Trust Board Meeting in Public

Trust Board Meeting in Public

Held on Thursday 4May2017at 10:00am

Lecture Theatre

Queen Alexandra Hospital

MINUTES

Present:Sir Ian CarruthersChairman

Mark NellthorpNon-Executive Director

Mike Attenborough-CoxNon-Executive Director

Melloney PooleNon-Executive Director

Chris AdcockDirector of Finance

Simon HolmesMedical Director

Rebecca KopecekInterim Director of Workforce

Rob HaighDirector of Emergency Care

Ed DonaldExecutive Director

Sheila RobertsInterim Chief Operating Officer

Debra ElliottDeputy Director of Nursing

John KnightonDeputy Medical Director

In Attendance:Peter MellorDirector of Corporate Affairs

Teresa CunninghamPA to Trust Board (minutes)

Alison FitzsimonsAssociate Director of Nursing

Dr Phil YoungConsultant Critical Care and Trust Guardian

Gill WaltonDirector of Midwifery and Maternity Services

Greta WestwoodDeputy Director of Research and Innovation

Item No / Minute
62/17 / Apologies:
Michelle Dixon, Deputy Chief Operating Officer
The Chairman welcomed Melloney Poole, a newly appointed Non-Executive Director, to the Trust and to her first meeting and also welcomed Debra Elliott, Deputy Director of Nursing, Alison Fitzsimons, Associate Director of Nursing and John Knighton, Deputy Medical Director to the meeting.
Declaration of Interests:
There were no declarations of interest.
63/17 / Minutes of the Last Meeting – 6April2017
The minutes were agreed as a true and accurate record.
64/17 / Matters Arising/Summary of Agreed Actions
All complete.
65/17 / Notification of Any Other Business
No notifications.
66/17 / Chairman’s Opening Remarks
The Chairman began by announcing the successful appointment of two new Non-Executive Directors, Melloney Poole and David Parfitt and Christine Slaymaker as Non-Executive Director Designate. Melloney had officially joined on the 1st May and both David and Christine will join on 15th May.There still remains a vacancy for a Non-Executive Director with ‘clinical experience’ and this will be advertised in due course.
The Chairman confirmed that it was intended to hold interviews for a new Chief Executive and Medical Director on 30th May 2017 and 2nd June 2017. It is also intended to recruit a substantive Director of Nursing.
Significant improvement is still required within the unscheduled care pathway. The Chairman thanked staff for their continued hard work and commitment during these difficult times. Plans are being developed with our healthcare system partners to try and expedite the discharge of those patients who were medically fit but still needed some form of support outside of the acute hospital setting.
67/17 / Chief Executive’s Report
The Chief Executive drew attention to key areas of his report:

Health and Social Care Grant – The Chief Executive is to arrange a meeting with Local Authorities to discuss how their particular allocations will be targeted. Our priority will be to improve flow through the unscheduled care pathway by moving patients into the community
A recent review of NHS Properties and Estates has identified aNational £10 billion capital funding gap
Delayed Transfers of Care
Workforce Racial Equality Standard

Local News:

Arterial Surgery
Triple Award Success for Research Staff
Team Brief

The Chairman asked if specific conditions had been placed on how the Health & Social Care grant allocations should be used. The Chief Executive hoped that there had been and that this would form part of the discussion with our local authorities.The Chairman recognised the financial pressures on both Portsmouth City Council and Hampshire County Council. The Chief Executive would be speaking to Sue Harriman, Chief Executive of Solent NHS Trust, tomorrow.
Melloney Poole commented that the Trust needs to identify what the shortfall costs are and track them at Executive level.
Mike Attenborough-Cox remarked that Hampshire priorities seem to be more focused on supporting Southampton University Hospital and not Portsmouth. The Director of Corporate Affairs commented that Hampshire County Council’s main focus is around delayed transfers of care and Southampton has more; they are not focusing on those patients that are medically fit for discharge as this is seen as a local issue.
The Chairman remarked that patient care needed to be the absolute priority.
68/17 / Integrated Performance Report
Quality
The Deputy Director of Nursingdrew attention to the following areas, with supportingcomment from the Medical Director:

