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PAPERS FOR A MEETING OF

THE COUNCIL OF GOVERNORS

TO BE HELD IN PUBLIC ON

TUESDAY, 4 NOVEMBER 2014

18.30HRS – 20.15HRS

AT

THE ARK, BASINGSTOKE

PUBLIC MEETING OF THE COUNCIL OF GOVERNORS

OF HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST

TUESDAY 4 NOVEMBER 2014, 18.30HRS

THE ARK, BASINGSTOKE AGENDA

Item

1 Apologies for Absence

2 Declaration of Interests

3 Minutes of the Meeting of the Council of Governors held on 22 July 2014

Elizabeth Padmore Paper 01

4 Matters Arising Elizabeth Padmore Paper 02

5 Chairman’s Report Elizabeth Padmore Verbal

6 Report of the Working Groups

Membership Working Group

Patient Experience Group

Tony Green

Maurice Alston

Paper 03

Paper 04

7 Reports by Governors on other Meetings All Verbal

8 Chief Executive’s Report Mary Edwards Paper 05

9 Governance Report Andrew Bishop Paper 06

10 Finance and Performance Report David French Paper 07

11 The Patient Environment Donna Green Presentation

CLOSE

Date of Next Meeting – Tuesday 24 February 2015 at Beech Hurst, Andover

After the meeting, the Governors will be available for a period of approximately 15 minutes to answer any questions from members and the general public

Members of Hampshire Hospitals NHS Foundation Trust

and the general public are welcome to attend

COUNCIL OF GOVERNORS 4 NOVEMBER 2014

MINUTES OF A MEETING OF THE COUNCIL OF GOVERNORS OF HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST (THE “COUNCIL”)

HELD ON 22 JULY 2014 AT BEECH HURST, ANDOVER PRESENT:

Elizabeth Padmore Chairman “Chairman” Joy Deadman Public, North Hampshire & West Berkshire “JD” Lilian Turner Public, North Hampshire & West Berkshire “LT” Tony Green Public, North Hampshire & West Berkshire “TG” Janet Budd Public, Mid & East Hampshire “JB” Jennifer Ramsay Public, Mid & East Hampshire “JR” Brian Richardson Public, West & South Hampshire “BR” Haydn Watkins Public, West & South Hampshire “HW” Trevor Parkinson Public, West & South Hampshire “TP” Rosemary Hamilton Public, West & South Hampshire “RH” Maurice Alston Public, Rest of England & Wales “MA” Jennifer Barber Staff, Other Healthcare Professionals “JeB” Stuart Fraser-Richards Staff, Admin Clerical & Managerial “SFR” Kevin Conn Staff, Medical & Dental Practitioners “KC” Mark Wilks Staff, Support Services “MW” Paula Southgate Staff, Nursing & Midwifery “PS” Tommy Geddes Stakeholder, University of Winchester “TPG” Gerald Merritt Stakeholder, Older Persons “GM”

IN ATTENDANCE:

Charlotte Maybury Assistant to Company Secretary “CM” Tim Grimes Interim Company Secretary “TNG” Mary Edwards Chief Executive “ME” Andrew Bishop Chief Medical Officer “AJB” David French Chief Financial Officer “DAF” Donna Green Chief Operating Officer/Chief Nurse/Deputy Chief Executive “DG” John MacMahon Non-Executive Director “JMM” Jeff Wearing Non-Executive Director “JW” Robert Beveridge Non-Executive Director “RB” Philip Whitehead Non-Executive Director “PW” Sarah Isted External Auditor 2013/14, PricewaterhouseCoopers LLP “SI” Neil Thomas External Auditor 2014/15, KPMG LLP “NT”

30/14 WELCOME AND INTRODUCTIONS The Chairman welcomed the public to the meeting of the Council of Governors. She explained that the meeting was a meeting of the governors in public, not a public meeting; and as such no questions would be taken from the public during the meeting.

31/14 APOLOGIES FOR ABSENCE Apologies for absence were received from Ann Jones, Anthony Bravo, David James, Honora Smith, David Leeks, Joanna Sutcliffe, Stephen Reid and Nicola Horlick. Zoni Asif’s absence was noted.

32/14 DECLARATION OF INTERESTS There were no new declarations of interest.

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33/14 MINUTES OF A MEETING OF THE COUNCIL OF GOVERNORS HELD ON 29 APRIL 2014 It was noted that Jennifer Barber had been recorded as present twice, and MW had not been recorded as present. DG had also been incorrectly recorded as present. CM was asked to amend the minutes accordingly. Subject to the aforementioned amendment the minutes were agreed as a true record of the meeting.

34/14 MATTERS ARISING Progress deriving from matters arising from the previous meeting was considered. All matters arising were noted as complete or covered by the agenda.

35/14 CHAIRMAN’S REPORT The Chairman congratulated TPG on his reappointment as stakeholder governor representing Higher and Further education for a further term of two years. The Chairman also congratulated TPG for being listed in the Queen’s honours for being awarded an MBE. The Chairman apologised on behalf of the Trust for the omission of LT and DL’s attendance record in the Annual Report; an erratum will be added to the website with the Annual Report to remedy this. The Chairman confirmed that both LT and DL had attended all meetings for which they were eligible. The Council participated in a very helpful workshop on patient feedback led by Jane Davies and Sandra McArdle earlier in the day. The Chairman noted that the workshop provided good insight into the views of patients. A number of events had occurred since the last meeting of the Council of Governors, namely the opening of the new radiotherapy centre by Clare Balding in May, a useful and informative seminar on clinical reprovision for governors in June followed by a health focus event with Dr Tamara Everington, a celebratory Wow! Awards lunch and the annual DONA Awards. The Chairman invited all governors and members to attend the WWI Commemoration event being held at AWMH on Saturday 2 August to mark the centenary of the first world war. HHFT has several finalists in the national Wow! Awards: Carrie-Ann Watts a sister on C4 was shortlisted in the ‘Wow! That’s really special’ category, the Critical Care Team for the ‘Wow! What a team’ category and HHFT as a whole for the ‘Best Organisation’. Judging will take place in September to determine the overall national winners. The AGM will take place in the Ark on 9 September and the Chairman encouraged governors to attend, and particularly to attend the AGM roadshows in their local areas. A tea party will take place on 12 September to at RHCH to celebrate the opening of the Butterfield front entrance and all governors are invited to attend. The Chairman noted that the winter pressures have not ceased as they usually do in the summer months and there continues to be an increase in ED attendances. The Chairman praised the staff for working so hard despite the challenges.

