviewed, though may be overtaken by the new Trust-wide annual appraisal process, due to launch March 2011.

September 2010

Return of sickness forms is at only 41% (page 23)

Performance improvement yet to be observed following introduction of the monitoring process. Anticipated that this position will improve from January onwards.

September 2010

Mandatory training completeness (page 23)

New indicator in pack previously reported at EB and the HRCC. We are currently reviewing the mandatory training needs analysis to make sure that only the required training for the necessary staff is included. When implemented this will improve the reported level of compliance with mandatory training. In addition a re launch of the Trust’s mandatory training programmes, including using increased levels of e Learning, will improve compliance through the coming year.

February 2011

CQUIN risks (pg 25) Surveys: initial assessment shows small fall in reported performance which puts the full £750k at risk. Negotiations continue with commissioners on this issue

Choose and Book: IT issues are still occurring in January and February. Close monitoring will continue, although delivery of the Q4 target is at risk (worth £83k)

Nutrition: action plan now looks more likely to be delivered, although details of site-wide cover to be finalised

First report

October 2010

January 2011

Simon Knight Acting director of performance 3rd March 2011

Month 10, January

This document contains commercially confidential information and must not be released or circulated

UCLH NHS Foundation Trust

Board of Directors Performance ReportMarch 2011

(Month 10 – January)

1. Executive summaries 2. Finance 3. Delivery of QEP4. Activity 5. Access 6. Patient Safety and Quality metrics 7. Workforce 8. Externally Reported Frameworks 9. Quarterly review slides

Page 1Month 10, January

Contents

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Number of MRSA Bacteraemias post 48 hr

18 √√ 0 1 0 1 0 11 2 3 6 Non-admitted closed percentage under 18 weeks

15 √ 95.0% 96.6% 98.2% 97.2% 96.0% 97.2% 98.6% 97.2% 96.8%

Number of clostridium difficile cases post 48 hours*

18 √√ 10 4 0 2 2 55 17 22 16 Admitted closed percentage under 18 weeks

15 √ 90.0% 94.7% 100.0% 93.4% 95.6% 94.6% 99.9% 93.1% 95.4%

Percentage Hand Hygiene Compliance

18 √√ 100% 93.5% 92.4% 94.4% 93.2% 91.6% 88.6% 91.1% 92.4%

62-day wait for first treatment from urgent GP referral to treatment: all cancers

16 √√ 85.0% 77.5% 88.9% 68.3% 86.7% 81.9% 93.0% 73.6% 89.9%

Percentage MRSA screening for all admissions

18 √ 100% 100% + 100% + 100% + 93% 100% + 100% + 100% + 95%

62-day wait for first treatment from consultant screening service referral: all cancers

16 √√ 90.0% 80.0% 80.0% 72.7% 72.7%

Falls with harm per 1000 bed days19 √ 0.10 0.22 0.00 0.44 0.18 0.11 0.08 0.15 0.08 31-day wait for second or subsequent

treatment: surgery16 √√ 94.0% 96.2% 100.0% 92.9% 100.0% 98.0% 100.0% 97.2% 98.9%

Complaints responded to within target time

20 √√ 85.0% 87.8% 100.0% 69.2% 93.3% 79.7% 96.6% 73.0% 76.1% 31-day wait for second or subsequent treatment: drug treatments

16 √√ 98.0% 100.0% 100.0% 100.0% 100.0%

Overall, how would you rate the care you have received

20 √√ 82.9% 82.4% 75.6% 79.2% 86.0% 79.4% 76.2% 78.6% 82.8% 31-day wait for second or subsequent treatment: Radiotherapy

16 √√ 94.0% 98.5% 98.5% 98.2% 98.2%

Percentage Last Minute Cancellations to Elective Surgery

17 √√ 0.8% 0.8% 0.0% 0.7% 0.9% 0.9% 0.0% 0.8% 1.0% 31-day wait for second or subsequent treatment: other

16 √√ 98.0% 100.0% 100.0% 69.8% 100.0% 55.2% 100.0%

Percentage cancelled operations admitted within 28 days*

17 √√ 95.0% 100.0% 100% 100.0% 100.0% 99.6% 100% 99.3% 100.0% 31-day wait from diagnosis to first treatment: all cancers

16 √√ 96.0% 97.3% 100.0% 97.6% 95.0% 97.8% 96.1% 98.1% 97.7%

Hospital standardised mortality ratio (1yr rolling data, 2 months in arrears)

21 √√ 0.70 0.68 0.63 0.59 0.80 Two week wait from referral to date first seen: all cancers

16 √√ 93.0% 94.7% 98.9% 91.4% 96.9% 94.0% 94.3% 93.2% 95.3%

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

16 √√ 93.0% 93.7% 93.7% 95.2% 95.2%

* The trust threshold is an aggregate of individual clinical board thresholds A&E attendances within 4 hours17 √√ 98.0% 98.7% 98.7% 98.8% 98.8%


This month Year to date This month Year to date

Executive summary 1: quality, access

Data quality score:√√ high data quality√ sufficient data qualityx not sufficient data quality

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Direct income (£m) 4-8 √√1.1 0.9 0.2 -0.5 0.6 6.6 3.0 0.6 1.2 1.9

% Elective activity variance from plan

6 √√ 0.0% -12.8% -20.0% -11.0% -14.2% -6.6% -20.0% -5.9% -6.8%

Direct costs (£m) 4-8 √√-1.2 -0.6 -0.6 -0.1 0.1 -6.1 -1.0 -5.5 -1.1 1.4

% Daycase activity variance from plan

6 √√ 0.0% 3.0% -18.7% 9.5% -1.5% 3.1% -7.1% 4.8% 2.6%

EBITDA (£m) 4-8 √√0.3 0.2 -0.5 -0.6 1.2 0.8 1.8 -4.7 -0.2 4.0

% Non-elective activity variance from plan

6 √√ 0.0% 3.7% 5.4% -1.2% 4.2% 4.9% -1.4% 5.2% 8.3%

Net surplus/deficit (£m) 4-8 √√0.1 0.2 -0.5 -0.6 0.9 -0.3 1.8 -4.7 -0.2 2.9

% Outpatient activity variance from plan

6 √√ 0.0% 4.4% 4.5% -2.2% 8.1% 2.1% 1.6% -0.5% 3.7%

Finance: Green: variance positive, Amber: between positive or up to less than 5% of budget, Red: variance less than 5% of budget

% Staff turnover 22 √√ 13.0% 13.1% 11.2% 13.7% 14.9% 13.3% 14.1% 11.3% 14.1% 13.4%

Externally Reported Frameworks

% Vacancy rate 22 √ 9.9% 7.0% 9.2% 12.7% 3.8% 10.8% 9.1% 10.6% 12.6% 6.3%Financial Risk Rating 4

√√

Monitor compliance 24√√

(Quarterly position)

% Sickness absence rate (1 month in arrears) 23 Χ 3.3% 3.1% 3.1% 3.5% 2.9% 2.5% 2.5% 2.5% 2.7% 2.3%

Agency staff spend as % of total staff spend 22 √√ 2.8% 3.1% 2.1% 2.5% 5.2% 3.7% 3.7% 4.2% 3.1% 4.3%

% Appraisals completed in the last 12 months 23 √ 60.8% 65.6% 51.0% 60.9% 75.6%


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No in month rating

This monthThis month Year to date Year to date

Executive summary 2: activity, efficiency, finance, workforce

Data quality score:√√ high data quality√ sufficient data qualityx not sufficient data quality


Financial Summary- Overall Rating

Year to date rating

Month 10 Actual

Month 10 Plan

Month 9 Actual

5 4

Area of review Key Highlights

4. Overall I&E

1. Operational Performance

2. Liquidity

3. Use of Assets

2. Financial performance2.1 Financial Performance Summary


Year to date Monitor Financial Risk Rating (FRR)

Month 10 actual

Month 10 plan

Month 9 actual

FINANCIAL SUMMARY –OVERALL RISK RATING

Against EBITDA, the YTD position is £0.8 million ahead of plan (£54.8m actual versus £54.0m plan) (YTD FRR = 3).In M10, a further £0.5 million has been released from the Board contingency (total FY budget is £5.0m). A total of £3.0 million YTD has now been released into EBITDA.At M10, the Trust has made a contribution of £129.0 million (contribution margin of 21.2%) before overhead & corporate costs. This is £0.5m ahead of plan (margin is 0.3 percentage points behind plan).Although net YTD clinical income from patient activity is £1.1 million ahead of plan (+£0.0m in-month), a total PCT risk adjustment of £3.4m (+£0.5m in-month) has now been booked at M10.

3 4 4


At M10, against EBITDA, the Trust has a 9.0% return on income (YTD FRR = 4). YTD positions are:Medicine £1.8 million ahead of plan ((+£0.2m in-month).Specialist Hospitals £0.2 million behind plan (-£0.6m in-month).Surgery & Cancer £4.7 million behind plan (-£0.5m in-month).The remaining Corporate budgets (including R&D & Education) are £3.9 million ahead of plan.

