THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST. Minutes of the Board of Directors Meeting held on 19 th December Part A: Public Session

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1 Agenda Item: A3 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting held on 19 th December 2017 Part A: Public Session Present: Professor Sir John Burn Chairman Mrs L Robson Business and Development Director Mrs H Lamont Nursing and Patient Services Director Mrs A Dragone Finance Director Mr D Stout (Vice-Chair) Non-Executive Director Mr K Godfrey Non-Executive Director Professor K McCourt Non-Executive Director Mr J Jowett Non-Executive Director Mr E Weir Non-Executive Director Mrs H A Parker Non-Executive Director Professor D Burn Non-Executive Director In Attendance: Mrs K Jupp, Trust Secretary Mrs A O Brien, Director of Quality & Effectiveness 17/202 Apologies for Absence Apologies were received from Mr A Welch, Medical Director. 17/203 Declarations of Interest Mr Ewen Weir declared an interest in all matters pertaining to Newcastle City Council and Professor David Burn declared an interest in all matters pertaining to Newcastle University. Sir John explained that he held a part time role as a Senior Strategic Advisor to Newcastle University and was a Non-Executive Director of NHS England. He added that he was the Chair of the Specialised Commissioning Committee at NHS England however had relinquished this responsibility on appointment as Trust Chairman and instead chaired the NHS England Audit Committee. Sir John advised that he role as Non-Executive Director for NHS England was due to end in June 2018 and that he had relinquished his Honorary Consultant with the Trust in order to be appointed as Trust Chairman. In relation to other roles held, Sir John explained that he was involved with a company named Quantum DX which had no direct relationship with the Trust and was the Executive Chairman of a Charity named Global Variome. 17/203 Minutes of the Meeting held on 23 rd November

2 The minutes of the meeting held on 23 rd November were agreed as a correct record subject to an amendment highlighted by Mrs Lamont to page 5 whereby the reference to a stall being manned is amended to refer to a study day being held. 17/204 Patient Story Mrs Lamont presented the patient story and explained that the story detailed the experience of Patient A, an elderly lady with Dementia and Mr A, her son and primary carer. Mr A had been looking after his mother at home until she was admitted to hospital and it was felt by the Multidisciplinary Team that Patient A should not return home as 24 hour care was now required. Mr A was very distressed by this news and found it difficult to communicate with staff during the discharge planning. Mr A had subsequently raised a number of concerns in relation to the planning of, and funding for, his mother s care in the community. Mrs Lamont explained that the representatives from the Trusts Patient Relations Team had held a positive meeting with Mr A and Mr A felt there were issues which he was happy to share to facilitate reflection and learning. She added that Mr A had commented on the better working relationship that had been established and that he felt that he had been listened to. Mrs Lamont explained that the version of the patient story circulated would be reviewed prior to publication on the Trust website to ensure that any patient identifiable factors were removed. Mr Stout queried what lessons had been learnt to which Mrs Lamont explained that there had been a number of lessons learned which had been discussed at a Matrons meeting and at one of the Trust Patient Safety Briefings. She explained that in Mr A s case, the X-ray Department had declined for him to act as a chaperone for his mother which had caused anxiety and worry for Mr A. In addition his mother was very confused and she gave the wrong information to the staff working in the X-ray Department. Mr Stout referred to the significant size of the organisation and asked how the lessons learned from patient stories were communicated to which Mrs Lamont confirmed that these were completed in a number of different ways including on the intranet and in Matrons Forums. Mr Jowett asked why the X-ray Department declined the chaperone offer to which Mrs Lamont explained that she did not know why this was the case however it was most likely that it was not felt necessary at the time. Mr Weir commented that it appeared that Mr A had concerns over the funding for his mother s care which was out with the control of the Trust. Mr Godfrey referred to the use of Multi-Disciplinary Team s (MDT) and commented that often the soft information such as the importance of the relationship between a carer and a patient was not discussed at such meetings, the focus being on clinical treatment. Professor Burn added that situations can be interpreted in different ways and sometimes when carers have a difficult working relationship with staff then this can create a distance and a barrier in terms of communication. 2