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36/14 REPORT OF THE WORKING GROUPS Membership Working Group TG presented the report of the MWG. At their recent meeting, the group discussed revisiting the membership leaflet to increase the emphasis on email communication in order to reduce costs. The members of the group have been encouraged to volunteer to speak at local groups and to write articles for local publications. TG highlighted that members can attend talks in support rather than as a speaker. LT noted the difficulties she had experienced in obtaining the contact details for her local Parish magazine. Patient Experience Group MA provided a verbal update on the patient experience group. The group now has 12 members, two of which are staff governors in contrast to previous years when only one staff governor was permitted to be a member. The new reformed group had their first meeting on 11 June with Jane Davies and ME in attendance. An overview was provided of the role of the PEG within the governance structure of the Trust and the members agreed the new terms of reference subject to a minor wording change. The group is currently focusing on restarting the programme of governor visits and the expectation is that every governor will take part in at least one visit per year. JS led a workshop at the last meeting on 15 July to decide what the visits should entail in the future. This is ongoing work for the group. The group also received useful information from Verity Gibbons, Assistant Risk and Compliance Manager and Erin Jarvis, Sister on the Emergency Department at BNHH and a CQC inspector on the new-style CQC inspections which the visits will be based on.

37/14 REPORTS ON OTHER MEETINGS GM reported on a recent meeting of the Over 55s Forum where ME had been invited to present on HHFT’s clinical reprovision programme.

38/14 CHIEF EXECUTIVE’S REPORT ME presented the CEO Report. It was noted that the Trust is under increasing pressure due to there being no decrease in activity over the summer months. There is an increase in funding from various sources for the CCGs and ME is hopeful that the Trust may be able to receive some additional funds. The new safer staffing reporting requirements are being satisfied with the Board receiving monthly updates on staffing levels. The staffing level information is also available on the Trust website. ME is impressed by the increasing number of staff members willing to become caremakers.

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There are 8 caremakers at present in the Trust. ME congratulated the finalists in the Health Education Wessex Awards one of whom is a winner. Clifton Ward has also been shortlisted as a finalist in the Nursing Times Award. CCG contracts negotiations have completed and all contracts have been negotiated on full PbR terms. The only exception is the 30% tariff cap on emergency department patients who are admitted to hospital. A discussion ensued regarding the 30% cap on the tariff which DAF noted costs the Trust approximately £6m per year. Clinical reprovision is progressing with plans for developing a business case and commencing the Monitor approval process. TPG asked for clarification regarding the government recommendations on NHS staff pay. It was noted that as a foundation trust, HHFT can deviate and has some flexibility; for example, there have been discussions on how to distribute any above plan profit to the staff. The Council discussed ways of raising extra funds for the Trust. DAF noted that Hampshire Hospitals Charity receives approximately £500k-£1m donations per year. There is also support from local charities, for example, the North Hampshire Medical Fund bought the planning CT scanner for the new radiotherapy unit.

39/14 ANNUAL REPORT & ACCOUNTS Overview of year 2013/14 It was noted that the Council had only recently received an overview of the year. Council to Receive Annual Report & Accounts DAF informed the Council that there is a legal requirement for them to formally receive the Annual Report and Accounts for 2013/14 and it was noted that this had been previously circulated. It was noted that the Report and Accounts have already been laid in Parliament. DAF noted that the Trust achieved a small surplus at year end and that all Monitor targets were green except for C.Diff. The external audit ran smoothly and this will be the last audit conducted by PwC as KPMG will be taking over for 2014/15. Both firms are working together during the transition process. Audit Committee Chairman’s Report RB presented the Audit Committee Chairman’s report. The Committee reviewed the Annual Report and Accounts before they were submitted to the Board for approval. There were some minor issues regarding matters of judgement but these were small and immaterial. The Committee recommended the Annual Report and Accounts to the Board for approval after detailed discussion. The external auditor report gave the committee full confidence to recommend the approval to the Board.

40/14 EXTERNAL AUDITOR’S REPORT SI presented the external auditor’s report. SI explained the role of the external auditor highlighting that they are appointed by the Council of Governors and governed by the

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Monitor Audit Code. PwC are required to provide an opinion on the report and accounts as to whether it has complied with Monitor’s Annual Reporting Manual (ARM) as well as conducting separate work on the Quality Report. Financial testing was carried out on the accounts and feedback was provided to the Audit Committee and senior management. The Quality Report, which is relatively new for Foundation Trusts, has been checked against the content requirements in the ARM and to ensure that content is consistent with other documentation, for example, survey results. Two mandated indicators were audited, this year C.Diff and the 62 day cancer wait, and one local indicator, which this year was the number of patient falls. Two minor issues with accruals were identified but these were minor and immaterial and reported to Audit Committee to help improve processes. PwC provided an unqualified opinion on the Annual Report and Accounts for 2013/14 and the Quality Report. The Chairman thanked SI and the members of the Audit Committee for the work on the audit and DAF, Anna Thame, Sandra McArdle and teams for their work in producing the Annual Report and Accounts.

41/14

GOVERNANCE REPORT AJB presented the governance report. AJB discussed the increase in deaths in January and December. This reflects an increase in the number of deaths and also an increase in the severity of illnesses of the overall population that were admitted. AJB drew attention to the increasing number of patients in hospital and to their longer stays. AJB discussed the CQC’s intelligent monitoring rating and noted that HHFT remains in Band 6. A discussion took place about patient moves. AJB confirmed that the “number of patient moves” relates to the number of patients moved for non-clinical reasons. The Chairman noted that the Board had discussed patient moves in depth and suggested that it would be helpful for the Council to have a similar discussion at a future meeting. The Council discussed the local CQUIN which focuses on reducing the number of outpatient follow-up appointments. Concerns were raised regarding whether this would mean a reduction in the level of patient care. KC discussed the system in orthopaedics which invites patients to see their GP who will decide whether it is best to try an alternative rather than seeing a consultant. The Chairman highlighted that patient care will always be at the forefront of decisions.

ACTION

42/14 FINANCE AND PERFORMANCE REPORT DAF presented the Finance and Performance report. Income was reported as being higher than last year but remains below plan. Profit is also below plan at the two month point. The CosRR rating is reported as remaining at 3. Cash is above plan, but DAF explained that this is due to capital spend being lower than plan due

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to a disputed invoice. All Monitor targets have been achieved and the ED 4 hour wait target was met at 95.4% to the end of May. DAF also reported that the ED target continued to be met throughout June. This is due to the significant effort of the staff as YTD there has been a 7.6% increase in ED attendances compared to last year. At present the Trust is achieving the local CQUIN for follow-up appointments as the new outpatient referrals are higher than the number of follow-up appointments. Total referrals are higher than last year. TP requested an update on the Candover unit. ME reported that the Board had recently reviewed a business plan which focused on projection scenarios. At the moment the business is in ‘ramp up’ stage. The private patient business is run as part of the overall HHFT business and has the same governance structures as all of the other departments. LT noted that she had been very impressed when she had visited Candover.

