Trust Board Papers - Barts Health NHS Trust

BARTS HEALTH NHS TRUST
TRUST BOARD MEETING (PART 1)
There will be a meeting of the Trust Board in public on Wednesday 10 April 2013 at 11.00
in the Main Lecture Theatre, Education Centre, The London Chest Hospital, Bonner Road, London E2 9JX
Scheduled to end by 13.30
AGENDA
Paper Lead
TB
1. WELCOME Sir Stephen
O’Brien
2. APOLOGIES FOR ABSENCE: Ms F O’Callaghan
Time
11.00
3. DECLARATION OF INTERESTS
To declare any interests members may have in connection
with the agenda and any further interests acquired since
the previous meeting including gifts and hospitality
(accepted or refused)
4. MINUTES
To approve the Minutes of the meeting held on
6 March 2013 and review the action log
24/13 Sir Stephen
O’Brien
11.00
5. MATTERS ARISING
5.1 Relationships with mental health
5.2 To consider any matters arising from the Minutes not
covered elsewhere on the agenda
Mr L Richards 11.05
6. PATIENT STORY
To hear a patient story Prof K Riley 11.10
7. CHAIRMAN’S REPORT
To receive the Chairman’s report
Sir Stephen
O’Brien
11.40
8. CHIEF EXECUTIVE’S REPORT
To receive the Chief Executive’s report 25/13 Mr P Morris 11.45
1

Paper
TB
Lead
Time
QUALITY, SAFETY AND PERFORMANCE
9. PERFORMANCE – 2012/13 MONTH 11
9.1 Integrated Performance Report
9.2 Quality and Safety performance
9.3 Financial performance
26/13
27/13
28/13
Mr L Readman
Prof K Riley/
Dr S Ryan
Mr M Ogden
12.20
GOVERNANCE AND ASSURANCE
10. ANNUAL PLAN 2013/14
To receive the final version of the annual plan 29/13 Mr P Morris 12.50
11. INFORMATION GOVERNANCE TOOLKIT
To ratify the 2012/13 IG Toolkit scores 30/13 Mr I Walker 13.00
12. BOARD ASSURANCE FRAMEWORK
To receive and approve the BAF 31/13 Mr I Walker 13.05
13. TRUST BOARD MEMBERSHIP
To note the reappointment of a Non Executive Director 32/13 Mr I Walker 13.15
14. STANDING ORDERS AND STANDING FINANCIAL
INSTRUCTIONS
To approve revisions to the SOs and SFIs 33/13 Mr M Ogden 13.15
15. USE OF THE SEAL
To ratify use of the Trust Seal 34/13 Mr I Walker 13.20
16. SINGLE OPERATING MODEL
To receive and approve the monthly submission 35/13 Mr L Readman 13.20
17. ORAL REPORTS FROM BOARD COMMITTEES
17.1 Quality Assurance Committee: 13 March 2013
17.2 FT Sub Committee: 13 March 2013
17.3 Finance and Investment Committee: 13 March and
10 April 2013
Ms S James
Sir Stephen
O’Brien
Mr G Dalal
13.25
2

Paper
TB
Lead
Time
ITEMS FOR INFORMATION
18. ANY OTHER BUSINESS
19. QUESTIONS FROM MEMBERS OF THE PUBLIC 13.30
20. DATE OF THE NEXT MEETING
The next meeting of the Trust Board in public will be held
on Wednesday 1 May 2013 at 11.00 in Room 8, Education
Centre, Burdett House, Mile End Hospital, Bancroft Road,
London E1 4DG.
21. RESOLUTION
That representatives of the press and other members of the
public be excluded from the remainder of this meeting
having regard to the confidential nature of the business to
be transacted, publicity on which would be prejudicial to
the public interest (section (2) Public Bodies (Admissions to
Meetings) Act 1960).
Ian Walker
Director of Corporate Affairs and Trust Secretary
Barts Health NHS Trust
020 7092 5212
3