3 Mrs Lamont agreed to review the format of patient stories to ensure that future patient stories detailed clearly any lessons learned and actions taken or planned (ACTION01). to receive the patient story. 17/205 Safety, Quality and Performance i) Integrated Quality Report Mrs Lamont and Mrs O Brien presented the report. Mrs Lamont presented the November HCAI 2017 position and confirmed that there had been no further cases of MRSA, therefore the position stood at 3 cases to date, compared to 5 cases in the same period last year. There were 6 cases of C. difficile in November bringing the total to 51 for the year to date, which is within trajectory. Fifty two cases have been reported for the year to date, with 6 successfully appealed, meaning that 46 cases counted against the Trust s target. This compared with 39 in 2016/17 and was within trajectory. The year-to-date C. difficile rate per 100,000 bed days at the end of November was against the target of 16.3 or less. There were 5 MSSA bacteraemia in November, bringing the total to 57 for the year-to-date. This is compared with 66 cases to the end of November 2016 and demonstrates a small improvement in the number of cases. Mrs Lamont explained that there were no national targets for MSSA performance however the Trust performed negatively compared to other Trusts in terms of the numbers of MSSA. Mrs Lamont highlighted that there were 13 cases of E. coli bacteraemia identified post 48 hours of admission in November giving a total of 120 to date. This is compared with 136 by the end of November The total number of falls for November 2017 was 268 bringing the running total number of falls for the year to date to 1,967, which was lower than the same period last year (total of 2,042 falls). The average falls per 1,000 bed days was equal to the same period last year at 5.9 falls per 1,000 bed days. Mrs Lamont commented that the position was still concerning as circa 250 patients had falls each month and a number of these were reported as serious incidents. Mrs Lamont explained that there had been a slight decrease in the number of pressure ulcers in November compared to October Targets had been set for pressure ulcer performance in each area of the Trust, with 26 of the 57 areas having achieved a 20% reduction. Mrs Lamont confirmed that there were no national targets regarding pressure ulcers and that it was difficult to define and compare pressure ulcer performance across Trusts. She added that the Trust reported circa 60 to 70 pressure ulcers per month which was of concern. 3

4 Mrs Parker referred to a recent Risk Management and Assurance Committee meeting whereby a discussion took place regarding the number and cost of litigation claims arising from cases of pressure ulcers. She added that there had been five cases to date and all highlighted a need to improve the documentation in relation to pressure ulcers. Mr Godfrey queried the level of serious harm from falls to which Mrs O Brien explained that following a discussion with Mrs Jupp it had been agreed that this information would be reported within the Integrated Quality Report from January (ACTION02). The most recent data available from the Safety Thermometer showed that the Trust continued to achieve the 95% harm free care target. Professor Burn queried the display format to which Mrs Lamont confirmed that the display format would be amended to show performance over a longer time period and to enable a comparison of performance both nationally and regionally (ACTION03). Mrs Lamont also agreed include the categories of harm from falls in the integrated quality report (ACTION04). It was noted that the CAT results demonstrated a stable set of results over the last six months, with total scores around 96%. The staff knowledge score had dropped slightly and was now under 93%. Mrs Lamont explained that the Trust Board had discussed previously removing the staff knowledge score and replacing with a score for ANTT training which was deemed to be a more appropriate indicator to use. The results of the Family and Friends Test were consistent with previous reports however it was highlighted by Mrs Lamont that the number of complaints had increased over recent months. This matter was under review and there was no evidence that the increase in complaints was related to one specific area. Mrs Lamont explained that for a number of complaints the deadlines had been renegotiated and this had been discussed at the Clinical Policy Group meeting this morning to identify a Directorate Lead to focus on this matter. Professor McCourt referred to Complaints Panel meetings and highlighted that requests to renegotiate complaints response deadlines were being submitted late. Mr Godfrey referred to the need for efficient and effective communications and queried whether texts and s were used for communicating complaints progress to which Mrs Lamont confirmed that the Trust needed to improve its methods of communication with complainants. Mr Weir referred asked about the review process for identifying deaths for patients with a learning disability to which Mrs O Brien explained that if patients have a learning disability as defined in their patient record then this automatically triggered a level 2 review. She added that lessons learned from the reviews were shared widely and that they were fed back into a national project. Mrs Lamont commented that the Trust had implemented the Learning from Deaths guidance early and Professor McCourt highlighted that the National Lead for Learning from Deaths had visited the Trust recently. She advised that some of the 4

