Item 14C Confirmed GA minutes 18 November

Confirmed at meeting on 18 February 2014
Cambridge University Hospitals NHS Foundation Trust
Minutes of the meeting of the Governor / Director working group on
Governance and Assurance held on Monday 18 November 2013 in the
Boardroom, Addenbrooke’s Hospital.
Present:
Governors
Mr D Brown
Mrs J Ewer
Ms G Francis
Mrs E Howe
Dr F Jacobsberg
Mr P Lester
Mr E Revell
Prof P Smith
Mr B Walker
Dr J Wells
Governor (Chair)
Governor
Governor
Governor
Governor
Governor
Governor
Governor
Governor
Governor
Directors
Ms L Berry
Mr R Eley
Non-executive director
Chief Financial Officer
In attendance:
Mr T Bennett
Ms C Boswell
Mrs F Cousins
Mrs H McGhee
Mr M Whelan
Director of Operations
PMO Director
Chief Operating Officer
Deputy Trust Secretary
Assistant Trust Secretary
(minutes)
Apologies:
Ms H Burchmore
Mrs W Menon
Mrs G Pharaoh
Governor
Governor
Governor
Dr P Southwick
Non-executive director
Dr A Alderton
Trust Secretary
22/13Minutes of the meeting 9 September 2013
The minutes were confirmed as a correct record.
23/14 Matters Arising
Governors were reminded that the meeting with Adam Cayley from Monitor was on
19 November 2013.
The committee welcomed Caroline Boswell, the new PMO Director.
24/13 Integrated Quality Report (Finance Section)
Chief Financial Officer reported
Received: Integrated Quality Report (Finance Section)
Noted
1. The Trust to the end of month six had an overall deficit including eHospital of
£7.1m against a plan of £7.8m. The Trust to the end of month six had an
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overall deficit excluding eHospital of £0.8m against a plan of £0.6m. It was
noted that there had been an in month adverse variance of £0.4m.
2. The Trust was currently at FRR 2 level including eHospital, or FRR 3 without
eHospital.
3. The key issue contributing to the current financial position was income. Clinical
income was currently £1.9m under plan. The year to date impact of the
emergency threshold was £2m. It was also noted that the case mix was not as
predicted, so whilst activity was up it was not necessarily reflected increased
income.
4. The Trust was likely to suffer a significant negative financial impact as a result
of exceeding the ceiling for C.difficile.
5. Specific divisions were struggling. It was noted that the Cancer division was
currently running a deficit against plan of £2.7m, and had experienced an
adverse variance of £900k in month six. It was noted that the Medicine
division was currently a deficit against plan of £1.4m, and had experienced an
adverse variance of £500k in month six. It was explained that both divisions
were meeting regularly with the Chief Financial Officer and the Chief Operating
Officer. Less significant concerns regarding critical care were highlighted,
however it was noted that the position would improve when costs incurred by
the division were recharged to the appropriate division.
6. The overall financial position of the Trust remained finely balanced.
7. In response to a question regarding increased levels of activity but reduced
levels of income, adverse variances could be as a result of less activity or not
being paid the expected amount for the work undertaken. It was noted for
example that the Trust could be paid up to £100k for a bone marrow
transplant procedure, but on average was receiving between £2000 and £3000
for inpatient procedures and £500 for outpatient.
8. The emergency threshold penalised the Trust for any non planned emergency
admissions of patients above the level admitted in 2008/09, by only paying the
Trust 30% of the tariff. The original purpose of the policy was to allow the CCG
to develop a “fighting fund” to develop community provision or fund other
forms of intervention to reduce the likelihood of emergency admissions.
9. The Trust received the full tariff for patients treated through the Major Trauma
Centre (MTC). The Trust was continually seeking to renegotiate the baseline
with the commissioners, due to changes in the health care system. It was
noted that when the MTC originally opened the Trust received funding from the
Strategic Health Authority to fund staff and infrastructure improvements to
facilitate the development of the service, until the level of demand for the
centre increased.
10. The major financial impact of the emergency threshold was around frail elderly
patients.