TB 24/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING (PART 1)
Minutes of the Trust Board meeting held in public on Wednesday 6 March 2013 at 11.00
in Rooms 1 and 2, Ground Floor, Pathology and Pharmacy Building, Newark Street,
The Royal London Hospital, London E1 1BB
Present:
In attendance:
Apologies:
Sir Stephen O’Brien (Chairman)
Mr P Wright (Vice Chairman and Senior Independent Director)
Mr P Morris (Chief Executive)
Ms S James (Non Executive Director)
Mr M Ogden (Chief Financial Officer)
Mr L Richards (Chief Operating Officer)
Professor K Riley (Chief Nurse)
Dr S Ryan (Medical Director)
Professor R Trembath (Non Executive Director)
Ms A Whitaker (Non Executive Director)
Mr T Lewis (Deputy Chief Executive and Development Director)
Ms F O’Callaghan (Director of Strategy)
Mr M Pantlin (Director of Human Resources)
Mr L Readman (Chief Information Officer)
Mr I Walker (Director of Corporate Affairs and Trust Secretary)
Ms H Shanahan (Deputy Chief Nurse, Patient Experience) – agenda item 6
Ms F Hollwey (Head of Patient Experience and Engagement) – agenda item 6
Ms P Mason (Patient) – agenda item 6
Ms M Mason (Relative) – agenda item 6
Ms M Banerjee (Non Executive Director)
Mr A Camp (Non Executive Director)
Mr G Dalal (Non Executive Director)
21/13 WELCOME AND INTRODUCTION
The Chairman welcomed everyone to the meeting. He explained that Ms Banerjee
would be taking a period of leave of absence for personal reasons.
1

TB 24/13
The Chairman noted that this was the final Trust Board meeting which Mr Lewis
would be attending before taking up his new role as Chief Executive of Sandwell
and West Birmingham Hospitals NHS Trust. On behalf of the Trust Board, the
Chairman expressed his gratitude to Mr Lewis for all he had achieved in his time at
both Barts and The London NHS Trust and Barts Health NHS Trust and wished him
every success for the future.
22/13 DECLARATIONS OF INTEREST
Attendees were reminded of the need to declare any interests they may have in
connection with the agenda.
No declarations were received.
23/13 MINUTES
The Minutes of the meeting of the Trust Board held in public on 6 February 2013
were received and approved as a correct record of the proceedings.
The Minutes were duly signed.
The Board noted the progress made on closing issues on the action log appended
to the Minutes. The following points were specifically noted:
The Chairman reported that he had discussed the issue of the name of the
Charity with its Chairman and an update would be provided at the next
meeting.
The Chief Operating Officer would provide an update on work with the
mental health trust at the next meeting.
Action: Chief Operating Officer
The Chief Operating Officer confirmed that he had discussed with CAG
leadership teams the importance of monitoring security arrangements and
challenging visitors to wards and clinical areas. The issue was also being
picked up in regular ward conversations.
The Deputy Chief Executive confirmed that a report on Estates and the New
Hospitals Programme would now be produced during the next quarter. The
existing action would be amended accordingly.
On New Hospitals benefits realisation, it was agreed to close the current
action and that the Deputy Chief Executive would discuss with the Chief
Executive how best to monitor benefits realisation for Barts Phase 2.
2

TB 24/13
24/13 MATTERS ARISING
There were no matters not covered elsewhere on the agenda.
25/13 PATIENT STORY
The Deputy Chief Nurse for Patient Experience introduced Ms Pam Mason, who
had formally consented to tell her story. She was accompanied by her daughter,
Ms Margaret Mason.
Ms Mason explained that she had been a foster carer for 14 years. She had a son
Philip who she had adopted when he was two years old, two birth daughters and
13 foster children. Her story related to Philip who was 35 and suffered from
Down’s Syndrome and autism. His understanding was very limited and his autism
meant that routine was very important to him.
Philip had started to become more acutely ill around four years ago and was
admitted to a ward via A&E Resus at The Royal London. His dad had wanted to
stay with Philip to provide him with the support he needed but the ward staff had
said that parents could not stay with adult patients. Eventually they had offered
his dad a chair and a mattress on the floor. But no one on the ward had
understood Philip’s needs.
Philip was subsequently admitted to hospital a second time and his dad was again
offered the floor to sleep on. He had then spoken to the bed manager who
managed to organise a bed for him. However, no one offered him anything to eat
or drink despite him not being able to leave Philip alone.
On Philip’s third admission, there was no bed available for parents and they were
not allowed to stay with Philip. They asked the ward staff if they could make a care
plan for Philip but were told that they only did that for children. They also asked if
they could come in the next morning to help care for Philip but were told that they
could not visit until 2.00pm. Philip’s parents then received a call from the ward at
5.30am asking them to come in because Philip needed support.
During that stay they had tried to give the staff a copy of a book about Philip and
his requirements but the staff had told his mum that they did not have time to read
it. Tablets were being left by Philip’s bedside despite him not knowing how to take
them. He was given tea in flexible cups which were not appropriate given his
condition. A request for a yoghurt to take his tablets with was refused as and on
one occasion he was given sandwiches because they had run out of food.
Ms Mason explained that she had contacted PALS, not to make a complaint but in
an attempt to understand what support was available for patients with learning
disabilities. She was particularly concerned about the experience of patients and
carers who were not confident enough to speak up about their problems or who
experienced language or other barriers in doing so.
3