4 4 4

2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 18 daysof the Trust’s operating expenses (YTD FRR = 3).At 31st January 2011 the Trust’s cash balance was £68.2 million against a planned cash position of £66.8 million, a favourable variance of £1.4 million.

3 4 3

3. Use of AssetsThe Trust made a 4.8% return on net assets (YTD FRR = 3). Of the current capital programme totalling 92.3m, 89.7% (or £82.8m) is approved & in progress. The plan for capital spend in 2010/11 has been revised to £65.6m – as per the M5 Monitor reforecast.

3 3 44. Income &

Expenditure Position

The “bottom-line” I&E position is a surplus of £7.4 million, a 1.3% return on income (YTD FRR = 3). The I&E position is £0.3 million behind plan, which predicted a £7.7 million surplus at M10. However, the YTD position also includes net YTD impairment costs of £0.2m.

3 3 3


Year to date Monitor Financial Risk Rating (FRR)

Month 10 actual

Month 10 plan

Month 9 actual

FINANCIAL SUMMARY –OVERALL RISK RATING

Against EBITDA, the YTD position is £0.8 million ahead of plan (£54.8m actual versus £54.0m plan) (YTD FRR = 3).In M10, a further £0.5 million has been released from the Board contingency (total FY budget is £5.0m). A total of £3.0 million YTD has now been released into EBITDA.At M10, the Trust has made a contribution of £129.0 million (contribution margin of 21.2%) before overhead & corporate costs. This is £0.5m ahead of plan (margin is 0.3 percentage points behind plan).Although net YTD clinical income from patient activity is £1.1 million ahead of plan (+£0.0m in-month), a total PCT risk adjustment of £3.4m (+£0.5m in-month) has now been booked at M10.

3 4 4


At M10, against EBITDA, the Trust has a 9.0% return on income (YTD FRR = 4). YTD positions are:Medicine £1.8 million ahead of plan ((+£0.2m in-month).Specialist Hospitals £0.2 million behind plan (-£0.6m in-month).Surgery & Cancer £4.7 million behind plan (-£0.5m in-month).The remaining Corporate budgets (including R&D & Education) are £3.9 million ahead of plan.

4 4 4

2. LiquidityThe liquidity ratio shows that working capital (cash plus debtors less creditors) is able to cover 18 daysof the Trust’s operating expenses (YTD FRR = 3).At 31st January 2011 the Trust’s cash balance was £68.2 million against a planned cash position of £66.8 million, a favourable variance of £1.4 million.

3 4 3

3. Use of AssetsThe Trust made a 4.8% return on net assets (YTD FRR = 3). Of the current capital programme totalling 92.3m, 89.7% (or £82.8m) is approved & in progress. The plan for capital spend in 2010/11 has been revised to £65.6m – as per the M5 Monitor reforecast.

3 3 44. Income &

Expenditure Position

The “bottom-line” I&E position is a surplus of £7.4 million, a 1.3% return on income (YTD FRR = 3). The I&E position is £0.3 million behind plan, which predicted a £7.7 million surplus at M10. However, the YTD position also includes net YTD impairment costs of £0.2m.

3 3 3


2. Financial performance2.2 Subjective analysis – financial summary

Direct Income, specifically, includes attributed HIV and other Community SLA income.

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Trust summary -249 140 139 717 1,909 -1,349 1,426 1,892 212 12,690

Medicine -9 -61 59 258 192 -92 -216 -159 1,400 179

Clinical Support 51 -400 283 -3,049Critical Care -2 0 -3 5 8Emergency Services 55 1 6 22 346 -15 44Infection -4 22 20 10 -101 -36 1 -7 -12 -864Medical Specialties -4 -83 -15 195 687 -77 -221 -495 1,139 4,039Pathology

Specialist Hospitals -138 -28 88 655 1,907 -697 464 1,764 1,557 10,601

EDH -4 0 -6 162 -316 10 420 -10 1,774 573Heart Hospital -80 19 -3 -65 -26 -364 39 -4 -668 -1,506Paediatrics -19 4 -8 3 88 -75 374 138 -219 149Queen Square -27 -38 152 384 845 -157 -325 802 283 463Women's Health -8 -13 -47 172 1,315 -111 -44 838 386 10,922

Surgery and Cancer -101 230 -7 -196 -190 -560 1,178 291 -2,746 1,911

Cancer -13 89 -18 -10 -753 73 1,414 -45 183 -589Gastrointestinal 1 105 16 -25 202 -105 -298 271 -1,323 351Imaging -9 14 2 -31 58 -47 66 60 -317 400

Surgical Specialties -80 22 -8 -132 304 -480 -4 5 -1,306 2,165

Theatres and Anaesthetics -1 -416

* The trust threshold is an aggregate of individual clinical board thresholds Page 6Month 10, January

Current month Year to date

2. Financial performance2.3 Activity variance

Trust elective inpatients

1,5001,6001,7001,8001,9002,0002,1002,200

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10/11 actuals 09/10 actuals10/11 plan

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3,5003,6253,7503,8754,0004,1254,2504,375

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2. Financial performance2.4 Clinical income variance

Notes: - The emergency threshold 30% marginal rate has been applied at divisional level. This differs slightly from the overall Trust liability – the difference of £490k is shown within the “Corporate” line. - A risk provision of £219k Soft Tissue Sarcoma work is also reflected within the “Corporate” line, together with a £476k adjustment for the rejected HIFU pass-thru business case. - A £221k adjustment was required to correct the Emergency Threshold calculation for HPB due to the delayed transfer & £828k for head & neck reconstruction plan corrections.- £325k has been charged back to Central Income for Q1 Paediatrics Chemo pricing challenges & additionally there is a £178k adverse variance against other income

▪ Trust clinical income was above plan year to date to month 10, driven by overperformance in daycases, non electives and follow up outpatients. This offset underperformance in electives and first outpatients. Total clinical income, excluding PCT risk, is above plan for the Trust and three clinical boards.

▪ The Medicine Board also recorded income above plan from activity. This was supported by overperformance in daycases and non electives. Elective underperformance in Medical Specialties and Infection contributed to the underperformance in this activity type.

▪ The Specialist Hospital Board's clinical income from activity was above plan at a board level but was below plan for elective activity. Underperformance was predominately in Queen Square and the Heart Hospital, though to a lesser extent Women's Health. The Heart Hospital was also below plan for total clinical income from activity due to underperformance in other activity types, except daycases and other. A practice development group has commenced work on building reputation and GP relationships to increase referrals. In Queen Square, in addition to underperformance in elective activity, underperformance was also recorded in first and follow up outpatient attendances. The division also recorded a large underperformance in drugs, devices and pass through income.

▪ The Surgery and Cancer Board was behind plan for income from clinical activity but this was offset by the surplus recorded against drugs, devices and pass-through. Underperformance in elective and first outpatient clinical income from activity was mainly from Gastrointestinal Services and Surgical Specialties. Elective underperformance is partly due to converting eligible cases to daycase where possible. Underperformance in Critical Care and unbundled activity was across all divisions.


2. Financial performance2.5 Subjective analysis - Short Term Cash Flow - Outlook

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Cash Forecast Cash Actuals Cash Plan Actual Prior Year 2009/10

Cash Actual at 28th Feb = £81.8m


2. Financial performance 2.6 Capital

Summary of Approved Schemes Month 10 2010/11

10/11 Current Plan

Approved Schemes

Remaining to be

Approved£m £m £m

Phase 3 44.1 44.1 - ICT Strategy 3.0 2.5 0.5 Externally Funded - PDC 6.4 3.9 2.5 Externally Funded - Other 5.3 4.9 0.4 Replace & Refresh 15.5 12.8 2.7 Property Fund 5.9 5.4 0.5 Investment in Service Quality 6.3 5.2 1.1 Development & Expansion of Service 5.9 3.9 2.0 Target reduction in Scheme value - - - Current 10/11 Capital Programme 92.3 82.8 9.6

Planned Slippage/Schemes to be rebid in 11/12 (26.7)10/11 Planned Expenditure 65.6Table 1 Summary of Approved Schemes

Reconciliation of Current Capital ProgrammeOpening 10/11 Capital Programme 111.8Additional External Funding 4.3Additional Revenue Funding 1.7Removed/Reduced schemes - external -15.5R&R & ISQ reduction - unapproved schemes deferred in to 11/12 or cancelled.