11. The decision making regarding the most appropriate treatment for a patient
would always be clinical. It was noted that the Trust would always receive
some payment for providing treatment.
12. The budget projections were based on historic trends and patterns. It was
noted that certain procedures and treatments were performed at very low
levels and a small variation in case numbers could have a major impact on the
financial position of the Trust.
13. The Trust had received an increased number of paediatric patients as a result
of the reduction of paediatric services at Bedford Hospital. The effect on the
Trust had been approximately three additional bed spaces, but had also
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affected Milton Keynes Hospital due to the proximity of Milton Keynes to
Bedford. Discussions were ongoing regarding the configuration of children’s
services across the region.
14. During the period of reduced levels of bone marrow treatments being
undertaken by the Trust, the alternative providers had been hospitals in
London. It was noted this activity had now returned to normal.
15. Excluding eHospital the Trust was currently running at a £0.8m deficit against
a plan of £0.6m. The Trust was aiming to generate a £4m surplus on a
£600m+ budget, and was therefore susceptible to small variations in financial
performance. It was noted that the Trust was seeking to address the deficit by
seeking to increase market share; reviewing the CIP programme and assessing
other opportunities.
16. The provision for the penalty for exceeding the C.difficile ceiling was not
currently aligned to the divisions and was being held centrally. It was noted
that the Trust was currently appealing a number of the currently reported
cases, where the evidence suggested that the case was unavoidable. Professor
Pat Troop had recently lead a Working Group focussed on reducing the level of
C.difficile within the Trust and this had identified actions which were
contributing to the current low level of cases.
17. The Trust had recently had its quarterly monthly meeting with Monitor by
telephone and the following points were identified
The CIP programme had been re-forecasted
The Trust was actively reviewing underperformance against the plans.
Vacancies were being actively reviewing prior to a decision to progress
to recruitment.
Spending on bank staff was been actively managed and analysed.
The Trust was seeking to protect elective surgery, and previously
outsourced surgical activity had returned to the Trust from the private
sector.
The Trust was seeking to minimise the cost of the redundancy
programme and less than half of the £4m allocated to the programme
had been used.
The number of C.difficile cases had reduced significantly from earlier in
the year.
The eHospital revenue budget was currently under spent by £1m and a
review of the baseline for the MTC was also likely to release £1m.
18. Due to the low level of certain treatments it was very difficult to predict
accurately the case mix and the financial year end position.
19. The Trust had a trust wide Trauma Committee which sought to ensure that the
Trust was seeking to recover all possible costs, and operate in the most
efficient way possible.
24/13 Integrated Quality Report (Performance Section)
Director of Operations reported
Received: Integrated Quality Report (Performance Sections)
Noted
1. The Trust had planned on the basis of an additional 40 bed capacity
requirement; however year to date the pressure was around double that
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figure. The Trust had experienced significant spikes in demand in April and
September.
2. The Trust had managed the increased demand through implementation of the
length of stay transformation programme, and the re-opening of ward c7. It
was noted that following the re-opening of ward C7, there had been a small
number of cancelled operations which had been subsequently re-arranged.
3. Despite the pressures on the Trust, the Trust had maintained compliance at
95.8% with the Accident and Emergency four hour wait target.
4. The Trust had opened G3 as a surge ward facility to manage short term spikes
in demand.
5. The Trust had maintained compliance against the 18 weeks referral to
treatment target and the cancer treatment targets.
6. £500k had been identified in support of the Winter Plan. The Trust was seeking
to expand the use of Addenbrookes at Home, and had amended the
governance arrangements to promote use of the scheme by clinicians.
7. In response to a question regarding the level of use of Addenbrookes at Home,
the current usage levels were around 20 patients however it was planned to
increase this over time to 60 patients.
8. Currently 2/3rd of the patients discharged to Addenbrookes at Home were from
the medical division and the remainder were from the surgery division. It was
noted that the service was designed to be flexible and respond to the
outcomes of the Integrated Older Peoples tender process. It was also noted
that the CCG had also commissioned 10 “step up” beds from Medihome.