43/14 COUNTER FRAUD UPDATE AG provided an overview of fraud cases in Hampshire and the consequences on prosecution. AG explained the legal definition of fraud and highlighted that it is a criminal offence which loses the NHS approximately £5bn per year. AG discussed the counter fraud strategy in Hampshire which includes anti-fraud materials provided for the Trust, alerts and mandatory training. Training has increased year on year with over 3,800 staff members completing their counter-fraud training in 2013/14. Recent fraud awareness surveys also show that there is an increase in fraud awareness. HHFT is the best in Hampshire for fraud awareness. AG explained that his role is to prevent and deter fraud which includes working with the internal and external auditors, risk managers and providing input during policy reviews. The main aim of AG’s role is to help to save the Trust money which could be lost due to fraud. There are four actions that can be taken to hold those that commit fraud to account:

1) Criminal action 2) Disciplinary action 3) Financial recovery 4) Referral to a professional body

PS reported on discovery of an incident of overpayments and praised AG and the counter-fraud team for their approach and for support that they offered to the individual. AG highlighted that criminal action is only taken if the individual does not repay the money lost. The Chairman thanked AG for his work in counter-fraud and also thanked him for delivering the presentation to the Council.

44/14 CLOSE Page 6 of 7


There being no further business the meeting closed. The next meeting will take place on 4 November 2014 at the Ark, Basingstoke. Signed as a true record by ………………………………. Chairman

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MATTERS ARISING FROM A COUNCIL OF GOVERNORS MEETING HELD ON 22 JULY 2014

Report to: Council of Governors meeting – 4 November 2014

Title: Matters arising

Author: Elizabeth Padmore

Purpose: To note

Decision Sought:

The Council of Governors is asked to note progress under matters arising

ITEM ACTION RESPONSIBLE UPDATE

63/13

It was agreed that the DIPC would be invited to present an infection control seminar to the Council next year to discuss other areas for improvement.

CEO/Company Secretary

Seminar 4 November 2014

41/14

The Chairman noted that the Board had discussed patient moves in depth and suggested that it would be helpful for the Council to have a similar discussion at a future meeting.

Company Secretariat Seminar tbc

RESTRICTED NOT TO BE COPIED OR SHARED WITHOUT THE PERMISSION OF THE CHAIR FOR A PERIOD OF 10 YEARS FROM THE DATE OF THE MEETING OR THE

PRODUCTION DATE – 4 November 2024 1/1


1. INTRODUCTION

This paper is a report of the meeting of the Membership Working Group held on 1 October 2014.

2. REPORT OF THE MEMBERSHIP WORKING GROUP (MWG)

The Group discussed a number of topics, as follows: Trust Membership Membership currently totals 17,733, comprising 11,166 public members and 6,567 staff. The gender split of membership is broadly in line with catchment population. However, there is variance in the age groups, e.g. 70% of members are between 60 – 75+yrs., whereas in the catchment population the figure is nearer 25%. Accordingly, the reverse is shown in the 22-49yr age group where only 16% are members in a catchment where 36% of the population is in this group. The MWG suggested that focus be given to communicating with and recruitment of younger people where possible. Membership Communication Of the public members 27% have agreed to receive communications by email. This figure remains constant indicating that there is scope for additional savings in postal costs. Accordingly, all governors are encouraged to solicit email addresses when recruiting new members. The Comms.Team posted the summer newsletter to 7,232 members with 129 returns. Additionally, 2,976 addresses were emailed with 14 bounces. The 2014 Annual Review and Plan was posted to 7,054 members and emailed to 2,989 addresses, with 21 bouncing. The AGM reminder was emailed to 2,959 with 6 bouncing. An invitation to the AGM was also sent to stakeholders including local authorities, MPs, CCGs, and local healthcare providers and to GP practice managers through the GP newsletter. A ‘dummy’ of the forthcoming Autumn issue of the Foundation Trust members’ newsletter was discussed and approved.

Members Meetings The MWG reviewed the feedback from recent meetings:


Title: Report of the Membership Working Group

Author: Tony Green (Chairman)

Purpose: For information

Decision Sought: The Council of Governors is asked to discuss the report

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AGM 9 September 2014 Of the 78 attendees 60 were members which included some staff. There were approximately 25 non-member visitors including Basingstoke MP, Borough Councillors and Health Professionals. It was agreed that the event was a success and enhanced by the Exhibition. This feature was regarded as interesting and very informative, especially to those not having a healthcare background. The MWG wishes to record its thanks to those members of staff that manned the displays for their time and enthusiasm. Promotion for the AGM and roadshows included press paid adverts in all local press, press releases which achieved editorial coverage. The dates were published in the summer newsletter and included in the Annual Review mailing. On site posters were placed in all three hospitals plus specific invitations to stakeholders and to staff through internal communications PULSE, the intranet and Midweek message. It was suggested that at future events more time could be devoted to the exhibition perhaps with less detail in the presentations. A printed flyer containing financial detail could be used to expand on the visual headlines. Could a similar exhibition be the centre of an ‘Open Day’ event? The MWG proposes (in jest?) that the pager call for Dr. Bishop should feature in the script to illustrate to members and visitors that senior clinicians are most often ‘on call’. Alton Roadshow 23 September 2014 Members attending totaled 24 with 4 non–member visitors recorded. 90% of respondents found the event to be ‘informative’ and 84% appreciated the update on strategy and future plans. The comments provided were positive without exception. There is some confusion over the links with Alton Community Hospital. One member was unaware of the role of Southern Health FT and assumed that HHFT could reinstate the lost beds on the upper floor. (Could the relationship be explained/clarified in future communication?) Winchester Roadshow 30 September 2014 Fifteen non-member visitors were included in the headcount of 52 people that attended with 31 recorded as members. 90% of respondents found the presentations informative and 94% thought likewise to strategy and future plans. The event was well received prompting 8 positive comments.

3. RECOMMENDATION

The Council of Governors is asked to discuss the report.

2/2



Title: Report of the Patient Experience Group

Author: Maurice Alston


Decision Sought: The Council of Governors is asked to discuss the report

1. INTRODUCTION

This paper is a report of progress of the newly formed Patient Experience Group which held four meetings from June to September 2014.

2. REPORT OF THE PATIENT EXPERIENCE GROUP (PEG)

The Group discussed, clarified and agreed a number of topics as follows: Terms of Reference The Terms of Reference have been approved by the CoG. The role of the Patients’ Voice Forum (PVF) in relation to the PEG has been clarified. The PVF is currently chaired by a member of PEG. Updating Members Members were given information on the wide ranging patient experience activities in the Trust to enable them to take full account of these in planning and implementing their own strategy. Governor Visits These were considered in some detail, recognising that the previous service visits had not fully met the expectations of Governors taking part. This led to a decision to implement a pilot scheme of Governor visits from which a definitive process would be established and shared with the CoG. In outline, the new approach comprises:

• Scheduled visits with two Governor’s and two members of the governance team to an agreed ward/department (all 3 sites included);

• Wards and departments contacted in advance of the Governors’ visit; • A pre visit briefing including the location, style and content of the visit by a member

of the governance team; • The CQC “Fundamentals of care” used as the framework for the content of the visits

and the contact with patients, their relatives and carers and with staff; • Two Governors and two members of the governance team visit the agreed location

and talk with patients, their carer’s and relatives and with staff. At the end of the visit the visiting team provide agreed feedback to senior staff. Any actions required are facilitated by the governance team.