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Property Fund schemes deferred in to 11/12 -3.5Current 10/11 Capital Programme at Month 10 92.3Table 2 Reconciliation of Capital Programme

Revised

Plan Actual Variance£m £m £m £m

Phase 3 36.0 34.5 29.9 4.5 ICT Strategy 2.7 1.5 0.8 0.7 Externally Funded - PDC 3.0 0.4 0.7 (0.4)Externally Funded 3.2 2.9 2.7 0.1 Replace & Refresh 7.7 5.3 3.0 2.3 Property Fund 2.4 2.0 2.1 (0.1)Investment in Service Quality 2.5 2.7 3.1 (0.3)Development & Expansion of Service 1.8 1.8 1.3 0.6 Total 59.2 51.1 43.6 7.5Table 3 Summary of Capital Expenditure

Summary of Capital Expenditure

Month 10 year-to-date


2. Financial performance2.7 Trust wide EBITDA variance analysis including Delivery of Efficiency

Commentary:

Patient Activity

■ Patient activity variance is shown before the PCT risk adjustment, but includes the Corporate adjustments as described on p7 (-£2.7m).

Pass thru

■ Pass-thru adverse variance is largely a result of the position in the Cancer Division.

■ Delivery of Efficiencies

For details - please see remainder of Efficiency report.

Corporate

■ The Corporate variance includes a +£1.5m variance on levy & other central income, & +£0.5m of overseas income overachievement, but excludes the release of the Board contingency (shown separately).

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Postive Variance Negative Variance

Graph shows the impact on overall Trust EBITDA of delivery of efficiencies alongside other key variances.

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3. Delivery of QEP3.1 Financial analysis

- The Month 10 YTD position shows that the Trust is achieving 96% against its QEP Target. The in month movement shows an adverse position both against plan - £0.1m & forecast £0.3m.- This position is due to: Surgery & Cancer under performing in month in Theatres £0.1m; continued under performance of theatre efficiency initiative & Cancer £0.1m; under performance of private patient income generation initiative. Actions plans are being discussed with the Divisions concerned & impact on FYE evaluated.- The forecast out-turn has also decreased in month by £0.4m (0.7%) due to the underperformance noted above. - The analysis between income generation & cost reduction shows cost reduction maintained at 75% of the forecast outturn with income generation at 25%.

QEP achievement ≥ 100%QEP achievement ≥ 75% ≤ 100%QEP achievement ≤ 75%

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3. Delivery of QEP3.2 Financial analysis

QEP achievement ≥ 100%QEP achievement ≥ 75% ≤ 100%QEP achievement ≤ 75%

Board QEP by Cost Reduction / Income Generation

16%

76%

38%

83%

21%

72%

11% 0%25%

73%

84%

24%

62%

17%

79%

28%

89% 100%75%

27%

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

100%

Medici

ne

Medici

ne 09

/10

SHB

SHB 0

9/10

S&C

S&C 0

9/10

Corpo

rate

Corpo

rate 0

9/10

Total

Total

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ull Y

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Cost Reduct ion

IncomeGenerat ion

Board QEP by Strand

43%25% 33% 30%

51%

54% 43% 45%

1% 1%

86%

8%

7%14% 23% 4% 14%6% 3%0% 0% 0% 0%0% 0% 11%

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

100%

Medici

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S&C

Corpo

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Total

Fore

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Out

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Other

Asset uti l isation

Procurement

Back Office

PCS

Workforce

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3. Delivery of QEP3.3 Efficiency ratios

Commentary:In month the return on non-pay metric has improved on a rolling 3 month basis, moreover, EBITDA margin is ahead of M10 09/10 as is return on pay (after excluding the PCT risk adjustment). This suggests that profitability has been maintained as the Income has grown. However, it is worth noting that the in month position has been impacted by the recognition of both HCAS & Clinical Lecturer backfill income (although this was received last year). Also, £3.0m of Board Contingency has been released at M10, which was not the case in 09/10.

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Tower theatre utilisation 85% 79.8% 80.8% 77.0%

% of Patients discharged pre 11am

35% 23.0% 26.8% 27.1% 18.1%

% utilisation rate on reportable clinics (excl DNAs)

85% 81.2% 75.4% 82.4% 83.0%


This month

3. Delivery of QEP3.4 Efficiency and productivity

Percentage utilisation of reportable outpatient clinics - All Services

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

Apr-10 May-10

Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

% utilisation rate on reportable clinics (excl DNAs)

▪ The Tower theatre utilisation rate was 79.8% in January, up from 74.8% in December. Performance in January marks the highest level of utilisation to date. The QEP team and clinical boards are agreeing performance trajectories for improvement to the target of 85%.

▪ Improvement in theatre utilisation is expected in Specialist Hospitals after underused evening Urology sessions are stopped from April. These sessions, along with cancellations in EDH reduced the utilisation rate in January.

▪ Pre-11am performance increased in January to 23.0%, up slightly from 22.7% recorded in December, but lower than 24.9% recorded in November. Performance remains below the target of 35%. A fall in performance was noted in both Medicine (28.8% to 26.8%), but this was offset by the increases in Specialist Hospitals (17.7% to 18.1%) and Surgery and Cancer (26.1% to 27.1%).

▪ The utilisation rate on reportable clinics increased to 81.2% in January, up from 75.8% in December. This increase reverses three successive falls in performance. Improvement was observed in all boards.

Percentage Tower theatre utilisation - All Services

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

Feb-10 Mar-10 Apr-10 May-10

Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11

% theatre utilisation

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Non admitted pathways% Non-admitted closed pathways under 18 weeks 95% 96.6% 98.2% 97.2% 96.0%

Non-Admitted Open Pathways Number Over 52Weeks 1,337 6 902 429

Non admitted median wait time (weeks) 6.6 5.1 0.7 5.0 5.3

Admitted pathways% Admitted closed pathways under 18 weeks 90% 94.7% 100.0% 93.4% 95.6%

Admitted Open Pathways Number Over 52Weeks 226 0 201 25

Admitted median wait time (weeks) 11.1 8.1 1.6 7.7 8.9

% pathways validated between 14 - 18 weeks (all pathways) 21.2% 3.1% 21.2% 18.2%

Diagnostic waiters

>6 week diagnostic waits 25 35 1 17 13

* The trust threshold is an aggregate of individual clinical board thresholds

Page 15

Month 10, January

This month

5. Access5.1 Access Targets - 18 Weeks

▪ The trust maintained compliance with 18 week admitted (90%) and non-admitted (95%) targets. Median wait times were well within Department of Health thresholds for admitted and non admitted closed pathways.▪ January was above threshold for almost all national admitted specialties, except Ophthalmology (due to the knock on effect of unplanned consultant leave over December) and Neurosurgery. We anticipate resubmitting our Neurosurgery data to reflect a late validated breach. This will show the specialty as being compliant. Non admitted pathways, were below threshold for General Surgery (due to two breaches) and Oral Surgery (due to DNAs in admitted pathways). ▪ The number of open pathways greater than 18 weeks decreased in January, mainly for Specialist Hospitals. The cohorts are fully expected to be data quality issues rather than being actual long waiters. These reported long waiters however, are driving the trust's relatively weak position against median waits for open pathways compared with other London providers. Funds have been provided to recruit fixed-term resources to validate all open pathways over 30 weeks. Posts have been appointed to in January and will be commencing work by early March. ▪ Divisions will be closely managed on their maintenance of clean pathways passing the 14 week threshold to improve performance. ▪ During January there were 35 patients waiting over 6 weeks for a diagnostic test. Of the 17 cases reported in Surgery and Cancer, 10 in Surgical Specialties were due to the reduced capacity over Christmas. Cancer patients were prioritised to avoid breaches of other targets. Additional lists are planned to increase capacity in February. The three breaches in GI were due to patient choice issues. The majority of the diagnostic waits in Specialist Hospitals were in sleep studies.

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Admitted PathwaysUCLH Q3 95.1% 98.1% 89.4% 91.7% 100.0% 92.6% 95.8% 94.1% na 100.0% na 99.5% 100.0% 100.0% 100.0% 99.4% 100.0% na 90.8% 96.9%UCLH Q2 94.3% 96.7% 88.0% 90.6% 100.0% 97.9% 95.0% 92.5% na 99.1% na 99.6% 100.0% 100.0% 100.0% 96.6% 100.0% na 90.4% 96.3%UCLH Q1 94.5% 100.0% 88.0% 91.5% 94.1% 95.1% 93.5% 94.8% na 100.0% na 98.8% 100.0% 100.0% 100.0% 94.0% 100.0% na 90.5% 97.1%

UCLH January 94.7% 100.0% 90.2% 91.0% na 83.8% 97.2% 89.8% na 100.0% na 97.8% 100.0% 100.0% 100.0% 93.9% 100.0% na 91.8% 97.8%UCLH December 95.1% 100.0% 90.3% 92.3% na 92.3% 94.6% 91.3% na 100.0% na 100.0% 100.0% 100.0% 100.0% 99.0% 100.0% na 90.4% 97.5%UCLH November 94.2% 98.4% 87.5% 90.1% 100.0% 87.5% 94.8% 92.1% na 100.0% na 98.9% 100.0% 100.0% 100.0% 99.3% 100.0% na 91.7% 95.6%