9. In response to a question regarding the implication of the lower than planned
use of Addenbrookes at Home, the Trust was managing the demand through
the length of stay programme and the appropriate use of ward G3.
10. The Trust was continuing to ensure that patients were appropriately discharged
without inappropriate delay. The number of bed days lost through assessment
had reduced from a peak of around 200 to around 25 in recent weeks. It was
also noted that Cambridgeshire Community Services had reopened recently
opened beds at Brookfield’s Hospital. It was further noted that the County
Council and the CCG had also commissioned interim bed space through
Sanctuary Housing to enhance the capacity of the domiciliary care services.
11. The Trust had implemented appropriate clinical governance arrangements with
regards to Addenbrookes at Home, to ensure that patient safety and quality of
care was not compromised. The Trust carefully selected patients prior to
discharging to Addenbrookes at Home.
12. The readmission rates were carefully monitored by each clinical area, and the
Trust as a whole had a readmission rate of 8.8% at present against a national
benchmark of 25%.
25/13 Turnaround Programme Highlight Report – September
The Chief Operating Officer reported
Received: Turnaround Programme Highlight Report – September
Noted:
1. The programme had moved from amber/red to amber confidence.
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2. The Trust had reviewed the forecasts for the programme and had confidence in
achieving £28.36m against the plan of £28.8. It was noted that the interim
projections to the end of month 7 indicated that the Trust remained on target
to meet and exceed the revised projection.
3. The Outpatients transformation programme was progressing to streamline the
administration process within the service. It was noted at present about 27%
of calls to outpatient were not answered and different processes had developed
within different clinics over time. The transformation programme would
standardise the banding of staff roles within Outpatients.
4. The Trust was expanding the use of Netcall to reduce the number of wasted
appointments. It noted that in one month alone £60k had been saved through
this project.
5. The Trust was implementing the effective clinic programme to ensure that
clinics were being used most effectively.
6. 120 WTE roles against a plan of 160 had been released through the workforce
transformation programme. It was noted that care needed to be taken to avoid
endangering patient care or compromising quality by excessively reducing the
workforce. In response to a question, staff where possible had been
redeployed both within the Trust and with other NHS bodies locally, and less
than 20 had physically left the Trust.
7. All the transformation programmes were regularly reviewed and quality impact
assessments were an integral part of the process.
8. Concerns regarding the uncertainty for certain groups of staff such as senior
nurses. It was noted that the Trust was currently developing a plan to reduce
the number of divisions from 7 to 5, and the appointment of a substantive
Chief Nurse with imminent.
9. The agenda for change process had standardised salaries and job descriptions
about 8 years ago. Concerns were expressed that the work being undertaken
in Outpatient suggested that this process had not been effectively
implemented and maintained.
10. The reference to WTE was potentially confusing as 1 WTE could be two people
working part time. For future reports it was requested that the number of
people involved and the associated salary costs were recorded in the report.
26/13 Monitor’s Continuity of Service Rating
The Chief Financial Officer reported
Received: Report on Monitor’s Continuity of Service Rating
Noted
1.
The Trust would now be graded 1, 2, 2*, 3 or 4 in future with the aspiration of
achieving a 3. It was noted that at the moment the Trust was expecting to be
graded 2. Governors expressed concern that this may make it difficult for the
Trust in terms of relationship with Monitor. It was noted that Monitor would be
aware of the relative position of all Trusts prior to setting the new criteria.
2. The introduction of the new rating system would make it difficult for the Trust
to enter into new borrowing arrangements, without increasing the levels of
surplus.
3. The models included in the report included the impact of eHospital.
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4. A briefing would be organised regarding the future accounting treatment of the
Forum and other projects, as a result of the introduction of the new rating
system.
27/13 Items to report to the Board of Directors
There were no issues to report to the Board of Directors.
28/13 Items to report to the Council of Governors
There were no issues to report to the Council of Governors.
29/13 Date of next meeting
This was confirmed as Tuesday 18 February 2014 from 16:00 to 18:00 in the
Boardroom.
30/13 Any other business
The Governors welcomed the improvements to the integrated report specifically
the inclusion of further information on the cost improvement programme and the
clarity of the financial information.
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