Six visits have been made, covering all three sites and eight Governors have taken part, some making two visits. Initial results have been very favourable and have enabled Governors and

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Governance staff to better understand the nature and extent of patient care in the trust, seen both from the viewpoints of patients and staff. The majority of the findings have been strongly positive. Where negative issues were identified, these were passed on to senior management for action. The pilot will be concluded by the end of December 2014 and proposals made to the CoG for full participation of Governors in a rolling programme of Governor Visits during 2015. Other aspects of Patient Experience Plans have been made (in some cases implemented) in the following areas:

• An introduction to the CQC new approach to the inspection and regulation of NHS Acute Hospitals to raise understanding and awareness of the CQC;

• Consideration of the results of national surveys and where appropriate making recommendations;

• Members taking part in ‘kitchen to ward’ observation visits to support improvement plans in relation to patient food;

• Providing a representative to the HHFT User Group 5 which will advise the architects involved in planning the new Cancer Treatment Centre.

General A verbal report of a meeting of the PEG on 21 October will be given at the CoG on 4 November. Overall, the newly formed PEG has fully “gelled” and is performing well as a team. PEG members wish to acknowledge the very helpful ongoing advice and support provided by members of the Trust’s Governance team.

3. RECOMMENDATION

The Council of Governors is asked to discuss and comment on this report.

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1. INTRODUCTION

This paper identifies issues that the Chief Executive wishes to bring to the Council of Governors’ attention which are not covered elsewhere in the agenda.

2. OPERATIONAL UPDATE

Our hospitals continue to deal with increasing numbers of patients, both planned and emergencies. There has not been the usual reduction in emergency workload through the summer months and staff have been under pressure as a result. We have continued our drive to attract new staff to work for us, particularly qualified nurses. We have employed all of our newly qualified nurses who wanted to work with us and they started in early October.

3. RADIOTHERAPY SERVICE

Phase 1 of our new cancer centre treated its first patients at the start of October. This followed a period of extensive testing of very complex equipment as well as review by the external experts who oversee radiotherapy services across the NHS.

The service will now expand its activity at the same time as we continue our plans to develop Phase 2 on the site of the proposed Critical Treatment Hospital. Phase 2 will contain two radiotherapy machines (linear accelerators) which will enable the majority of patients from north Hampshire to receive their treatment locally. Patients requiring more specialist technologies will continue to receive their treatment at Southampton, with whom we are working closely.

4. CLINICAL REPROVISION UPDATE

West and North Hampshire CCGs have recently been informed that NHS England requires a further review before they can proceed to consultation on our proposals to centralise services for the sickest. As this will create more delay we have decided to maintain our engagement with the public as well as continuing our detailed plans for the Critical Treatment Hospital. We have already received support from Monitor to proceed to a full business case, which they will use to make judgement and give final approval for our plans. In addition the Independent Trust Financing Facility has indicated that our high-level plans would meet their criteria for a loan application.


Title: Chief Executive’s report

Author: Mary Edwards


Decision Sought: The Council of Governors is asked to note the report of the Chief Executive

1/2


5. COUNTESS OF BRECKNOCK HOSPICE

The Countess of Brecknock Hospice in Andover has recently re-opened following refurbishment, funded by national grant. The refurbishment has generated 6 individual rooms with en-suite facilities plus improved day-care facilities for supportive treatments and better day hospice facilities.

A 24/7 Hospice at Home service was set up whilst the work was taking place and this has proved to be highly valued by patients and their families. This service will continue as part of the service offering for patients receiving palliative care in this area.

6. NORTH HAMPSHIRE GP ALLIANCE

The GP practices in North Hampshire have established a formal provider organisation which will provide shared services to them, such as back office functions. This organisation could also become a service provider over time should they tender for appropriate contracts from the CCGs. The Alliance is being led by Dr Amanda Britton and she has already started a dialogue with HHFT to create a positive partnership with us.

6. RECOMMENDATION

The Council of Governors is asked to note the Chief Executive’s report.

2/2


Report to: Council of Governors Meeting ‐ 4 November 2014

Title: Hampshire Hospitals Governance Paper

Author: Anne Stebbing, Tim Sayer, Julia Parfitt, Sandra McArdle, Katharine Carter

Purpose: Standing Item

Decision Sought: The Council of Governors is asked to consider this report

1. PURPOSE

The paper is to update the Council of Governors on quality and safety across Hampshire Hospitals NHS Foundation Trust and to provide assurance on governance. It covers the reporting period from July 2014 to September 2014.

2. QUALITY AND SAFETY

The paper includes the quality scorecard, graphs and latest information regarding the Care Quality Commission (CQC).

3. SCORECARD

1

Aug‐13 Sep‐13 Oct‐13 Nov‐13 Dec‐13 Jan‐14 Feb‐14 Mar‐14 Apr‐14 May‐14 Jun‐14 Jul‐14 Aug‐14 Red Amber Green

Mortality rate for all diagnosis (%) 1.2 1.2 1.1 1.0 1.2 1.1 1.4 1.3 1.2 1.1 1.4 1.1 1.3 1.2 1.3 >1.8 1.3‐1.8 ≤1.2

Crude no. of in‐hospital deaths 112 N/A 105 97 119 102 123 134 111 109 127 108 123 120 114

Average length of stay (excluding day cases) 4.5 <4.45 4.2 4.2 4.4 4.3 4.4 4.8 4.4 4.6 4.8 4.8 4.5 4.9 4.4 >5.10 4.46‐5.09 ≤4.45

No. of clinical audits registered 17 N/A 11 12 25 19 14 17 15 24 10 19 25 19 10

No. of clinical audits completed 10 N/A 13 11 15 9 13 7 0 22 9 10 7 15 5

Rate of all reported patient incidents (per 100 admissions) 6.95 6.95 6.16 6.05 6.54 7.41 7.83 8.98 6.81 6.59 6.63 7.32 6.41 7.07 6.89 >9 7.1‐9 ≤7.09

Rate of patient incidents resulting in moderate, severe harm or death (per 100 admissions) 0.59 0.59 0.59 0.55 0.57 0.60 0.74 0.56 0.51 0.30 0.63 0.57 0.42 0.49 0.40 ≥0.8 0.6‐0.8 ≤0.59

No. of serious incidents requiring investigation (including never events) 5.75 N/A 9 3 3 8 5 3 5 2 13 10 6 12 4

No. of patient falls resulting in moderate, severe harm or death 5.75 4.3 9 2 3 4 8 5 8 4 10 4 2 4 2 >9 6‐9 ≤5

No. of confirmed hospital acquired grade 2, 3 and 4 pressure ulcers CQUIN 26 11 23 18 22 19 28 26 20 32 25 22 21 38 21 >18 12‐18 ≤11