TB 24/13
She felt that there was a particular need to focus on staff awareness and training,
including of the catering staff who had passed Philip’s bed without stopping to ask
him about his choice of food because they had assumed he was not able to make a
choice despite one of his parents being available to help him. It might, for
example, be helpful to identify people who could visit wards to talk to staff and
carers about what would help during the stay.
She also emphasised the need to recognise that it was not appropriate to keep
moving patients with autism. In Philip’s case, he had been moved from one ward
to another without his parents being informed so that they could reassure him.
The Chairman thanked Ms Mason for being willing to tell her story to the Board
and invited questions and comments from Board members. The following points
were made in discussion:
The Chairman noted that this was the second patient story which had
involved the experience of a patient with autism.
The Chief Operating Officer asked about Philip’s experience in A&E. Ms
Mason confirmed that this had not been problematic and the difficulties
had arisen in the ward environment.
The Chief Nurse thanked Ms Mason for telling the story and said that
she was extremely sorry to hear about her family’s experiences. She
was also very grateful to Ms Mason for offering to work with the Trust
on improving the experience of patients in the future. A learning
disabilities action plan was due to be presented to the Quality
Assurance Committee the following week which would include a focus
on strengthening and better utilising available resources. In addition,
the Trust would be launching its Care Campaign later in the week with a
focus on the fundamental, basic standards of nursing care.
Ms James apologised to Ms Mason for this experience. As in the
previous case the Board had heard about, it appeared that the Trust
was failing to make use of the invaluable help and expertise that carers
were able to offer.
The Chief Nurse asked Ms Mason whether she had raised the issues
with the Senior Sister or Charge Nurse at the time. Ms Mason explained
that some of the responses were coming from staff at that level. The
Chief Nurse felt that some of the flexibility and standard practice of the
past of working with carers had perhaps been lost and Ms Whitaker
encouraged the empowerment of staff to be able to exercise greater
flexibility in response to individual circumstances.
4

TB 24/13
The Deputy Chief Executive hoped that the increase in single room
capacity at The Royal London meant that it was now easier to
accommodate carers being able to stay with patients overnight. He also
observed that a common theme from recent patient stories had been a
failure of the organisation to respond when concerns were raised.
Consideration therefore needed to be given as to how issues could be
addressed more rapidly at the time they were identified rather than
waiting to apologise later.
The Chief Operating Officer cited the example of the Virginia Mason
Hospital in the United States which identified ‘stop the line’ events
which could be raised by patients, carers or staff and had to be
responded to by an Executive within half an hour. While there may be
practical challenges in implementing such a system, it provided a clear
focus on the need for effective escalation routes.
The Medical Director expressed his regret and frustration at what Philip
and his family had experienced. He noted that on a paediatric ward it
was normal for parents and carers to be closely involved in the care of
their children and there was therefore no reason why this could and
should not be the same for patients with learning disabilities.
The Medical Director noted that doctors should act as advocates for
patients and asked Ms Mason whether she had felt able to raise her
concerns with the doctors treating Philip. Ms Mason said that the
doctors were aware of some of the issues but had not intervened. She
emphasised that she had been satisfied with the quality of clinical care
provided by the doctors and nurses on the wards.
Ms Whitaker asked how the voices of patients and carers who were not
as confident in raising their concerns were heard. The Chief Nurse
explained that a review was being undertaken of the PALS and
complaints function with a focus on the routes for concerns to be raised
and escalated. There was also a key role for Matrons to play in
intervening rapidly to address problems locally as they arose.
The Chief Information Officer was very sorry to hear about this
experience and said that he would welcome the opportunity to work
with Ms Mason to look at how the care record held by parents and
carers could be integrated into the main patient health record.
Professor Trembath emphasised the importance of learning from the
practice and experience of colleagues in mental health services.
5