NonAdmitted Pathways

UCLH Q3 97.2% 91.8% 92.1% 97.6% 94.4% 98.8% 95.8% 98.0% na 100.0% 98.2% 91.3% 100.0% 98.3% 98.5% 96.6% 99.2% 100.0% 96.2% 97.5%UCLH Q2 97.5% 100.0% 92.3% 95.9% 100.0% 98.5% 97.6% 95.0% na 100.0% 99.9% 94.1% 99.8% 99.3% 100.0% 96.0% 99.0% 100.0% 97.2% 97.9%UCLH Q1 97.2% 99.1% 93.9% 95.8% 100.0% 98.9% 95.5% 95.3% na 96.2% 99.4% 97.5% 99.2% 96.8% 97.3% 96.4% 96.8% 100.0% 96.4% 97.6%

UCLH January 96.6% 91.3% 95.0% 95.9% na 97.4% 91.9% 95.2% na 100.0% 97.7% 97.1% 100.0% 96.5% 100.0% 96.8% 99.4% 100.0% 95.5% 96.6%UCLH December 97.6% 100.0% 95.9% 97.5% 100.0% 100.0% 95.2% 96.8% na 100.0% 96.4% 100.0% 100.0% 98.4% 95.7% 97.2% 96.7% 100.0% 96.5% 98.1%UCLH November 96.8% 94.3% 90.2% 96.0% 100.0% 99.4% 95.8% 98.3% na 100.0% 98.5% 85.9% 100.0% 98.6% 100.0% 96.8% 100.0% 100.0% 95.6% 96.9%

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Two week wait from referral to date first seen 93% 94.7% 98.9% 91.4% 96.9%

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

93% 93.7% 93.7% 2

31-day wait from diagnosis to firsttreatment 96.0% 97.3% 100.0% 97.6% 95.0%

31-day wait for second or subsequent treatment: surgery 94% 96.2% 100.0% 92.9% 100.0%

31-day wait for second or subsequent treatment: drug treatments

98% 100.0% 100.0%

31-day wait for second or subsequent treatment: Radiotherapy

94% 98.5% 98.5%

31-day wait for second or subsequent treatment: other

98% 100.0% 100.0%

62-day wait for first treatment from urgent GP referral to treatment

85% 77.5% 88.9% 68.3% 86.7%

62-day wait for first treatment from consultant screening servicereferral

90% 80.0% 80.0%



This month

5 Access5.2 Access Targets – Cancer

▪ In January all the 31 day cancer waiting time targets for first and subsequent treatments were achieved. The two-week target for GP referrals and the breast symptomatic referrals were also met. The 62 day GP and screening targets were not met. For screening one breach pushed us below the threshold.

▪ 62 day target from GP referral: in January there were breaches for Urology, Gynaecology, Haematology (originally referred to Head and Neck) and several late referrals from other Trusts. Gynaecology breaches related largely to late referrals from Barnet and Chase Farm and Women’s Health are managing this with Barnet and Chase Farm.

* Urology have now completed their action plan in relation to capacity and escalation issues and results will now improve, but a small backlog of overdue cases remain in the system which will cause breaches as they are treated.

* Gynaecology and GI are taking a similar proactive approach to urology to review any outstanding issues on a weekly basis to avoid breaches. Executive Board has now mandated that all Clinical Boards must adopt this proactive approach to the management of all 62 day pathway patients.

* We are working with our cancer network to establish a sector-wide approach to reallocation of breaches where patients have been referred to a second Trust late in the pathway. We will be using as a possible model the recent agreement brokered by Mike Richards for Trusts in the Manchester area, where Trusts that send patients on after day 38 take full responsibility for the patient.

▪ Please note that January's cancer waiting times performance is still provisional.

Cancer 62 day referral targets

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

100%

Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11

Cancer 62 Day GP referral to treatment Target (GP referral)

Cancer 62 day referral to screening Target (screening)

Cancer 2 week referral targets

90%91%92%93%94%95%96%97%98%99%

100%


Cancer GP referral to appointmentCancer 2 week wait from GP referral to appointment: breast symptomsTarget

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A&E attendances within 4 hours 98% 98.7% 98.7%

% Last Minute Cancellations to Elective Surgery 0.8% 0.8% 0.0% 0.7% 0.9%

% cancelled operations admitted within 28 days 95% 100.0% 100% 100.0% 100.0%


Page 17

Month 10, January

This month

5. Access5.3 Access Targets - A&E and other

▪ We continued to record strong A&E performance when compared to the rest of London. Performance for January was 98.7% against a London rolling 4 week average of 94.3% for type 1 attendances. The year-to-date performance was 98.8% recording UCLH as the highest performing acute Trust in London.

▪ 0.78% of elective surgery was cancelled during January, better than the former CQC standard of 0.8%. Only Specialist Hospitals (0.9%) was above threshold, driven by the Heart Hospital (4.5%) and Women's Health (1.5%). Within the Heart Hospital, cancellations were influenced by a lack of ICU and ward beds and external ITUs not accepting patients due to the 'flu.

A&E 4 hr wait target - All Services

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 117,000

7,500

8,000

8,500

9,000

9,500

A&E Attendances A&E attendances within 4 hours

A&E attendances within 4 hours

Last minute cancellations to elective surgery

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%


20

40

60

80

100

120

140

Numbers of Last Minute Cancellations to Elective Surgery% Last Minute Cancellations to Elective Surgery% Last Minute Cancellations to Elective Surgery

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Number of hospital acquired MRSA Bacteraemias* 0 1 0 1 0

Number of clostridium difficile cases post 48 hours* 10 4 0 2 2

Percentage Hand Hygiene Compliance 100% 93.5% 92.4% 94.4% 93.2%

Percentage MRSA screening for all admissions 100% 100% + 100% + 100% + 92.5%

CVC Line infections Available from ~Feb/Mar11



This month

6. Quality6.1 Infection

MRSA bacteraemia / infections - All Services

0

2

4

6

8

10

12

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

MRSA actuals monthly MRSA threshold monthly

MRSA actuals YTD MRSA threshold YTD

Clostridium difficile infections post 48 hrs - All Services

0

20

40

60

80

100

120

140


CDiff actuals monthly CDiff threshold monthly

CDiff actuals YTD CDiff threshold YTD

▪ There was one post 48 hour MRSA case recorded in January in the Cancer division within the Surgery and Cancer board. This was the first case within the division for over a year.

▪ There were four post 48 hour cases of Clostridium difficile in January, below our threshold of 10.

▪ Early indications are that our MRSA threshold for 2011/12 will be 5 cases. It is also likely that there will be a stretching Clostridium difficile threshold, possibly 59 (compared with our current run rate of 5.7 per month).

▪ The target for hand hygiene compliance has been set at 100% as part of the MRSA improvement strategy. Performance is rated as green at 95% and red if less than 90%. To note, hand hygiene reporting was 84.3% in January

▪ More MRSA screens continue to be performed than the total number of eligible patient admissions - and this is increasing each month. This does not mean that every single patient has necessarily received an MRSA screen, since some patients may be screened more than once.

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Complaints responded to within target time 85.0% 87.8% 100.0% 69.2% 93.3%

Overall, how would you rate the care you have received 82.9% 82.4% 75.6% 79.2% 86.0%

12 question composite score 85.5% 85.5% 80.7% 86.5% 86.5%

Switchboard calls answered in 30 seconds 90.0% 88.5% 88.5%


This month

6. Quality 6.3 Patient experience

Patient Complaints - All Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


10

20

30

40

50

60

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80

90

Number of Patient Complaints Complaints responded to within target time Target

Patient experience - 12 Question composite indicator - All Services

60%

70%

80%

90%

100%


12 question composite score Target

▪ In January, 87.8% of complaints were responded to within timescales agreed with the complainant or, in the absence of an agreed timetable, 25 working days. This was an improvement from last month's performance of 77.8%. ▪ Performance for Surgery and Cancer (69.2%), was due to Surgical Specialties (83.3%) and GI (50%). Complex complaints continue to be an issue in Surgical Specialties, but a new handling procedure developed as part of a pilot has already demonstrated improvement from last month's performance. In GI, a new complaints coordinator started in February so the division anticipates to see improvement from next month.▪ Our patient experience indicator "overall rating of care" remains below threshold at a Trust level for December. The 12 question composite indicator from patient surveys is also being tracked as a potentially more sensitive indicator of patient feedback than the single question. Both indicators will be monitored on an ongoing basis. ▪ The 12 question composite score was on target for January. This target has been set as the average performance over the first 6 months of the year.