No. of medication errors resulting in moderate, severe harm or death 5 4 6 8 6 8 2 1 2 3 3 2 0 1 0 >8 5‐8 ≤4

No. of hospital acquired MRSA bacteraemia Penalty 0.25 0 0 1 0 0 1 0 0 0 0 0 0 0 0 ≥2 1 0

No. of hospital acquired C. Difficile Penalty 3.4 3 5 4 0 2 7 5 0 3 4 1 2 5 4 >3 2‐3 <2

Compliance with venous thromboembolism risk assessment (%) Penalty 93% >95% 90.8 91.7 93.3 94.7 94.4 95.6 95.3 96.1 95.6 96.2 95.6 95.4 95.5 <90 90‐94 ≥95

No. of hospital acquired venous thromboembolism events 12 <11 14 11 14 25 10 10 10 11 11 13 5 NA NA >16 12‐16 ≤11

No. of complaints 50 N/A 46 54 47 37 34 46 71 60 54 40 47 51 43

% complaints responded to within 25 working days 54 95% 48 56 59 65 70 61 51 47 42 43 33 50 71 <75 75‐94 ≥95

No. of patient moves ‐ out of hours (New definition) CQUIN 391 TBC 307 344 418 380 480 517 422 449 459 467 442 455 302

No. of patients moved 3 or more times (New definition) 254 TBC 256 259 292 279 264 266 211 236 264 282 264 266 175

No. of operations cancelled on or after the day of admission for non‐clinical reasons Penalty N/A 0 1 1 0 0 0 1 1 0 0 3 0 0 0 >5 1‐5 0

No. of operations cancelled twice Penalty N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 >5 1‐5 0

No. of same sex breaches for non‐clinical reasons Penalty 0.6 0 0 0 0 0 0 3 0 1 0 0 1 0 0 ≥2 1 0

Traffic Light Rating: Data Quality Rating:

Green ‐ the Trust is performing well and in line with the monthly goalAmber ‐ the Trust is showing a small deviation from the monthly goalRed ‐ the Trust is not performing well, showing a large deviation from the monthly goalWhite ‐ the data is not for traffic light rating

Traffic l ight rating TBC

Not for traffic l ight rating

Red ‐ inadequate assurance in the quality of the data with ineffective controls

Green ‐ adequate assurance in the quality of the data with sufficient controlsAmber ‐ inadequate assurance in the quality of the data with some controls

Patient Experience Measures


Traffic l ight rating TBC

Patient Safety Measures

Data quality

rating

Traffic Light Thresholds

from Apr 14Note

13/14

monthly

average

Monthly

goal (from

Apr 14)


Not for traffic l ight ratingQuality

Priority

Clinical Effectiveness Measures


2


4. CLINICAL EFFECTIVENESS

4.1 Learning from Clinical Audits

Title Background/Purpose Results Outcome / Actions

Audit of compliance with guidelines for Henoch‐Schönlein Purpura (HSP) this is an IgA‐mediated, autoimmune hypersensitivity vasculitis in children

Child Health

BNHH

July 2014

This audit was undertaken to check that children diagnosed with HSP are followed up to ensure that any renal complications are not missed.

This condition can affect the kidneys in 40‐60% of patients, it can be absent at diagnosis but develop weeks or months later

The results showed that there was widespread variability of follow up. This included the standard not always being achieved for providing advice for weekly urine testing and blood pressure

To improve the follow up process, the HSP information sheet provided to patients has been updated. The consultant will ensure the discharge summaries are fully completed and contain advice regarding follow up to the G.P. A summary sheet of the follow up plan will also be produced for the ward.

The results of this audit have been discussed at the paediatric MDT meeting in July 2014

Re‐audit of chest drains

Medical

Trustwide

July 2014

A re‐audit of the safety and insertion of chest drains are undertaken following a safety alert from the NPSA

The results showed that there were no problems relating to the insertion of the drains and importantly no complications occurred as a result of the insertion of a chest drain.

The Respiratory Consultant provides an in house training program for junior doctors to cover all sites. We are now currently collecting data for the national chest drain audit, this report will be released later in the year and results will be compared with this audit

Audit of the management of upper gastrointestinal (UGI) bleeding

Medical

RHCH

August 2014

This audit was

completed to ensure

patients presenting in

the Acute Medical Unit

(AMU) are assessed and

treated in accordance

with NICE guidelines.

The results showed that the majority of patients presenting with suspected UGI bleeds were not being assessed using the Blatchford Score which advises on risk assessment, referral and discharge management.

To ensure the correct assessment is completed, a simple UGI bleeding proforma has been designed; this has been implemented in the AMU and once evaluated, will be rolled out to the rest of the Trust.

3


Audit of dementia screening for fractured neck of femur patients

Orthopaedics

BNHH

August 2014

This audit was

completed to ensure

patients with dementia

are identified and

assessed and referred on

via the GP for further

support if necessary

The results showed that over a six month period, 82% of patients were identified and assessed. 8% of these patients met the criteria for GP notification, this information was not documented in any of their discharge summaries

To improve compliance, training on the importance of dementia screening will be included in the doctor’s induction and posters displayed in their meeting rooms. The EPR system is being updated to automatically notify GP’s of patients who need further support. A re‐audit is planned for Feb 2015.

5. PATIENT SAFETY

5.1 SERG Sub‐group (pressure ulcers and patient falls)

A Serious Event Review Group (SERG) Sub‐Group has been established to ensure that all serious adverse events pertaining to falls resulting in severe harm or death and grade 3 and 4 hospital acquired pressure ulcers are actively investigated, and improvement plans are delivered to ensure lessons are learnt and risks reduced.

Examples of learning and changes to practice as a result of investigations presented to the SERG Sub‐group April to June 2014

What we learned:

Communication between nurses on the wards about patients at high risk of pressure ulcers needsto improve

The nursing handover of patients with high risks should happen when staff leave for breaks aswell as between shifts

Falls equipment available on the wards should be reviewed regularly to ensure it is in workingcondition

The ‘Cast Care Plan’ (used for patients with a plaster cast) does not currently include assessmentof pressure areas

Therapists are not trained in Pressure Ulcer management and assessment of skin

Reducing the risk of falls in patients newly admitted, before their falls risk assessment iscompleted, is a challenge

Clinical documentation: There is evidence of duplication and patients’ notes being kept inmultiple places. This is complicated by paper and electronic formats of documentation being usedconcurrently

What we do differently now:

The ward sister receives a daily report detailing individualised plans of care to prevent pressureulcers on all at risk patients

Guidance has been produced for the handover of at risk patients particularly for staff breaks (asopposed to formal shift handovers)

All equipment in the falls equipment stock cupboard is reviewed daily

The ‘Cast Care Plan’ has been revised by the plaster technicians. The care plan will be sent to theward with the patient after application of a cast

4


Pressure ulcer prevention training for therapy staff is in progress

Placement of patients in admission assessment units is carefully considered before their falls riskassessment is completed. Patients who appear ‘at risk’ of falls are prioritised