5 Trust Governors were due to meet with the Trusts Learning Disability Nurse in January. Mrs O Brien advised that there had been an increase in the number of incidents reported however this was viewed positively. She highlighted that the Trust remained in the lowest quartile for reporting and this was due to the Trust reporting mis-labelled samples in a different way to other Trusts. Such samples are entered onto the Trusts QPulse system however this system does not interface with the national system and it was deemed inappropriate for Trust staff to record the on QPulse and then re-enter the data on to the national system. Mrs O Brien reported that there were six Serious Incidents in November which related to two category three pressure ulcers, two falls resulting in fractures, one delayed diagnosis of cancer and one unexpected death. Regarding the delayed diagnosis, this was within the Dental Directorate and related to an abnormal CT scan result which was unreported for seven months. Mrs O Brien explained that the unexpected death related to a child in paediatric oncology. The patient had undergone both chemotherapy and radiotherapy, however unfortunately both forms of treatment had failed. The patient had joined a research trial and during an operation to insert a large IV line a very rare complication arose and the patient died. A detailed internal investigation had been undertaken which did not identify any issues relating to the insertion technique. Mrs O Brien confirmed that there had been no Never Events in November however one Never Event had been reported in December in Ophthalmology Theatres whereby a wrong size lens had been inserted. The correctly sized lens had been identified at the start of the operation however an unexpected complication arose whereby a different size lens was required. A recalculation of the lens size was performed using the previous patients record in error. Mrs O Brien commented that a similar issue was identified three to four years ago however since January 2014 no Never Events related to this had been identified. She explained that the Trust undertook the highest number of ophthalmology procedures in the Country and the investigation had identified that a trainee had been asked to check the patient record however the trainee was not fully equipped to review the system. Mr Godfrey identified the need for a dual check process to occur to which Mrs O Brien agreed to review and report back in January 2018 (ACTION05). Mrs O Brien referred to the Greatix reporting in the report which had been introduced in November 2016 in order to share learning. She explained that over 400 reports had been submitted and that the percentage of Greatix reports submitted by Consultants was higher than the percentage of Datix incident reports. It was noted that the Trust Mortality performance was positive, with the HSMR having reduced and being within the as expected range. Similarly with the SHMI score the Trust was beneath the national average. Mrs O Brien highlighted that the Trust was conducting a review of approximately 50% of patient deaths and to date only one patient death had been identified as potentially preventable. However in this case the patient had been transferred from another Trust to this Trust and had died on transfer to NuTH. Sir John queried 5

6 whether this had been fed back to the originating Trust to which Mrs O Brien confirmed that it had. Sir John requested that the graph be updated to should show annual oscillation to which Mrs O Brien agreed to implement for future reports (ACTION06). Mr Godfrey queried why level 2 deaths were different to the previous policy to which Mrs O Brien confirmed that only level 2 deaths were shown on the database. Mrs O Brien agreed to explore whether all deaths should be shown on the database (ACTION07). Mr Stout referred to a previous Board discussion on the impact of the population in London and the depth of coding and Mrs O Brien advised that the Trust did have a shortage of clinical coders however recruitment levels had improved over recent months. She added that the recording of co-morbidities had improved and highlighted that as part of the GDE programme a better electronic solution will be implemented. Mrs Robson explained that a piece of work had been undertaken to compare the depth of coding at the Trust with other regional and Shelford Group Trusts. The work highlighted that the Trust was coding to a similar depth as with other Shelford Trusts but less than with Trust regionally. to receive the briefing and note the current position. ii) HCAI Mrs Lamont explained that this report had been covered earlier under item 17/205(i). Mrs Parker referred to the Risk Management and Assurance Committee meeting held yesterday whereby the risk relating to the increase in cases of MSSA and E.coli were discussed. She added that the rating of the risk had been debated, particular in relation the potential reputational impact of the media coverage highlighting the Trust as an outlier. to note the content of the report. iii) Nurse Staffing Mrs Lamont presented the report and explained that reasonable progress had been made in terms of nursing recruitment. She highlighted that at present the total vacancy factor was 6.94% and the Band 5 vacancy factor was 8.31%. This was 2% higher than in the previous year. It was noted that the Trust had held a number of successful recruitment events and adverts posted on social media had been viewed widely. Mrs Lamont advised 6