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Number of Falls with harm* 5 0 3 2

Falls with harm per 1000 bed days 0.10 0.22 0.00 0.44 0.18

Incidents per 100 admissions 6.4 11.7 4.9 6.1

Percentage of VTE Risk Assessments Completed 90.0% 90.1% 84.5% 93.1% 88.6%



This month

6. Quality 6.2 Safety

VTE Risk assessment - All Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Percentage of VTE Risk Assessments Completed Target

Patient falls per 1,000 bed days and Overall - All Services

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0.5

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2.5

3

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Patient falls Number of Falls with harm Falls per 1000 beddays

▪ There were five reported falls with harm during January. The falls (in Women's Health, Queen Square and Cancer) contributed to the falls with harm per 1,000 bed days being above threshold in Surgery and Cancer and Specialist Hospitals. Boards are reviewing these incidents to identify lessons learned and improve training and documentation.

▪ There is a CQUIN target of 90% of admitted patients to have a VTE risk assessments for Q4. The performance for VTE risk assessment for January was 90.1%. Improvement was noted in Specialist Hospitals (up from 81.6% last month). Work which is anticipated to improve performance has commenced within consultant teams at the Heart Hospital and Queen Square. In addition, a change to the daily report due in February is expected to improve performance in the Paediatrics divisions.

The data source of data used to track VTE risk assessments has changed from Nov 2010

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Percentage Emergency Readmissions within 28 Days* 6.8% 6.3% 12.5% 7.5% 3.9%

Hospital standardised mortality rate - all services 70.3% 68.0% 62.6% 59.1% 79.8%

Global Trigger - Adverse Events per 100 admissions (YTD) 42.5

Deteriorating Patients -Number of Cardiac Arrests 18 11 2 3



This month

6. Quality 6.4 Clinical outcomes

Mortality in Hospital - 56 HSMR Diagnoses1yr rolling data, reported 2 months in arrears

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

Rel

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> W

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Ris

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RR 0.74 0.73 0.74 0.74 0.72 0.71 0.68 0.68 0.68 0.69 0.69 0.69

Low 0.69 0.68 0.68 0.68 0.66 0.65 0.63 0.63 0.63 0.63 0.64 0.64

High 0.80 0.79 0.80 0.80 0.78 0.77 0.74 0.74 0.74 0.74 0.75 0.74

Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10

▪ Dr Foster benchmarking data continued to show that we were not an outlier on emergency readmissions over the past 12 months, with results within the expected range.

▪ Work is ongoing to assess the financial risk due to Emergency Readmissions being excluded from PbR in the draft guidance for 2010/11. This overlaps with validation work that will commence shortly, at the request of the Quality and Safety Committee, that will assess clinically each readmission.

▪ Our HSMR performance remained better than threshold at a Trust level.

▪ Global trigger tool (GTT) and deteriorating patient indicators are Quality Account priorities for 2010/11. At present this indicator is based on a small dataset and we are still establishing a robust baseline. However, so far the rate of adverse events per 100 admissions is at the low (good) end of the IHI benchmarked spectrum.

Global Trigger Tool - YTD adverse events per 100 admissions - reported 2 months in arrears

05

10152025303540455055606570

Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11

Global Trigger - Adverse events per 100 admissions

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Agency staff spend as % of total staff spend 0.0% 2.8% 3.1% 2.1% 2.5% 5.2%

Nursing & Midwifery bank fill rate 89.3% 86.3% 88.1% 90.6% 100.0%

Vacancy rate 9.9% 7.0% 9.2% 12.7% 3.8%

Average time to recruit from request to recruit pack date to start date 14.6 20.2 19.4 22.4 19.5 15.3

% Staff turnover 14% 13.0% 13.1% 11.2% 13.7% 14.9%



This month

7. Workforce 7.1 Performance indicators

% Agency spend - All Services

-6.0%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%


% Agency staff spend 2010-11 % Agency staff spend 2009-10

Average time to recruit from request to recruit pack date to start date

0

5

10

15

20

25


Average time to recruit (request pack - start date) Target

Temporary Staffing: The monthly expenditure on agency staff in January was below £1m for a second month. The shift booking data indicates that the increase in bank spend is not directly related to increased temporary staffing activity during this period. It is predominantly the result of the late invoicing (£540k) of Hayes expenditure of shifts worked in previous months. The 2.5% increase in VAT has also impacted on Month 10 spend. Strong progress continues to be made to increase the Nursing and Midwifery (N&M) Bank fill rate and to reduce agency spend. The overall Bank fill rate for January was 89% of filled shifts compared to 87% bank fill in December. This is a month on month increase of 2% and is also an increase of 19% compared to the bank fill rate in January 2010.

Recruitment: The average length of time to recruit for January is 20.2 weeks. This is an increase of 6 weeks compared to December and 3.4 weeks above the average length of time to recruit for the year to date. An analysis of number of new jobs advertised (WTE) in January identifies that 68% of all posts where from the Specialist Hospital Board, which is an increase of 15% compared to the trend of 53% year to date. This increased activity has had an impact on the length of time to recruit figure. Discussions are underway to address this. ECRB was implemented at the beginning of January and has resulted in much reduced turnaround time of routine CRBs. Simple CRB requests are received in 4 working days. The impact on complex CRBs has yet to be identified. ECRB will significantly reduce the number of new starters commencing on risk assessments, and will have a positive impact on time to recruit.

% Agency spend - All Services

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

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

% Agency staff spend 2009-10 % Agency staff spend 2010-11

N.b The adjustments shown hfor Agency spend have been made manually. The updates made by finance will be reflected automatically in Month 11

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Staff Sickness % 4% 3.3% 3.1% 3.1% 3.5% 2.9%

% of employees with 4+ short episodes of sickness in the last six months (<28 days)

6.1% 6.0% 5.4% 6.7% 5.2%

% of employees with long episodes of sickness in the last six months (>=28 days)

2.6% 2.3% 2.7% 2.8% 2.2%

% Monthly Absence Form (MAF) returned 80% 57.6% 65.2% 52.0% 57.0% 53.1%

Appraisal Rate 85% 60.8% 65.6% 51.0% 60.9% 75.6%

Mandatory training completeness 80% 34.8% 35.0% 35.9% 34.7% 29.2%



This month

7. Workforce 7.2 Performance indicators

Trust Appraisal completion rate - All Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%


% Appraisals completed in the last 12 months Target

Staff Sickness:The monthly absence form return rate is now being reported a month in arrears. The month 9 sickness absence rate has risen in month 8 from 2.2% to 3.3%. This reflects sickness absence data collated from 65.2% of the workforce. Obtaining comprehensive and accurate absence reporting data remains a strong focus for the Trust's Sickness Absence Group and a project has been ongoing during February to improve data and the overall monthly absence form return rate. In 2011/2012 the Trust will be moving to an electronic system for the reporting of absence data and this will improve the accuracy of the data further.

Appraisals:The appraisal rate across the Trust decreased by 2.8% in month 10. This is due to less appraisals taking place over the Christmas holiday period. Rates next month are expected to increase. A new policy and approach will be launched in April 2011. This streamlines appraisal and reporting process.

Mandatory Training :The EB and the HRCC have received information on the Trust's mandatory training compliance rates. The figures presented indicate an overall compliance rate of 35%. A more detailed breakdown will be provided in the March report. We are currently reviewing the mandatory training needs analysis to make sure that only the required training for the necessary staff is included. When implemented this will improve the reported level of compliance with mandatory training. In addition a re launch of the Trust’s mandatory training programmes, including using increased levels of e Learning, will improve compliance through the coming year.

Staff in post WTE

6270 6312 6355 6380 6436 6484 6496 6595 6611 6672

0

1000

2000

3000

4000

5000

6000

7000

8000


Corporate Medicine Specialist Hospitals Surgery & Cancer

udrhg

Est financial value

(assuming £500m contract income) Director Lead Current month Target

Q1Risk of non-payment




N1 £750,000 Sandra Hallett 90% 50% Q2, 90% Q4 75% payment on achieving 50% assessment

25% payment for 90% of inpatients assessed

N2 £750,000 Tony Mundy Not yet agreed Paid on achievement of agreed level of improvement

R1a £375,000 Tony Mundy 25% on delivery of agreed plan andbaselining

25% on delivery of audit results50% production of evidence of 6 months implementation with run

charts

R1b £375,000 Geoff Bellingan25% on delivery of agreed plan,

baselining and performance measures agreed

25% on evidence of implementation50% on evidence of system being embedded and delivery of agreed

performance

R2a £300,000 Paul Glynne miscellaneous25% for participation in Q2 baseline

audit and agreeing improvement trajectory

25% at the end of Q3 on achievement of Q2 and 3 performance trajectory

50% at the end of Q4 based on achievement of performance

trajectory for that quarter

R2bi £100,000 Paul Glynne miscellaneous 25% for Q1 on achievement baselining and trajectories agreed



trajectory for that quarter.