A documentation review is underway led by the nursing documentation working group. There iscurrently a pilot launching in Orthopaedics

5.2 Nutrition Strategy update

This report provides an update of the progress of the implementation of the Trust Nutrition Strategy for the period April 2014 – August 2014. The key aims of the Nutrition Strategy for 2013/2016 are:

Ensure all staff involved in the nutritional care of inpatients receive some formal nutritioneducation

Improve the provision of suitable foods and snacks for inpatients with Dementia

All inpatients are screened using the Malnutrition Universal Screening Tool (MUST) within 24hours of admission and appropriate nutritional care plans initiated by ward staff

Regular audit of the quality of hospital food and level of patient satisfaction at ward level

The following actions have been completed:

Implementation of red jugs and beakers across elderly care wards to help identify whereadditional support is required to ensure patients nutritional needs are met

Implementation of small (750ml) jugs that are easier to lift and encourage patient independence,aiding hydration in the elderly

Large print menus available on each ward at RHCH for the visually impaired, to assist with menucompletion

Dissemination of Nutrition & Hydration Policy across the Trust

The annual MUST audit was carried out in May 2014

The main findings of the Trust wide MUST audit are:

56% compliance with completion of the MUST assessment within 24 hours of admission

Where this was required 39% of patients had repeat nutrition screening on a weekly basis

There was 30% compliance with the implementation of the appropriate care plan

58% of those who should be referred to a dietician following the MUST assessment were referred

In response to the MUST audit the following actions have been taken / are underway:

1. Share widely the results of the MUST audit with wards and clinical leads in July and August 20142. Targeted dietetic support for the worst performing wards, with repeat mini audits to ensure

improvement in practice, has been taking place since August 2014 and will continue for severalmonths

3. Competency based mandatory nutritional training for all clinical ward based staff to be re‐established. Currently, the dietetic department is in discussion with the education teamregarding logistics and an achievable timeframe for this action.

4. Assessment of ward housekeepers and domestics for nutritional education to be completed byend of December 2014

5. Trust wide re‐audit of MUST is planned for early next year.

5


5.3 SIRIs Please note SIRIs are recorded by the date they are reported externally not the date of the incidents. There have been four SIRIs reported in August 2014:

There has been a cannulation injury to a patient’s hand that has required plastic surgery (Medicine, RHCH)

A patient had a fall resulting in significant skin damage to their sacrum (Medicine, BNHH)

A grade 3 pressure ulcer has been identified on the patient’s heel (Long Term Conditions, BNHH)

A patient was found unresponsive and died (unexpected death) (Unscheduled Care, BNHH)

Investigations are underway and will be presented to the Trust Serious Event Review Group. 6. EXPERIENCE

6.1 Complaints and Concerns (negative PALs) There were 54 complaints in July and 43 in August 2014. The breakdown by category and division is shown on charts 18 and 19. There were 54 concerns received in July and 47 received in August 2014. The acknowledgement rate for complaints in July was 100% and 98% in August, with 1 of 43 late. In July the response rate for all responses made within the Trust’s local aim of 25 working days was 50% with 27 of the 54 responses sent within the target. Of the 27 late responses 4 were sent within 5 days and 4 within 10 days and 4 up to 20 days late. In August the response rate for all responses made within the Trust’s local aim of 25 working days was 71% with 36 out of 51 of the responses sent within target in August 2014. Of the 15 late responses 2 were sent within 5 days and 3 within 10 days and 2 up to 20 days late. There are currently 8 still open (at 10 September 2014). Complaint responses The review of the complaint responses made in July and August 2014 identified the following main themes: Poor customer care

Staff attitude and manner

Communication and Information

Poor communication

Discharge issues

Administration issues Access

Delays and waiting times

Clinical

Care and treatment

Lack of compassion

6


Privacy and dignity

6.2 Thank yous and compliments There were 42 letters of thanks received centrally in July and 38 in August 2014 and they are represented below:

Thank Yous and Compliments July and August 2014

Andover War Memorial Hospital

Basingstoke & North Hampshire Hospital

Royal Hampshire County Hospital

July Aug July Aug July Aug

Corporate, 0 0 1 0 0 0 Family & Clinical Support Services 0 0 8 2 0 1 Medical Services 1 0 9 6 6 8 Surgical Services 0 0 9 18 7 3 Private Patients 0 0 1 0 0 0 Total 1 0 28 26 13 12

20. No. of new litigation casesData source: Legal services

17. No. of complaints by DivisionData source: Customer care

18. No. of negative PALS by DivisionData source: Customer care

19. Complaint response rates (3 day acknowledgement

and 25 day response)Data source: Customer care

Patient Experience Measures

0

10

20

30

40

50

60

70

80

Corporate Family Medicine Surgical Total

0

10

20

30

40

50

60

70

80

90

100

Apr‐12 Jul‐12 Oct‐12 Jan‐13 Apr‐13 Jul‐13 Oct‐13 Jan‐14 Apr‐14 Jul‐14

Corporate Family Medicine Surgical Total

0

10

20

30

40

50

60

70

80

90

100

% Acknowledged within 3 days % Responded to within 25 days

0

1

2

3

4

5

6

7

8

BNHH AWMH and RHCH

7


There were a total of 180 WOW! Award nominations made in July 2014 with 50 nominations made by staff and 130 made by the public. Of these 113 of the nominations were for individuals and 67 were team nominations. There were 98 nominations within the category of ‘Above and Beyond’, 79 for ‘customer care’, 2 for ‘innovation and 1 for patient safety’. There were a total of 130 WOW! Award nominations made in August 2014 with 36 nominations made by staff and 94 made by the public. Of these 74 of the nominations were for individuals and 56 were team nominations. There were 45 nominations within the category of ‘Above and Beyond’ and 75 for ‘customer care’. 7. QUALITY PRIORITIES

There following progress on quality priorities has been reported in June 2014. Caring

Priority outcome Reason for choice Progress

We will ensure call bells are answered in a timely way (patient safety)

The results of national inpatient surveys indicate that patients are concerned about this and that it has an impact on how safe they feel

The matrons have devised a Call Bell audit tool. The tool is currently being tested within speciality medicine as although it is short it comprises a mix of objective measure and subjective patient experience questions. A standard has been tentatively set within the audit tool as it is being tested. The audit tool will live within the compulsory audit section of Auditr and will be a regular on‐going audit. The CCT have shared the details of those complaints that relate to call bells and the details of wards that have included a call bell audit in their actions.

We will improve patient experience through the delivery of bespoke customer care training for staff and will achieve a reduction in complaints related to staff attitude (patient experience)

The Board of Directors identified this as a key quality priority

A bespoke training package has been developed, it can be adapted to reflect the issues identified in specific areas, using examples from those areas. The training has been provided to all Band 7 nurses and the Firs, using examples from their areas of work. Further dates and venues are being arranged.