7 that the recruitment event held in November had resulted in 82 new recruits which was very positive. Mrs Lamont advised that it was great to see new staff joining the Trust however highlighted that the presence of new staff created extra pressure on the existing staff in terms of training and support. It was noted that a new Nursing Foundations Programme had been launched to support newly qualified registered nurses (RNs) in the first year of their career, with a particular focus on those RNs who were unsure of which clinical area to start in the career. The aim being to support these staff and provide focused career advice in the first year of work. Mrs Lamont explained that evidence showed that staff leaving the Trust often returned back to the Trust as didn t receive the same level of support and advice out with the Trust. Mr Godfrey referred to the Campus for Ageing and Vitality (CAV) and asked whether bed capacity at that site was to be increased to which Mrs Lamont explained that there had been concerns identified regarding staff isolation at the CAV. She added that there were plans being developed to move the Cherryburn and Belsay Units across to the Freeman Hospital site after the Winter season. Mrs Lamont explained that at the Freeman Hospital site, staff can flex between Wards when resources are stretched however this is not possible at the CAV. Mr Godfrey queried whether there was a risk included within the Trusts risk register regarding the isolation point to which Mrs Lamont confirmed that there was. Mrs Lamont highlighted that there was a need to consider the Trust uplift and supernumerary levels in future as increases were required however there would be an associated financial impact. to note the content of the report. iv) Business Delivery & Performance Report Mrs Robson presented the report and explained that despite the challenges and Winter pressures the Trust had achieved the overall four hour A&E waiting time target in November but narrowly missed meeting the type 1 standard at 93%. It was noted that the Trust achieved the Referral to Treatment (RTT) incompletes target during November 2017 however the results for the Admitted (90%) and Non-Admitted (95%) performance were still being validated. However, the Trust expected to achieve both standards in November Whilst the November diagnostic performance was currently being validated, the Trust was not expecting to achieve the 6 week diagnostic standard, albeit the figures were very close. The Trust had successfully recruited 20 Italian radiographers who were due to join the Trust relatively soon and it was expected that the diagnostics target would improve as a consequence of this. 7

8 The Trust failed to meet the 62 day urgent and 62 day screening standards in October 2017; all other cancer standards were achieved. Mrs Robson advised that only three out of the nine Trusts in the region achieved the 62 day target. She added that there were national concerns regarding the achievement of the Cancer Standards. The Trust reported 18 ambulance handover delays in November 2017; all delays were due to the administrative process of handing over the patient on the IT system rather than the patients being held in ambulances awaiting entry to the department. Mrs Robson advised that the Trust had experienced a number of diversions last week and was currently reporting OPEL 2. Mrs Robson highlighted that the Trust mandatory training levels were at the required standard. In relation to the Single Oversight Framework, Mrs Robson reminded Board members that the Trust had been categorised as a level 1 Trust. Mrs Robson informed the Board of Directors that the Trust expected to deliver just under 99% of the planned activity and income levels. It was noted that the level of penalties applied to the Trust had reduced this month however such penalties were receivable as a consequence of the Trust having not signed a Control Total with NHS Improvement. Mr Godfrey queried whether there was a financial benefit to receiving ambulance diverts to which Mrs Robson advised that the financial value was small when compared to the resulting significant operational pressure. Mr Godfrey asked whether the Trust was able to identify when the North East Ambulance Service applied their override policy to which Mrs Robson confirmed that this was the case and most were due to the consequences of Norovirus or when no beds were available elsewhere. v) Patient Experience to note the content of the report. Mrs Lamont presented the report and advice that the report had been covered in part under item 17/205(i). The Trust had engaged in the national Patient Experience And Reflective Learning (PEARL) project which aimed to gather and analyse feedback from patients and families in the Assessment Suite and Critical Care Units at the Royal Victoria Infirmary and Freeman Hospital. 70% of Assessment Suite respondents had rated the quality of care as Excellent or Good, and a further 24% as average. Mrs Lamont referred to the Children and Young People s Survey results on page 5 of the report and highlighted that the Trust had received the most responses to the 8