R2bii £100,000 Paul Glynne 25.2% 25% for Q1 on achievement baselining and trajectories agreed




R2biii £100,000 Paul Glynne 88.4% 25% for Q1 on achievement baselining and trajectories agreed




R2c £300,000 Gill Gaskin25% for participation in Q2 baseline

audit and agreeing improvement trajectory

25% for participation in Q1 baselining audit and agreeing

improvement trajectory


trajectory for that quarter

R3 £450,000 Paul Glynne 25% for preparation of plan 75% for delivery of plan paid in Q4

R4 £900,000Paul Glynne

(Diabetes & COPD)Gill Gaskin

(Heart Failure)

Not yet agreed Not yet agreedPayments will be made at the end of quarters 2 and 4 on the basis of achieving the agreed improvement

trajectories.

Payments will be made at the end of quarters 2 and 4 on the basis of achieving the agreed improvement

trajectories.

L1a £600,000 Tony Mundy 68.0% 100.0%Q4 based on achievement of

agreed performance improvement for the year

L1b £600,000 Tony Mundy 0.57 1.00Q4 based on achievement of

agreed performance improvement for the year

L1c £650,000 Paul Glynne Evidence of adherence to HPA SSISS protocol

L2 £650,000 Geoff Bellingan 25% for preparation of plan75% paid at the end of Q4 based

on delivery of plan.

L3i Paul Glynne 100.0% 99.0%

L3ii Paul Glynne 97.4% 98.0%

L3iii Paul Glynne 1 1

7000000 Page 25

Red Month 10, JanuaryAmberGreen

25% payment for Q1 based on participation in Choose and Book

project

25% payment in Q3 based on achieving performance target by

the end of this quarter

50% payment for maintaining performance in Q4.

Performance Indicators

Implementation of nutritional assessment and support

Improving timeliness of discharge - % discharged pre-noon

Improving timeliness of discharge - proportion discharged in line with predicted discharge date

Improving outpatient information – timeliness and content

Choose & Book - Directory of service rating of either 0 or 1

Implementation of Dementia Pathway

Choose & Book - 98% slot availability

Choose & Book - 99% of appropriate services available

£500,000

Loca

l

Hospital Standardised Mortality Rates

Surgical site recording and improvement

Reducing deaths in low mortality procedures

Reg

iona

lN

atio

nal VTE Assessment

Improving Patient Experience

Implement IHI Global Trigger Tool

Implement Enhanced Recovery Programme in at least 2 recognised specialties (one to be new to Trust)

Improving inpatient discharge information – content and electronic transmission

Improving timeliness of discharge - % weekend discharges

Improving care for LTC patients (diabetes, COPD and Heart failure) - reduction in readmission rates

8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators8. Externally Reported Frameworks 8.2 CQUIN Indicators

udrhg

Thresholds WeightingQ1

PerformanceQ2

Performance Q4 to date Jan-11 Comments

Refer to comments 1.0 3 4 1 1MRSA is red for the YTD up to quarter 4 to date against a threshold of 8. The full year threshold of 8 is phased in the early part of the year (2 from April to July) with a zero tolerance from August to March. See page 18 for detail.

Refer to comments 1.0 17 19 4 4Clostridium difficile is green for the YTD position up to quarter 4 to date against a threshold of 100. Our full year threshold is 119. The monthly threshold is 10 for every month except March 11 where it is 9. See page 18 for detail.

85% 88.7% 81.6% 77.5% 77.5% See page 16 for detail. To note, our submission to Monitor includes breach sharing for this indicator.

90% 100.0% 66.7% 80.0% 80.0%See page 16 for detail



94%

96% 0.5 97.9% 98.0% 97.3% 97.3%See page 16 for detail



100% 0.5 100%+ 100%+ 100%+ 100%+See page 18 for detail

95% 0.5 98.9% 99.0% 98.7% 98.7%See page 17 for detail

N/A 0.5

Green Amber/ Green Amber/ Red Amber/ Red

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

Note: Thrombolysis is a Monitor indicator but we do not provide this service in the Trust therefore we are not measured on this


Overall governance rating

Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability

Incidence of MRSA

Incidence of Clostridium difficile

Screening all admissions for MRSA

31 day wait for second or subsequent treatment: Radiotherapy (from 1 Jan 2011)

31 day wait for second or subsequent treatment: Surgery

Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge

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

62 day wait for first treatment from consultant screening service referral

Indicators

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

62 day wait for first treatment from urgent GP referral

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

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

1.0

1.0

0.5

8. Externally Reported Frameworks 8.1 Monitor Indicators – Compliance Framework

G

Agenda Item 10

Quality & Safety Committee Report

University College London Hospitals NHS Foundation Trust February Quality & Safety Committee Summary to the Board of Directors

General issues 1. Infection scorecard January 2011 and MRSA 2010-11 Action plan There were no new infection outbreaks in January. There was one case of MRSA bacteraemia and four cases of Clostridium difficile. In response to the Executive Board’s request for greater assurance that all measures were being taken to achieve the improvement in MRSA bacteraemia performance a number of recommendations were made. These will now be developed.

• The level of improvement in MRSA bacteraemia reduction at UCLH has been considerable and comparable to the best performers

• Common causes of bacteraemia in other Trusts were intravenous lines, wounds, compliance and blood culture contamination which echoes root causes found at UCLH.

• Successful Trusts had significant director level engagement in infection prevention strategies, focused on root causes and held those responsible for the bactereamias formally to account

• The MRSA strategy group has facilitated improvements in performance and will now develop performance measures and practice improvements further.

• Further work is required to improve IV line insertion and care, preventing surgical infection and blood cultures.

• The MRSA screening compliance system is ready to roll out to the Trust 2. Venous thromboembolism (VTE) prevention Trustwide, 90% of patients, including cohorted risk groups (73% excluding cohorted patients) were risk assessed in January, meeting the CQUIN target. Work is ongoing to identify additional cohort patients where appropriate. Divisions were reminded that efforts must continue to improve individual VTE risk assessments and reduce the number of patients who should have been assessed but were ‘missed’. 3. Control Drugs (CD) QSC received the CD report from the Accountable Officer for quarter three. Over 90% of ward monthly CD audits were completed. The majority of CD management incidents related to minor deviations from policy or minor or resolved CD stock discrepancies. 3 unresolved CD discrepancies that occurred between October and December were escalated to the Accountable Officer. The outcome of an investigation led by the Divisional Senior Nurse is awaited. One serious drug administration ‘near miss’ occurred involving the wrong route administration of oral liquid medicine. This has been investigated locally and Trustwide lessons are being learned 4. Divisional Scorecards / Quality Indicators QSC received exception reports on quality indicators from the divisions of critical care, emergency services, women’s health, surgical specialties and theatres & anaesthetics.

• Critical Care reported that, during a sustained period of significant increased clinical activity, the division has made good progress in its plan to create a research team, sustains a low HSMR for critically ill patients, with no MRSA bacteraemias and low readmission rates. No SIs in the reporting period, however the issues relating to pressure sores are being pursued internally as very serious incidents.

1

• Emergency services reported successful delivery of the 4 hour target for quarters 1-3 and was the highest performing acute Trust in London against the indicator at end of Q3. A new complaints response process has been successfully implemented. Delivery against the required response turnaround times since September 2010 was 100%. There has been sustained reduction in Falls resulting in harm (YTD=1.16) Patient feedback for ‘Overall do you feel you have been treated with respect and dignity whilst in hospital?’ was 96.7%. VTE risk assessment has improved to 86.5%.

• Women’s Health reported strong VTE Risk Assessment Performance and sustained

improved performance in Maternity PPH with reduced incidence and lower blood loss. Hand Hygiene compliance was 97%. There were a lower number of maternity complaints in the last 2 months and the response rate in January was 100%. Antibiotic durations documentation improved from mid-60% range to 80% range. In maternity the modified early warning system chart has been in use to detect deterioration for all high risk women. No cases of MRSA.

• Surgical Specialties reported that a new enhanced recovery pathway for trauma &

orthopaedic patients has been implemented. Ward T10 is ward of the year for pre-11am discharge and no falls with harm or MRSA cases in the reporting period. The division achieved over 80% for patient experience Oct-Dec and the composite score for December was 88%. VTE risk assessment compliance was over 90% in January. Root cause analysis is in place for two pressure ulcers in December and a MDT meeting is now held prior to admission for high risk cases. Readmissions in December were 6.4%

• Theatres & Anaesthetics reported that a new nursing structure is in place with 25 team

leaders appointed in main theatres. The Productive Operating Theatre program has been launched in day surgery. Launch of a new hand washing audit tool in theatres has improved compliance.

• QSC noted the comparative trust scorecard.