TB 24/13
The Chairman concluded that there was a clear sense of outrage among Board
members at what Philip and his family had experienced and that there was a need
to receive an update on actions taken in the near future, including in relation to
work with the mental health trust. The Chief Nurse proposed further discussion at
the Quality Assurance Committee meeting the following week as part of the item
on learning disabilities, specifically considering whether the issues highlighted in
this story were adequately addressed by the proposed strategy. The outcome of
this discussion would then be reported back to the Board.
Action: Chief Nurse
The Chairman thanked Ms Mason and her daughter for attending the meeting and
the Deputy Chief Nurse for Patient Experience and the Head of Patient Experience
and Engagement for supporting Ms Mason in telling the story.
26/13 CHAIRMAN’S REPORT
The Chairman reported on the following matters:
The delivery of operational performance standards remained a key priority
for the Trust Board. Improving performance on those indicators which
were currently tracking below trajectory was essential if the Trust was to
drive forward its wider strategic initiatives.
With a strong leadership team in place in the top tiers of the organisation,
there was a need to focus on staff engagement and organisational culture.
27/13 CHIEF EXECUTIVE’S REPORT
The Chief Executive introduced TB 14/13, his report on recent developments, and
highlighted the following:
As set out in the report, there was agreement in principle from the Boards
of both Barts Health NHS Trust and University College London Hospitals NHS
Foundation Trust to bring together The London Chest, St Bartholomew’s
and The London Independent Hospitals to create one of the largest and
finest cardiac centres in the world from both a service and research
perspective.
There was now a 24/7 specialist heart rhythm centre on the Barts site which
was able to offer direct access via the London Ambulance Service to
patients in north London suffering from three of the most serious acute
heart rhythm problems. The Chief Executive reported that he had visited
the centre the previous week and had been very impressed by it.
6

TB 24/13
On operational performance, MRSA, emergency care, cancer 62‐day waiting
times and mixed sex accommodation breaches remained off track. There
were encouraging signs on two of these indicators while two required
greater focus:
o On MRSA, the current run rate was significantly below that in the
first half of the year and there had been no bacteraemias at The
Royal London for over 100 days. However, the Trust would not be
compliant with its annual threshold for 2012/13.
o There had also been positive progress on cancer 62‐day waits with a
narrowing of the problem in urology. There was an improvement
plan in place which, if achieved, should deliver compliance with the
national standard by the end of April 2013.
o Mixed sex accommodation breaches were being driven substantially
by failures to move patients from critical care to general beds within
six hours when they were clinically fit for step down. Improving
overall patient flow and discharge arrangements should significantly
reduce the number of such breaches.
o On emergency care, The Royal London and Whipps Cross were
concerns. Performance at the former had slipped recently while the
latter had not recovered from a downturn in performance around
November 2012. Significant work was being undertaken to improve
performance but this had not yet translated into the required
improvements in compliance. While the Trust remained on track to
meet the 95% All Types standard at year end, there were concerns
that there was not yet a sufficiently robust plan to deliver a run rate
of 95% or above from April 2013. The Chief Executive reported that
he would be reviewing with the Chief Operating Officer the action
plans in place on a site and CAG basis to achieve compliance on a
sustainable basis.
The publication of the report of Sir Robert Francis’ public inquiry into the
failings of care at Mid Staffordshire NHS Foundation Trust had been a major
development since the previous Board meeting and was the subject of a
separate agenda item and paper. In response to a request from the
Secretary of State for Health, the Trust was able to confirm that it neither
prevented nor discouraged staff from raising concerns which could be
considered to be in the public interest as part of its contractual
arrangements with them as employees. As reported in the separate Board
paper, the Trust Management Board had discussed the Francis report in
detail shortly after its publication. In addition, the Chief Executive was
personally attending each CAG Board before the end of March where the
Francis report would form part of the discussion. He was also meeting oneto‐one
with all 38 Group and Clinical Directors.
7