8


Safe


We will help patients understand their medicines and the side effects associated with them

Patients have told us that they would like more information about medicines at discharge

Information on the helpline is included in discharge medications and further planning is underway.

We will reduce the time patients spend in unnecessary isolation through the introduction of rapid molecular screening for infectious agents

Rapid screening will prevent patients from being unnecessarily isolated in side rooms

Work on this is underway

Responsive to people’s needs (Patient Experience)


Patients and their families and carers will receive consistent advice post operatively on discharge from hospital

Staff identified this a quality priority and while patients have told us we provide the right amount of information pre‐operatively we have identified that we could improve post‐operative information

Work on this is underway within the division

“Patient Listening " sessions will be established for patients to share their experience of our service with us face to face

We receive feedback and information from patients in a number of ways. We intend to use “active listening” in this way because it is extremely powerful in helping

These session are underway

9


front line staff improve patient experience

Effective


In theatres they will carry out a multidisciplinary “simulation session” once a month to support shared learning and improvement

This will support learning from near misses and incidents and this quality priority provides an opportunity for this and involves the multidisciplinary team

The Anaesthetic and Paediatric departments of the Trust held an interactive simulation session called MAST ‐ Make Airway Safe Team ‐ focusing on difficult Paediatric airway training in June. Teams from all theatre sites took part as well as teams from ENT scrub, Paediatric wards, Anaesthetists, ED. Nightingale theatres ran a simulation of a paediatric emergency within theatres in May.

We will introduce the requirement for all clinical staff to participate in at least one audit or quality improvement initiative in 2014/15

This will support the culture of continued quality improvement throughout the Trust

Additional training and support days are being delivered by the Governance Team. All individuals involved in registered audits are recorded on the audit database. Learning from audits is included in monthly board reporting.

Well Led


We will develop individual consultant dashboards in each of the clinical divisions

This quality priority will support quality and data improvement across the Trust

Planning is underway

8. NHS CHOICES 8.1 Users Overall Rating NHS Choices scores user’s overall rating out of 5 stars. Ratings are based on comments made in the past two years. HHFT current scores at the end of August 2014 are:

10


Basingstoke and North Hampshire Hospital ‐ 4 stars based on 92 ratings Royal Hampshire County Hospital ‐ 3.5 stars based on 60 ratings Andover War Memorial Hospital ‐ 5 stars based on 20 ratings During August 2014 1 person left a 5* rating following their experience with orthopaedics, 1 person left a 3* rating and 1 person left no rating following visits to the emergency department at Basingstoke and North Hampshire Hospital. There were no comments made during August for Andover War Memorial Hospital. At the Royal Hampshire County Hospital 1 person left a 5* rating following a visit to the emergency department and 1 person left a 5* rating following their experience with general surgery. 8.2 Services near You The NHS Choices website records information regarding HHFT and for the following measures HHFT Basingstoke and Royal Hampshire County Hospitals are scored as red (Appendix I). The results of neighbouring Trusts are also included.

Care Quality Commission National Standards This red score for Basingstoke and North Hampshire Hospital relates to the findings of the CQC visit Jan 2014, in which improvement was required in relation to Outcome 9, Medicines management. The Trust completed an action plan in response to the findings and it is likely that this measure will remain red until a subsequent inspection. This red score for the Royal Hampshire County Hospital relates to the findings of the CQC visit in Nov 2013, in which improvement was required in relation to Outcome 4 and Outcome 13 meeting patients’ needs and staffing. The Trust completed an action plan in response to the findings and it is likely that this measure will also remain red until a subsequent inspection. The score for Andover War Memorial Hospital is green, the site is registered as part of HHFT and the CQC have not visited this site.

Open and Honest Reporting All three HHFT hospital sites are scored as red “amongst the worse” for this indicator. The CQC describe this indicator as: a new indicator that combines several other indicators to give an overall picture of whether the hospital has a good patient safety incident reporting culture….This new combined (composite) indicator is mainly constructed from the patient safety incident reporting and response indicators used by CQC as part of their Intelligent Monitoring system. We are unable to interrogate the data for the time periods reported by the CQC in this indicator. However, our internal analysis, using our core data, shows that for the period 1 April 2013 – 31 March 2014 the reported monthly average of incidents graded as moderate, severe, or death was 55 per month. For the period 1 April 2014 – to date (12 Sept 2014) the monthly average is 47 incidents graded as moderate, severe, or death, this indicates an improvement. Overall incident reporting is included monthly in the scorecard included in this paper. This indicator and new area of risk was identified in the CQC Intelligent Monitoring Report (IMR) July 2014 and reported to the Board of Directors. In response to the new risk in the IMR a number of actions have been initiated and recorded in the table below:

11


Identified Risk Internal Review

Proportion of reported patient safety incidents that are harmful (risk)

The Governance team have implemented the following steps to ensure severity harm grading of patient safety incidents is appropriate:

Patient safety incidents graded as causing moderate harm will included in the review of serious incidents at the Serious Event Review Group review

Divisional Governance Leads will confirm severity of all patient safety incidents resulting in moderate harm, severe harm or death prior to upload to the National Reporting and Learning System

Midweek Message has contained reminders to staff about the importance of reporting incidents

The monthly data quality assurance audit carried out by the governance team is shared with the divisional governance leads for review and action locally and to share collective learning

Improvements have been made to the datix system to support feedback to staff who have reported incidents

Reminders to staff to include their email address to ensure they receive feedback on incidents reported have been included in Quality Matters

Food: choice and quality All three HHFT hospital sites score red “amongst the worse” for Food: choice and quality. This indicator shows the results of the 2014 Patient‐Led Assessments of the Care Environment (PLACE) and shows a combined score for choice and quality of food. The poor (red) category shows that the hospital was in the bottom 20% of all scores for choice and quality of food. At least 50% of the PLACE assessment team is made up of patients or members of the public. The Board of Directors and Governors were made aware of the results and our response on 28 August 2014 and an action plan is being prepared to address the findings of these surveys. 9. RECOMMENDATION The Council of Governors is asked to consider this report. Further information is available on all these items if required.

12

Council of Governors - 4 November 2014

Council of Governors Finance and Performance Report

Report to: The Council of Governors November 2014

Title: Performance Report for period ending 30/09/14

Author: Paul Gray/John Haynes

Sponsoring Director:

David French

Purpose: Standing Item

Decision Sought: The Council of Governors is asked to note the report


The Trust is planning a surplus of £1.5m in 2014/15 with a year end cash balance of £13.1m. Capital expenditure of £18.2m had originally

been planned but this has now been forecast downwards to £12.6m due primarily to delays in the public consultation process for the critical

treatment hospital.

The YTD surplus at the end of Q2 was £0.2m compared to the Plan of £1.2m. Although £3.7m higher than last year, clinical income is £1.9m

behind Plan. The Trust has set a challenging income target based on the levels of contract over-performance seen in previous years which

historically have occurred in the latter half of the year. Expenditure is higher than behind Plan for the YTD, driven by increased staffing num-

bers due to higher than expected activity levels, and lower than anticipated cost savings.