5. Risk Coordination Board QSC noted the report.

Patient Experience 6. Safety of Tertiary Paediatric Services The clinical director for the paediatric division reported on the Healthcare for London review of trusts performance against the issues raised in Dr Edward Baker’s report on Commissioning safe and sustainable specialised paediatric services: a framework of critical inter-dependencies(2008) Trusts were criticised for disjointed care and failure to meet interdependency. In response UCLH is to address the need for ear, nose and throat services, paediatric critical care and paediatric anaesthesia. 7. National Inpatient Surveys 2010 Picker Inpatient survey results The Trust has received the interim results for the 2010 national IP survey. This showed that improvements have been maintained and UCLH performed better than average on 26 questions. Low scoring questions from the previous survey had all improved. Performance was worse on 7 questions including, food, availability of hand gel, being admitted sooner and clinical information given by nurses. DoH Cancer Patient Survey The National Cancer Patient Experience survey showed a significant difference between London & non London trusts with 17 out of 34 lowest performers being in the

2

worst performing 20% including UCLH. Explanation, information and emotional support were consistent themes. The medical director for the surgery & cancer board reported on plans to address patients poor satisfaction with their care including: improving communication, food, the cancer network and an MDT cancer steering group across all three boards to look at excellence in cancer care. CQC Maternity Survey (February 2010) The Trust showed a better performance than in the previous survey in areas such as cleanliness, antenatal screening and overall rating of care. However the survey indicated that a number of areas for improvement still need to be targeted particularly in postnatal care. The Trust is voluntarily repeating the survey in February 2011. 8. Complaints QSC received the quarterly report for October to December 2011. Overall numbers of complaints fell during the quarter. This fall follows a usual pattern over the Christmas period. Sixty complaints have been received in January which reflects more usual monthly figure. The overall target response time met rate decreased slightly, from 83% in the previous quarter to 79%. Themes identified were: administration, cancellations, letters, treatment, nursing care and poor communication.

Three cases were referred to the Ombudsman and one existing case closed with a decision not to investigate. This maintains the Trust’s position of not having any cases accepted for investigation by the Ombudsman. The complaints pilot in surgical specialties and paediatrics is underway: 17 cases have been received to date. A review meeting is scheduled later in February. 9. Patient Issues Committee (PIC) QSC noted the PIC report for February 10. Trust corporate audit programme Divisions were asked to take note of the corporate audit programme and incorporate into their divisional clinical audit planning Tony Mundy Medical Director

3

H

Agenda Item 11

Finance & Contracting Committee Report

Report Title: Finance and Contracting Committee Report Approved by: Richard Alexander Prepared by: Mark Claridge Date prepared: 3rd March 2011 Submission to: Board of Directors – 9th March 2011 Previous papers: N/A Reference documents:

N/A

Purpose of the paper/report: This report updates the Board of Directors on the issues, considered at the meeting of the Finance and Contracting Committee (FCC) on 2nd March 2011, relating to the financial performance and contracting position of the Trust as at 31st January 2011. Issues/Action/Recommendation: The Board of Directors is asked to:

• Note the financial performance for the first ten months of the current financial year. • Agree the proposal for managing liquidity at the end of the current financial year • Note the contracting update presented to the FCC. • Note the financial planning update presented to the FCC

Financial Implications: N/A

Other Implications: N/A

Page 1 of 4

Page 2 of 4

1. Finance Director’s Report 1.1 The Committee noted that the Trust’s overall year-to-date income and expenditure

position, at month 10, is a surplus of £7.4m (£0.3m behind plan), whilst year-to-date EBITDA is £54.8m, £0.8m ahead of plan (EBITDA for the same period last year was £51.4m).

The month 10 year-to-date financial position is set out in table 1, below:

Month 10 year-to-date Service Line

Budget £m

Actual £m

Variance £m

Medicine Board 2.8 4.6 1.8Specialist Hospitals Board 22.3 22.1 (0.2)Surgery & Cancer Board 13.1 8.4 (4.7)Research & Development 0.0 (0.1) 0.0Education (2.2) (2.1) 0.0Corporate Budgets 17.9 21.9 3.9EBITDA 54.0 54.8 0.8ITDA (46.3) (47.4) (1.1)Net Surplus/(Deficit) 7.7 7.4 (0.3)

Table 1 – Month 10 YTD financial position (figures shown with rounding) 1.3 The Committee noted that the Trust had experienced a challenging month in January

with a number of operational issues affecting financial performance. However, this had been offset by two material elements of income (high cost area supplement for Agenda for Change staff and additional non-recurrent clinical lecturer back-fill funding) totalling £1.1m, and the further release of £0.5m from the Board contingency (£3.0m has now been released for the year-to-date).

Without these adjustments the year-to-date financial position across the Trust would have been approximately £1.6m worse than plan.

1.4 The Trust has made a year-to-date contribution, before indirect costs, of £129.0m, (a contribution margin of 21.2%), which was £0.5m above the level planned at month 10.

2 Clinical Board Performance 2.1 Both the Surgery and Cancer Board and the Specialist Hospitals Board have fallen

short of their forecast financial position in month 10 – both by £0.2m.

2.2 For Surgery and Cancer the key areas of concern in-month were:

• Cancer - £0.5m behind plan (due to lower than expected private patient income and an overspend on pay costs),

• Theatres - £0.3m behind plan (due to fewer sessions, with some over-runs to accommodate additional activity).

There has been a marked improvement in performance within GI Services, which was ahead of plan for the first time this financial year.

The Surgery and Cancer Board is taking action to strengthen its management in the light of these continuing financial problems. This includes changes in its core team and divisional management.

2.3 The Specialist Hospitals Board has seen a deterioration in its financial position, with the key issues being as follows:

Page 3 of 4

• Queen Square - £0.7m behind plan (due to a noro-virus outbreak as well as a delay in building works, both of which contributed to a reduction in elective activity),

• Heart Hospital - £0.3m behind plan (due to the ongoing effects of the influenza outbreak, resulting in blocked ITU beds and cancellations of elective work that were worse than expected).

Both clinical divisions remain the subject of weekly performance meetings. A new Divisional Senior Nurse at Queen Square has been appointed, and a new General Manager post has been created.

3 Efficiency and QEP 3.1. The Committee noted that the year-to-date QEP performance is £0.8m behind plan.

The majority of the under performance is in Surgery and Cancer (£0.9m). Whilst the Board’s main focus is developing initiatives to deliver next year’s QEP, it is continuing to identify schemes to make up this under-performance; however it is unlikely they will fully deliver this financial year.

3.2 The Trust’s forecast position for the year-end is savings of £25.9m, an under achievement of £0.6m against the £26.5m QEP plan. However, the savings plans for 2010/11 are currently forecast to yield £28.4m of full-year savings – a contribution of £1.9m of savings towards next year’s QEP.

4 Balance Sheet and Cash 4.1 The Trust’s cash position at 28th February 2011 was £81.8m, which is £17.4m ahead

of plan. This favourable variance has resulted from:

a) The year-to-date slippage (against the original plan) on the capital programme, although there is now an increasing ramp-up of capital expenditure taking place over the latter part of the year.

b) Advance payments from PCTs, relating to March SLA income (approximately £8m), received before the due payment dates.

4.2 The Finance Director informed the Committee that the Trust had recently written to Monitor asking it to consider treating the Trust’s agreed, un-drawn Foundation Trust Financing Facility (FTFF) loan in the same way as a WCF – i.e. as part of the liquidity metric calculation. However, despite the issue being taken through senior committees within Monitor, the Trust’s request was turned down.

The Trust’s original cash plan for the year assumed set up of a WCF in order to achieve the required liquidity metric to result in an overall FRR of 4. However, the Trust could still achieve this FRR, without needing to set up a WCF, based on the following assumptions:

• Settlement of part of the Windeyer transaction with UCL before 31st March 2011.

• Capital expenditure in 2010/11 no more than £1m higher than forecast.

4.3 The Committee recommended, given the uncertainty of the above assumptions, that in the event of the Windeyer transaction not being settled this financial year, or capital expenditure being greater than forecast, that the Trust draws down an element of the FTFF loan, as necessary, to achieve the required liquidity metric. This would incur the interest charge of 3.94% p.a. on the drawn down balance, but would save 1.75% in PDC dividend payment in the current financial year (and a further 1.75% next year).

Page 4 of 4

The Trust would also then not incur the cost of setting up a WCF, in this financial year.

The Trust has made contact with FTFF to inform them of the possibility of drawing down an element of the loan this financial year, up to a maximum value of £20m.

The Board is asked to agree to this proposal.

5 Contracting Update 5.1 The Deputy Chief Executive provided the Committee with a report showing month 10

year-to-date contract performance, based on both Trust proposal and PCT contract value, against contact baselines.

5.2 The Committee reviewed the latest position in respect of billing and payments made against commissioner contracts for 2010/11.

The Committee noted that payments from PCTs in respect of month 9 over performance were due to be received on 2nd March 2011, in line with national billing and settlement timescales. The Deputy Chief Executive informed the Committee that letters have been sent to all commissioners with significant outstanding debt, with the exception of NCLACA where the issue of payment of 2010/11 over performance is being dealt with separately.