TB 24/13
The following points were raised in discussion:
The Vice Chairman asked for an update on the work of the Integrated
Cancer System (ICS) for north east and north central London. The Chief
Executive recalled that, at its previous meeting, the Trust Board had
recognised that the ICS had 12‐14 clinically‐led tumour groups which were
reviewing specialist cancer provision from a patient and population health
perspective and the Board had agreed to support this approach. A
proposition on the approach to radiotherapy was still to emerge. Decisions
had already come forward in relation to urology, where there was a clinical
consensus for University College London Hospitals NHS Foundation Trust to
be the preferred location for bladder and prostate cancers, and in relation
to upper tract renal cancers, where the Royal Free London NHS Foundation
Trust was the preferred location. Decisions were due shortly on liver and
pancreatic cancers and head and neck cancers, and later in the year on
gynaecological and blood cancers.
Of the five tumour groups where decisions were upcoming, Barts Health
had interests in all of them. It was also important to recognise that
common cancers, such as lung, breast and skin cancer, would always be an
important part of the service provision of Barts Health, including in terms of
prevention and early detection.
The Vice Chairman noted that it would be important to fully understand the
clinical, operational and financial impacts on other Trust services of the
forthcoming decisions on the locations for specialist cancer treatment. The
Chief Executive agreed and explained that the Director of Strategy was
working closely with the CAGs to ensure that such implications were
assessed.
The Director of Strategy emphasised that the activity impact of any changes
in the location of specialist cancer services would be marginal when
compared to the overall level of Trust cancer activity. The core of the
Trust’s cancer services would remain very significant and span prevention,
diagnosis, secondary care and palliative care.
Professor Trembath informed the Board that Queen Mary University of
London and University College London had agreed to commission an
independent review of where there was academic competition and
complementarity in work on cancer to support decisions on how the
academic endeavour could best support future clinical service provision.
The Trust Board noted these and the other items set out in the Chief Executive’s
report and, as requested, delegated approval of the Trust’s 2012/13 Information
Governance Toolkit submission to the Chief Executive. It was noted that a paper
providing details of the Information Governance Toolkit submission would be
presented at the next meeting of the Trust Board.
Action: Director of Corporate Affairs and Trust Secretary
8

TB 24/13
28/13 PERFORMANCE – 2012/13 MONTH 10
(i) Integrated Performance Report
The Deputy Chief Executive introduced TB 15/13, the first Integrated Performance
Report for Barts Health. He recorded his thanks to all those who had worked on
the development of the new Integrated Performance Framework (IPF), particularly
Ms Susan Murray. Inevitably the IPF remained work in progress and would be
further developed in the months ahead in response to feedback.
The following points were highlighted:
The IPF reflected the Board’s previous decision that there should be a key
focus on the views of the Trust’s patients, staff and students, regulators and
partners.
In terms of the RAG status, Red indicated below the line performance,
Green indicated above the line performance, Blue meant that no threshold
had yet been set and Grey meant that data were not yet available.
Little progress had been made to date on integrating the domain relating to
the views of partners and significant work was still required to integrate
financial information into the IPF.
In terms of the views of regulators, the position was as the Chief Executive
had set out earlier in the meeting. The Trust was compliant with the
Cooperation and Competition Panel’s indicators for the second successive
quarter and the Deputy Chief Executive agreed to circulate the details of
these following the Board meeting.
Action: Deputy Chief Executive
In terms of patient views, the ratings were based on Real Time Feedback
results. It was encouraging that the Cancer CAG was rated Green and this
provided an area for other CAGs to seek to learn from.
On staff and student views, many of the red ratings were currently driven
by surveys of postgraduate medical trainees. However, the results of the
monthly ‘Pulse’ surveys of 2,000 members of staff would soon be available
to feed into the IPF.
Alongside continuing to develop the IPF, a key challenge would be to stand
down other reports and indicators which duplicated or overlapped with
information in the IPF.
9