SIRI –there had been an increase in the overall year-end number of SIRIs which was attributable to the increase in the number of breaches of the Decision to Admit (DTA) target. 1 Never Event had been reported in March involving a wrong site surgical procedure. Thankfully, no harm had been caused to the patient and an investigation is currently underway. The Trust had suffered a total of 5 Never Events during the financial year 2016/2017, no long term harm had been caused to patients.
Pressure Ulcers – the year-to-date position is 17 avoidable grade 3 and 0 (zero) grade 4 pressure ulcers. This compares to 15 avoidable grade 3 and 0 (zero) grade 4 pressure ulcers in the financial year 2015/2016
Dementia/VTE – there has been continued non-compliance with step 1 in March, with compliance being maintained at 74.27%, compared to 74.8% in February and 70.3% inJanuary. The Trust had not achieved the required 90% average in quarter 4 The VTE risk assessment figure for March was 95.14% (subject to validation); compared to the February figure of 96.10%. The National average for VTE assessment (NHS England, Q2 2016-17) is 95.51%
Falls – the current year-to-date position is 42 confirmed falls incidents, 34 resulting in severe harm (reported as SIRIs) and 8 resulting in moderate harm. The current position is favourable when compared to the financial year 2015/2016 when a total of 49 fallswere reported (34 reported as SIRIs and 15 as moderate harm)
Safety Thermometer – the Trust achieved 100% data collection for March. To date the Trust has maintained high submission rates, with 100% beingachieved each month
Patient Moves –an overall increase in the number of reported non-clinical moves; however, a decrease in moves between 0001hrs – 0700hrs is reflective of the relentless focus on the implementation of the Urgent Care Transformation Programme, specifically discharging patients earlier in the day which reduces the number of non-clinical moves experienced by patients overnight. Risk assessments had been undertaken on all those patients that had been moved and patients had not been moved if it had been deemed unsuitable
Friends and Family – ED response rate remained at 14.4% in March. This remains below our 15% target but is above the February national average of 12.7%. Reported satisfaction rate has decreased slightly to 94.1%; however, this continues to exceed the February national benchmark of 87%. The number of patients who would not recommend ED has decreased to 1.4%; however, this remains significantly better than the February national average of7%.
Infection Control:
MRSA - the Trust reported 0 patients with MRSA bacteraemia in March. The year-end position is 1 unavoidable and 0 (zero) avoidable cases, against an objective of 0 (zero) avoidable cases
C.Difficile -the Trust reported 1 patient with C.Difficile attributable to the Trust in March against a monthly objective of 3. The case had occurred in the Cancer Clinical Service Centre. The Trust’s year-end position is 33 cases against an annual target of 40 cases. The Trust’s objective for 2017/18 remains at 40
MSSA - there had been 2 patients reported with MSSA bacteraemia attributed to the Trust in March
Some difficult and different organisms are becoming more prevalent in society. 81 patients across the country have died from a new bug (Carbapenemase producing Enterococci). Whilst itappears to be affecting some hospitals, Portsmouth Hospitals has not yet been affected.
HSMR –the Trust HSMR for the 12 months to December 2016 is 109.92, The rate continues to be classed as high as thelower confidence interval is above 100
Stroke – the Trust has provisionally achieved 7 of the 13 key measures for February (see table) but this is based on only 55 admissions (clockstarts). The Trust achieved level D SHMI
Sepsis –the quarter 4 audit to meet the CQUIN requirements is currently underway. The deadline for National submission is Friday 12th May 2017. CCG CQUIN performance mitigations have been discussed with Commissioners. The Trust has agreed a year-end CQUIN achievement of 92.5% in aggregate as part of year-end accruals. The shortfall is reflective of some underperformance againstNational CQUIN schemes
Regulation 28 letters from the Coroner - The Trust received 1 regulation report in March. The Coroner raised concern at an inquest that endoscopy reports are posted to GP practices rather than being emailed on the day of discharge and has asked that consideration be given to changing the practice and to putting in place an emailing system. The Head of Legal Services is liaising with the Medical Director and Endoscopy to consider whether the Coroner’s proposal isfeasible. The response is due to be served by 24th May 2017

The Interim Chief Operating Officer commented that it was becoming more difficult to find capacity for stroke patients as the demand for the service continues to grow. The Trust is very focussed on continuing to improve the service.
Mike Attenborough-Cox asked whether the discharge threshold for patients was kept under review. The medical Director confirmed that it was.
Melloney Poole questioned how our Stroke performance was going to be maintained with the current staffing levels, and how was this going to be resolved. The Medical Director replied that the resignation had only been received in the last two weeks and had been unexpected; so plans for both the short and long term need to be developed. The vacancy has been advertised. The key concern is the availability of Thrombolysisand these rates are being maintained.
The Director of Emergency Care added some detail around medically fit for discharge patients and mortality. National studies report that a reduction in bed occupancy from 94% to 90% confers an improvement of all markers in mortality rates by around 5%. 50% of patients aged 85 years and above are likely to die within a year of their hospital admission, this is not just down to remaining in hospital, it is also age related and unfortunately, these patients if they remain in hospital for a long period are quite likely to die in hospital.
Melloney Poole raised concern about the connection of mortality with patient moves and delayed discharges. The Medical Director explained that it was safer to move a patient who had been declared medically fit for discharge patients as they were normally the fittest patients in the hospital. The Interim Chief Operating Officer added that the Trusts aspirations were to keep patient moves to a maximum of three per patient. The real issue arises at night when there is sometimes simply nowhere for patients to go.
Mark Nellthorp fully recognised that patient moves were a concern, particularly at night but pointed out that there had recently been a need to move patients because of single sex issues.He wondered, at times of extreme pressure, whether we were focusing on the right targets. The Deputy Director of Nursing assured the Board that patient safety was always the top priority. She had benchmarked us with other Trusts and ourcompliance with the single sex requirement was good. The Interim Chief Operating Officer added that patient safety and inappropriate moves were discussed regularly each day at operational meetings.
The Medical Director agreed to circulate the Coroner’s response.
Action: Interim Medical Director
Operations
The Chief Operating Officer drew attention to the following areas of her report:

A&E - 4 hr standard performance was 78.07% (75.32% last month). There had been 95 breaches of the 12 hr Trolley Wait Standard. The trajectory had been to achieve 80% in April, however because of the Easter period we had only achieved 79.06%. There is a gradual trajectory to reach 90% by September
Discharges
RTT - 91.3% had been achieved against the 92% standard (at aggregate level) and againstthe revised improvement trajectory of 91.8%.The total number of patients waiting had reduced by 258 to 28,495.The number of patients waiting more than 18 weeks had reduced by 266 to 2,469. The number waiting more than 40 weeks had reduced by 4. There had been 0 breaches of the 52 week maximum wait standard
Diagnostic Waits - Trust performance was 99% against the 99% diagnostic standard and improvement trajectory of 99.1%. There had been 56breaches of the standard
Cancer - Provisional performance for March was 86.1% and achieved, provisional performance for quarter 4, 85.8% and achieved. The Trust is currently forecasting achievement of all 8 key national standards; this is the first time this has been achieved since September 2015. It is also likely that the 62 day standard will be achieved for quarter 4. There are provisionally 6 patients who have been treated in excess of 104 days - 1 dermatology due to patient choice, 2 lower GIcomplex pathways with multiple (6&7) diagnostics, 3 urology 2 due to outpatient and 1 diagnostic capacity shortfall
Delayed Transfers of Care - Delayed transfers of care had been 6.5%. There had been an average of 250 patients medically fit fordischarge compared to 246 in February
Robust plans were in place for Easter weekend and, as a consequence, the Trusthad been better able to cope with the pressures. Easter was followed by the ‘Perfect Week’, which had been very successful. The level of commitment and enthusiasm had been impressive. Thank you to everyone who took part

The Chairman commented that the Trust appeared to be building momentum in terms of its performance and asked how this could be maintained. The Interim Chief Operating Officer replied that CSC performance reviews had been reinstated at the request of the CSCs and that the Executive Team would looking to hold those accountable to account. The Medical Director added that for the first time the Trust had achieved 100% theatre efficiency in April. He promised to circulate a summary of how we compare with other Trusts.
Action: Interim Medical Director
The Chairman asked how the Trust would achieve the 90% A&E performance target by September. The Interim Chief Operating Officer responded by saying that performance, finances and quality are all inextricably linked. The Emergency Department is focussed on efficiencies and particularly in avoiding unnecessary breaches in Minors. There is a gradual trajectory to get us to 90% by September.
The Chairman also asked about the progress with closing down escalation beds. The Interim Chief Operating Officer commented that prior to Easter good progress had been made, however during Easter it had been necessary to re-open them;focus is now on trying to close them down again.
Melloney Poole asked if the Interim Chief Operating Officer recalibrates the trajectory against failure to meet the target. The Interim Chief Operating Officer replied that we are currently on track to meet the target.
The Chairman remarked that if the Trust could resolve the medically fit for discharge issues then it would transform the Trust. The Chief Executive added that when it comes to medically fit for discharge patients we need to concentrate on those things that we can effect within the hospital and that there was still much scope for improvement in our own discharge processes.
Mike Attenborough-Cox felt strongly that we needed to look at radical ideas to reduce the numbers of those patients who were medically fit for discharge but required some support outside of an acute hospital setting otherwise the numbers would just keep increasing. He suggested keeping the public informed of our statistics to help them better understand where the issues lie. The Director of Corporate Affairs cautioned that we needed to make the right decisions for the right reasons and not alienate our partners. The Director of Finance agreed to try and identify the extra cost that was being incurred.
Action: Director of Finance
Finance
The Director of Finance drew attention to the following areas of his report:

The accounts for 2016/17 have been submitted to the Auditors
The Trust's Income and Expenditure position at the end of March 2017 was an actual deficit of £17.8m. This is £19m adverse to the planned surplus position of £1.2m. The deficit position includes a partial loss ofallocated STF funding for the year of £7.6m against a potential full year sum of £14.6m
The Trust continued to see high use of temporary staff to maintain urgent care services and additional capacity that has remained open due to the volume of patients that have been in hospital as delayedtransfers of care
Non-pay costs include unplanned use of the private sector to support RTT delivery and outof hospital purchase of beds
The Trust submitted a forecast year end position at the end of Q3 to NHSI. The financial out-turn identified under a realistic case was a £16.1m deficit with a loss of potential STF funding recognised as a part of thisdeficit projection of £7.3m. The final out-turn figure was a further £1.7m deficit beyond this forecast
The Trust has spent £10.0m of capital against a programme for the year to date of £14.2m. The Trust has a cash balance of £5.2m at the end of March. The minimum level of cash holding required by the Department of Health has increased to £5.1m to reflect the capital carried forward to 2017/18. The Trust has drawn total cash againsta limit of £41.7m for its working capital facility and £10.9m Department of Health uncommitted loan
The Trust has been advised that the cash support application submitted to the Independent Trust Financing Facility (ITFF) meeting in February 2016 was not taken forward and the Trust continues to be in discussion with the NHSIabout the implications and management of this

Workforce