5.3 The Chief Executive updated the Committee on the most recent progress made with NHS North Central London to achieve settlement on contract over performance,

5.4 The Deputy Chief Executive informed the Committee that the Trust had now received an initial contract offer from NHS North Central London for 2011/12, albeit at a level that was significantly below even the PCTs’ own forecast outturn figure for 2010/11.

The Committee also reviewed a summary of commissioning intentions, together with a financial assessment, which NHS North Central London expects to form part of the 2011/12 contract.

The Deputy Chief Executive informed the Committee that it was also the desire of NHS North Central London to have two contracts with the Trust next year, one covering all specialist work for the five PCTs within the sector and a second contract for “DGH” type work commissioned from Camden and Islington PCTs (only) for their residents.

5.5 The Committee also reviewed a letter from NHS North Central London setting out the process if agreement on the 2011/12 contract is not reached by 31st March 2011. The Deputy Chief Executive advised the Committee that the Trust was currently reviewing whether this was relevant to UCLH, particularly as the existing contract expires on 31st March 2011.

6 Financial Planning 2011/12 Update 6.1. The Finance Director presented the Committee with the financial planning update,

which included the draft financial plan for the Trust for 2011/12.

The Committee engaged in a detailed discussion on the key assumptions being made within the plan, including the current estimated QEP requirement, the uncertain nature of the risk from PCTs’ commissioning intentions, and the adequacy of the current level of planned contingencies.

6.2 The Committee asked for the paper to be included within the report and presentation of the overall draft financial plan to be taken to the March Board.

Jane Ramsey Chair of FCC Richard Alexander Finance Director 3rd March 2011

I

Agenda Item 12

Seal Report

Seal Report - March 2011

BOARD OF DIRECTORS MEETING – 9 March 2011

Entries in the Seal Register since the last Report to the Board Number Date of Entry Entry Details

Supporting Information

464 15 December 10 Licence for alterations between University College London NHS FT and University of London

This document relates to Warwickshire House and Bonham Carter House, for the installation of wheelchair accessible external lift at ground and basement floor levels

465 15 December 10 As above As per 464

466 21 January 11 Article of agreement between University College London NHS FT and Russell Cawberry Limited

This document relates to The final stage contract for relating to the Brain Tumour Centre Scheme

467 21 January 11 As Above

As per 466

468 11 February 11 Deed between University College London NHS FT and University College London

This document allows the Trust to erect scaffolding and permits reciprocal crane oversailing at the Rayne Institute, the Cancer Centre, and 7 Mortimer Market

469 17 February 11 Underlease between University College London NHS FT and Radiology Reporting Online LLP

This document relates to an underlease co-terminus with the JV agreement, for part of the 6th Floor West Wing, 250 Euston Road, for a 10 year term. Includes 2 plans

470 23 February 11 Lease between University College London NHS FT and London Power Networks Limited

This document relates to the lease of a Transformer Chamber at the Cancer Centre

J

Agenda Item 13

Register of Board Members’ Interests


Report to Board of Directors Meeting 9th March 2011

REGISTER OF BOARD MEMBERS’ INTERESTS

Introduction The Code of Accountability requires Board directors to declare interests which are relevant and material to the NHS Board of which they are a director. The Trust’s Standing Orders require that a Register of Interests is established to record formally declarations of directors’ interests. These details are kept up to date by means of an annual review of the Register in which any changes to interests declared during the preceding 12 months, and all newly declared interests, will be incorporated. Annual Review 2011 The annual review of the Register of Board Members’ Interests has recently been conducted and the revised Register is attached herewith for information. Recommendation The Board is requested to note the revised Register of Interests which will be published following the meeting. Tonia Ramsden Director of Corporate Services and Secretary to the Trust

REGISTER OF BOARD MEMBERS’ INTERESTS

FEBRUARY 2011

Interest Declared Board Member Directorships (including non-executive directorships) held in private companies or PLCs:

Director, Sue Atkinson Associates Ltd (Consultancy) Sue Atkinson Co-director, London Intensive Care Ltd Geoff Bellingan Co-director, CPX Ltd (provide cardiopulmonary exercise testing) Geoff Bellingan Standard Chartered PLC Richard Delbridge Director, The Glynne Medical Practice Ltd Paul Glynne Director, London Acute Care Ltd Paul Glynne Vice-Chairman, NM Rothschild & Sons (Corporate Finance) Limited Richard Murley Chairman of Radiology Reporting On-line (RRO) Robert Naylor Non-executive Director and Chair of the Medical Advisory Panel, BUPA

John Tooke

Non-executive Board Member, UCL Business PLC John Tooke

Ownership or part-ownership of private companies, businesses or consultancies likely to do business with the NHS:

Sue Atkinson Associates Ltd (Consultancy) Sue Atkinson Majority or controlling share holdings in organisations likely or seeking to do business with the NHS:

Position of authority in a charity or voluntary body in the field of health and social care:

Trustee, UCLH Charities Sue Atkinson Member of Research Committee, Intensive Care Society Geoff Bellingan Council member, European Society of Intensive Care Medicine Geoff Bellingan Critical Care Committee member, Royal College of Physicians (RCP) Geoff Bellingan Member, Acute and General Medicine Committee, RCP Paul Glynne Member, Payment by Results Committee, RCP Paul Glynne Member, Workforce Review Team, RCP Paul Glynne Chairman of Trustees, Oxford Policy Institute Nicholas Monck Trustee, Covent Garden Cancer Research Trust Tony Mundy Member, Organising Committee, Crisis Urban Investors Richard Murley Non-executive member, Department of Health Audit Committee Jane Ramsey Non-executive Board member, UK Centre for Medical Research & Innovation (UKCMRI)

John Tooke

Connections with a voluntary or other organisation contracting for or commissioning NHS services:

Honorary Visiting Professor, Department of Epidemiology and Public Health, UCL

Sue Atkinson

Chair, Public Health Action Support Team (PHAST) – A social enterprise community interest company

Sue Atkinson

Honorary Consultant, Imperial College Healthcare NHS Trust Gill Gaskin Senior Associate Fellow, University of Warwick Institute of Public Management

Robert Naylor

Associate Member of the Board, NHS London Jane Ramsey Member, Medical Schools Council Executive Committee John Tooke Connections with an organisation or company entering into a financial arrangement with the Trust

Former employee of Oracle Corporation and shareholder Richard Alexander Any other relevant interests; Board Member, Food Standards Agency Sue Atkinson Providing Public Health advice for the North East London Integrated Impact Assessment (Health for N.E. London Consultation)

Sue Atkinson

Member, Finance Committee, London School of Economics Richard Delbridge Member, London Workforce Advisory Forum Gill Gaskin Member, Council of Management of the National Institute of Economic & Social Research

Nicholas Monck

Member of Advisory Council, Transparency International (UK) Nicholas Monck Trustee of BGI (Better Government Initiative) Nicholas Monck Member, Steering Committee of the Alignment Project (led by the Treasury)

Nicholas Monck

Member, Advisory Committee to the Office of National Statistics’ Centre for Measuring Government Activity (including NHS output)

Nicholas Monck

Editorial Board, BJU International Tony Mundy Editorial Board, Current Opinion in Urology Tony Mundy Editorial Board, Urologica Internationalis Tony Mundy Honorary Civilian Consultant Urologist to the Royal Navy Tony Mundy Member, Financial Reporting Councils Financial Reporting Review Richard Murley Member of the Board, Foundation Trust Network Robert Naylor Director, UCL Partners Robert Naylor Lay member, Royal College of Veterinary Surgeons Investigations Committee

Jane Ramsey

Chair, Croydon Care Solutions Ltd (a local authority wholly-owned company for the provision of services to people with disabilities and learning disabilities)

Jane Ramsey

Chair, UK Health Education Advisory Committee, reporting to HEFCE John Tooke Member, National Institute of Health Research Advisory Committee John Tooke Member, Health Education National Strategic Exchange John Tooke Any of the above interests held by a spouse, partner, close relative or other associated person:

Consultant in Medicine for the Elderly, Barnet & Chase Farm NHS Trust

Dr. Penelope Wiseman (wife of Richard Murley)

Employee, T-Mobile Richard Foster (son of Michael Foster)

Technical Director, WSP Group, Consulting Engineers (undertake work for NHS organisations from time to time)

John Parker (spouse of Gill Gaskin)

Director, The Glynne Medical Practice Ltd Dr. S.J. Glynne (wife of Paul Glynne

General Practitioner, Balham Park Practice, Wandsworth Dr. S.J. Glynne

Employee, Healthcare Purchasing Consortium James Naylor (son of Robert Naylor)

Employee of Cancer Research Technology Development Laboratory (part of Cancer Research UK)

Dr. Nat Monck (son of Nicholas Monck)

Documents

BOARD OF DIRECTORS meeting papers...BOARD OF DIRECTORS Agenda for the meeting to be held on Wednesday 9th March 2011 at 2.00pm in the Education Centre, 1st Floor West Wing, 250 Euston