TB 24/13
The following points were made in discussion:
Ms James welcomed the new IPF and agreed on the need to retire other
reports. She asked who would be leading on this. It was confirmed that the
Chief Information Officer would be leading on this in future, working with
Executive Director colleagues.
The Chief Nurse reported that discussions were continuing about how the
important narrative on quality and safety of care currently contained in the
separate Quality and Safety report could be integrated into the IPF. In the
meantime, it was planned to continue with a separate Quality and Safety
report.
Ms James felt that it would be helpful to review the new report in detail to
ensure that Board members fully understood the presentation of the
indicators and the approach to exception reporting. It was agreed that a
separate session would be arranged with the Chief Information Officer to
increase familiarity with the IPF.
Action: Director of Corporate Affairs
Ms Whitaker encouraged the use of exception reporting within the body of
the Integrated Performance Report rather than as separately appended
reports. The Chief Information Officer confirmed that this was the
intention.
Ms James reminded Board members that the Quality Assurance Committee
had a role in looking at specific performance issues in greater detail at the
request of the Trust Board.
The Vice Chairman asked for further details of VTE screening performance
in the context of the chart on page 13 of the report. The Deputy Chief
Executive explained that the Trust as a whole was compliant with the 90%
minimum standard in the year to date but performance had deteriorated
sharply since autumn 2012. Actions were in place to recover performance
at The Royal London, Mile End and Barts but performance had also recently
deteriorated at Whipps Cross. The Executive Team was discussing what
further action was required to improve performance, including monitoring
compliance by individual consultant.
The Director of Academic Health Sciences highlighted continued poor
compliance with statutory and mandatory training requirements. A new
Trust‐wide database was providing greater visibility of compliance
information and enabled managers to review individual compliance for
each member of their staff. Managers had been reminded of their
responsibility to drive compliance in their teams and it had been reiterated
that a failure to comply with statutory and mandatory training
requirements constituted a failure of personal objectives.
10

TB 24/13
The Vice Chairman asked how the minimum standard of 95% was set. The
Director of Academic Health Sciences explained that this was a standard
identified by the Care Quality Commission and that it reflected an
allowance for the volume of staff turnover in the organisation.
The Director of Human Resources felt that the requirements for statutory
and mandatory training were well defined and it was therefore a cultural
issue of tolerance of non‐compliance that needed to be tackled.
The Deputy Chief Executive reminded Board members that one of the
important principles of the IPF was that the same set of information would
be available at all levels of the organisation. Work was continuing to deliver
this. The Chief Operating Officer supported this approach, giving the
example of VTE screening where the availability of daily data at a local level
had helped to identify recording problems in some areas which were now
being addressed.
The Chairman thanked all those involved in producing the new report and looked
forward to its continued development in the period ahead.
(ii) Clinical quality and safety performance
The Medical Director and Chief Nurse introduced TB 16/13, the Quality and Safety
Report for January 2013, and highlighted the following issues:
There had been three Care Quality Commission (CQC) inspection visits since
the previous Trust Board meeting and a meeting with the CQC to discuss
Never Events. Verbal feedback had been received on the inspection visits
and the formal reports were awaited. A visit to Mile End Hospital had
identified some concerns in relation to staffing levels and mealtimes; a
follow‐up visit to the Ainslie Unit had identified some improvement but
more work to be done; and the verbal feedback on a visit to Barts which
had focused on cancer services had been positive.
Progress had been made on reducing the number of outstanding legacy
complaints and serious incident reports although this had not been as rapid
as originally planned. The revised target was to reduce these to zero by the
end of March 2013.
A consequence of the focus on closing legacy complaints was that
performance on current complaints had deteriorated.
A discussion of serious incident reporting to the Board was scheduled for
the next meeting of the Quality Assurance Committee.
11