The cash balance at the end of September of £13.1m was £2.7m higher than Plan driven by lower capital expenditure and increased trade

creditors offsetting the surplus shortfall.

The Trust has achieved a CoSRR of ‘2’ at the end of the second quarter, against a Plan of ‘3’. The Trust has reviewed the forecasts of activity and expenditure for the second half of the financial year and expects to achieve CoSRR ‘3’ again at the end of the year.

Financial Performance

Full Year

Plan

YTD

ActualYTD Plan

Summary Financial Performance £m

Surplus / (deficit) (CoSRR) 1.5 0.2 1.2

Cash Balance 13.1 13.1 10.3

Capital Expenditure 12.6 4.9 5.3


Key Monitor performance targets

There have been 21 cases of CDif-

ficile YTD, above the objective of no

more than 19. The annual objective

is for no more than 37 cases.

Seven cases were submitted to the

CCG appeal panel on the 15th Octo-

ber for consideration that there were

no ‘lapses of care’ in these cases.

The ED 4 hour target was achieved

in September with performance of

96.5% versus the target of 95%.

This improvement was not enough to

recover the quarter overall and the

Q2 performance of 94.6% just failed

the target. Year to date performance

is 95.1%.

All RTT targets were achieved for the

Trust overall.

Relates to Target (see notes) Period Threshold Weighting HHFT - YTD 2014/15Q1 Penalty Points

Rating

Q2 Penalty Points

Rating

Acute Clostridium Difficile - meeting the Clostridium difficile

objective 2014/15 37 1.0 21 0 1

Acute Cancer 31 day wait for second or subsequent treatment -

surgery Quarterly >94% 99.4 0 0

Cancer 31 day wait for second or subsequent treatment -

drug treatments Quarterly >98% 100 0 0

Cancer 31 day wait for second or subsequent treatment -

radiotherapy Quarterly >94% N/A 0 0

Acute Cancer 62 Day Waits for first treatment (from urgent GP

referral) Quarterly >85% 89.0 0 0

Cancer 62 Day Waits for first treatment (from consultant led

screening service referral) Quarterly >90% 97.4 0 0

Acute Referral to treatment time, 18 weeks in aggregate, admitted

patients Quarterly >90% 1.0 90.8 0 0

Acute Referral to treatment time, 18 weeks in aggregate, non-

admitted patients Quarterly >95% 1.0 96.5 0 0

Acute Referral to treatment time, 18 weeks in aggregate,

incomplete pathways Quarterly >92% 1.0 95.4 0 0

Acute Cancer 31 day wait from diagnosis to first treatmentQuarterly >96% 0.5 98.8 0 0

Acute Cancer 2 week (all cancers)Quarterly >93% 96.4 0 0

Cancer 2 week (breast symptoms)Quarterly >93% 95.0 0 0

Acute A&E Clinical Quality - Total Time in A&E under 4 hrsQuarterly >95% 1.0 95.1 0 1

All Compliance with requirements regarding access to

healthcare for people with a learning disability Quarterly n/a 0.5 Y 0 0

Notes

1

2

3 All the above targets (apart from the last) attract national financial penalties

RTT (Note for Monitor compliance purposes both measures needs to be achieved in each month of the quarter rather than simply over the entire quarter period).

2014/15 and Quarterly

1.0

1.0

0.5

Cdiif cumulative performance


Compared to last year, YTD non-elective activity in the Medical Division is 0.7% lower whereas Surgery is 3.8% higher. Family division is 8.8% lower; an element of this reduction in non-elective activity includes the new pathway recording for Emergency Paediatrics on the BNHH site from November 2013. Lower birth numbers also affect the Division’s performance. ED attendances are also shown below; trust-wide ED at-tendances are 8.2% higher YTD compared to 13/14, 12.3% higher on the Basingstoke site.

Activity: Inpatient Volume Trends

3500

3700

3900

4100

4300

4500

4700

TOTAL NON ELECTIVE

500

550

600

650

700

750

800

Surgery Non Elective

1200

1300

1400

1500

1600

1700

1800

1900

2000

Family Non Elective

1500

1550

1600

1650

1700

1750

1800

1850

1900

1950

2000

Medicine Non Elective


Year to date new outpatient attendances are broadly equal to that of 13/14 but follow-ups are 3.1% higher. Commissioners are keen to see a reduced ratio of new to follow-up appointments and a CQUIN scheme has been agreed with the CCGs. The CQUIN scheme will look at pathways and define an exemplar pathway that will reduce the follow-up appointments that are required.

Activity: Outpatient Volume Trends

10000

11000

12000

13000

14000

15000

16000

TOTAL FIRST OPA

4000

4500

5000

5500

6000

6500

7000

7500

Surgery First OPA

3000

3500

4000

4500

5000

5500

6000

Medicine First OPA

2000

2200

2400

2600

2800

3000

3200

Family First OPA

22000

24000

26000

28000

30000

32000

34000

TOTAL F-UP OPA

10000

11000

12000

13000

14000

15000

16000

17000

Surgery F-UP OPA

8000

9000

10000

11000

12000

13000

14000

Medicine F-UP OPA

2500

2700

2900

3100

3300

3500

3700

3900

Family F-UP OPA


The table opposite shows all re-ferrals to the Foundation Trust for our core geographical localities. All localities show broadly con-sistent monthly variation in refer-ral numbers. There are no locali-ties with significant declining re-ferral volumes.

The second table shows total re-ferrals and the underlying trend in referral growth since 2010. GP referrals in Sept 2014 were 9.7% higher than Sept 2013 for HHFT overall, with RHCH / AWMH sites 8.4% and the BNHH site 10.9% higher. YTD growth in referrals has in-creased to 5.9% vs. last year overall; 6.5% higher for RHCH / AWMH and 5.3% higher for BNHH. Referral growth at the RHCH site is predominately from historical referring practices and across most specialities. Ortho-paedics has seen a significant increase compared to 2013/14.

GP Referrals

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Ap

r-1

0

May

-10

Jun

-10

Jul-

10

Au

g-1

0

Sep

-10

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Feb

-11

Mar

-11

Ap

r-1

1

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-1

3

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Andover

Basingstoke

Berkshire West

East Hants

Eastleigh

Winchester

Other

5000

6000

7000

8000

9000

10000

11000

Apr

-10

May

-10

Jun-

10

Jul-1

0

Aug

-10

Sep-

10

Oct

-10

Nov

-10

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Sep-

12

Oct

-12

Nov

-12

Dec

-12

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3

Aug

-13

Sep-

13

Oct

-13

Nov

-13

Dec

-13

Jan-

14

Feb-

14

Mar

-14

Apr

-14

May

-14

Jun-

14

Jul-1

4

Aug

-14

Sep-

14

TOTAL

Linear (TOTAL)

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