9 survey (360) and achieved more scores categorised as Better than other Trusts than any other local Trust. Mrs Lamont highlighted that the CQC results for the Maternity Survey were due for publication in December/January however additional reports from the Picker Institute were very encouraging with the Trust being ranked as the Best performer amongst the 68 Trusts that Picker worked with on this survey. In the CQC benchmark data for the Emergency Department (ED) survey, for the majority of questions, the Trust scored About the same as other trusts. The Trust score was Better than others in two questions being told how long to wait and able to get food/drinks in the department. Mrs Lamont highlighted that the scores were a significant improvement on two years ago. Professor Burn commented that the ED environment was very challenging and therefore a recommendation rate of 92% was fantastic. A feedback event was held in October 2017 to invite feedback from staff who had recently used Trust services or whose family or friends had used Trust services. The overall feedback was very positive. Sir John recommended that in future Trust Board meetings that the Patient Experience report is discussed alongside the Patient Story. 17/206 Strategic Items to note the content of the report. i) Report of the Chief Executive Mrs Robson presented the report and explained that a significant amount of work had been undertaken in relation to patient flow to assist with Winter pressures. She added that 2.23 million of Winter funding had been received with conditions attached, such as achieving an A&E waiting time target of 94.93%. Mrs Robson referred to the expected increase of 2% in the A&E waiting time target as a consequence of the inclusion Battle Hill activity for which the Trust had validated. Reference was made to two key procurement exercises that were underway. The North Tyneside Urgent Treatment Centre re-procurement exercise had commenced and the Newcastle Gateshead CCG integrated urgent care consultation had been initiated. It was anticipated that there would be a movement to reduce the number of Walk-in Centres and in some cases convert to Urgent Treatment Centres (UTCs). Sir John queried whether this change would be positive to which Mrs Robson explained that pathways were currently being redesigned however it could impact on increasing demand in A&E. It was noted that the ACS proposal for Cumbria had been submitted and was likely to be approved. The Northumberland ACS proposal had been submitted on 9

10 Friday. Mrs Robson advised that there was a need to understand the impact on the collective position. In relation to the STP development, many of the Trust Clinical leads were involved in the workstreams and requests had been made for capital funding for specific service issues such as Congenital Heart Disease. The Trust had been notified that it would continue as a level one provider until at least April Work was continuing to review Cranial Thrombectomy service with Gateshead Foundation Trust. A Programme Board with Gateshead had been established to ensure a single approach to joint service reviews. Mrs Robson highlighted that the Great North Care Record had been launched through a presentation from Sir John. It was noted that the presentation had been well attended and was well received. Mr Godfrey asked about the current take up level for the staff flu vaccination programme to which Mrs Lamont confirmed that it stood at 60%. It was expected that the Trust would receive at least 75% of the CQUIN payment. 17/207 Finance to receive the update. i) 2017/18 Month 8 Finance Report Mrs Dragone presented the position as at 30 th November 2017 and highlighted that the Trust reported a 2.4 million deficit which was behind Plan. Further no agreement had yet been reached with NHS Improvement regarding the Control Total. The Trust achieved a risk rating of 3 which compared to the Plan rating of 2. Mrs Dragone explained that the higher rating was due to the impact of the cash. Sir John asked whether the Trust had received any additional national funding for Winter to which Mrs Dragone confirmed that some funding had been received however this would not be reported until next month. Mr Godfrey asked whether there had been any situations of commissioner default to which Mrs Dragone acknowledged that the CCGs were all under significant financial pressure. Operating income for the period was million, 6.2 million ahead of Plan and total operating expenditure was million, 7.9 million ahead of Plan. Elective work was becoming challenging due to Winter pressures and there had been an increase in activity which had not yet translated into an increase in income. The Trust reported an EBITDA surplus of 30.7 million which was 1.7 million behind Plan. 10

11 Mrs Dragone highlighted that the Trust s revised Plan required 31.6 million of cost improvements and delivery at Month 8 was 20.9 million. Plans were in place to deliver a further 4.8 million resulting in a shortfall of 5.9 million against the 2017/18 target. Year to date expenditure against the 32 million Capital Plan was running at 9.4 million, 11.0 million behind Plan. The Cash balance at the end of November 2017 was 123 million; 24.2 million higher than Plan. The under spend against the Capital Programme of 11.0 million was the main reason for increased cash holding. 17/208 Items to Receive to receive and acknowledge the overall financial position for the period to 30 th November i) NHS Providers Briefing: NHS improvement Transactions Guidance ii) NHS Providers: November 2017 Budget iii) NHS Providers: Q2 2017/18 finances and performance Items i)-iii) were received for information. 17/209 Any Other Business There was no other business on this occasion. The meeting closed at 14.05pm The next scheduled meeting would be held at 12-45pm on Thursday, 25 th January