TB 24/13
The report included benchmarking data on the Standardised Hospital
Mortality Indicator (SHMI) as previously requested by the Board. Mortality
data were also increasingly available at specialty level. In response to
reported cases elsewhere in the country, the Medical Director confirmed
that within Barts Health clinical coding was a matter which was left solely to
the decisions of clinicians and professional coders.
The Deputy Chief Executive felt that it would be helpful to gain a better
understanding of the key drivers of the Trust’s low overall mortality rate
and also asked whether mortality data were available for each of the
hospital sites. The Medical Director explained that hospital site data were
not published but to the best of his knowledge none of the legacy trusts had
overall mortality rates in excess of 1.00. In relation to understanding the
reasons for the Trust’s low mortality rate, information had been circulated
to CAGs on SHMI by coding group and Dr Foster had been commissioned to
provide the Trust with additional information for those groups with a
particularly low SHMI to assist the analysis of the reasons for good
performance. It was agreed that an update on this work should be
provided to the Trust Board in around three months’ time.
Action: Chief Information Officer and Medical Director
There had been 11 MRSA bacteraemias in the year to date. Despite
exceeding the annual threshold, if this was the end point for Barts Health in
2012/13 it would represent an improvement of around a third compared
with the 2011/12 position across the legacy trusts. The Medical Director
observed that there had recently been increased medical engagement in
root cause analysis of MRSA and C. difficile cases.
The following points were made in discussion:
The Vice Chairman asked about the ambition on pressure ulcers. The Chief
Nurse explained that it was the Trust’s aim to eliminate all avoidable
pressure ulcers and that the current trajectory represented a reasonable
step towards this. Some pressure ulcers were unavoidable given the acuity
and dependency of patients being admitted to the Trust’s hospitals and the
fact that the community services operated by the Trust were often caring
for chronically ill patients and those in the late stages of life.
Ms James asked how the Red rated indicators from the CQC’s Quality and
Risk Profile, as listed on page 17 of the report, were tracked. The Chief
Nurse explained that these were all responses to questions from the
national patient and staff surveys which had been previously reported to
the Board. They were therefore part of the survey action plans which were
kept under regular review. The timetable for survey reporting was due to
be discussed at the next Quality Assurance Committee meeting.
The Trust Board noted the report.
12

TB 24/13
(iii) Financial performance
The Chairman noted that the Finance and Investment Committee was due to meet
in the next week and had therefore not had the usual opportunity to review the
financial position in detail.
The Chief Financial Officer introduced TB 17/13, the finance report for January
2013, and highlighted the following points:
The Trust continued to forecast an overall breakeven position for the year
end but the margins within which the Trust was currently operating, with a
year to date surplus of just £200,000, meant that it would not be possible to
confirm breakeven until after completion of the annual audit of the
accounts.
There remained a shortfall against the current year’s CIP target which
would add to the following year’s already significant challenge.
PricewaterhouseCoopers LLP had been engaged by the Trust to help CAGs
and corporate directorates to identify CIP opportunities for 2013/14 and
beyond. This work included assessing the robustness of CIP plans and
undertaking quality impact assessments. Progress would be reviewed at an
event the following day involving senior clinical leaders and an update
would be provided to the Finance and Investment Committee on 13 March
2013.
The draft capital programme would be presented to the Finance and
Investment Committee in April. From 2013/14, the affordable level of
capital expenditure would be significantly lower than in previous years,
necessitating some difficult decisions on what could and could not be
funded.
The following points were made in discussion:
Ms James asked about PricewaterhouseCoopers’ approach to undertaking
benchmarking against other trusts. The Chief Financial Officer explained
that they were adopting a sophisticated approach which took casemix and
volumes at specialty level and compared the specialty to organisations with
a similar casemix and volumes. PwC were also able to access data on the
clinical outcomes delivered by the comparator organisations.
The Chief Operating Officer noted that the meeting with clinical leaders the
following day would spend a significant amount of time reviewing the
benchmarking approach and addressing any concerns in order to gain the
confidence of clinical teams in the benchmarking data.
13

TB 24/13
The Chief Executive observed that the initial benchmarking work indicated
that there were significant CIP opportunities. This was positive. However,
it was important not to become overly focused on the detail of the
benchmarking data at the expense of putting efforts into translating the
opportunities into robust and implementable schemes. The challenge of
delivering the scale of CIPs required should not be underestimated,
particularly with new leadership teams.
The Chief Executive also emphasised the importance of combining a focus
on CIP delivery with maintaining a tight control environment. While he
believed that there was an adequate policy framework in place, including
Standing Financial Instructions and a Scheme of Delegation, he was
concerned about compliance. It was essential that managers ensured that
individuals were clear about and complied with their responsibilities within
the control framework.
Ms Whitaker sought confirmation that the year to date financial position
showed an adverse variance of £6.6 million to the original budget. The
Chief Financial Officer confirmed that this was the case. When the original
budget was set, it had been planned to have a cumulative surplus of £6.7
million at Month 10 but the actual figure was now just £0.2 million.
The Vice Chairman questioned whether it was realistic to expect CAGs to
have robust and deliverable CIP plans in place within the next six weeks,
particularly given the current reorganisation of the CAGs. The Chief
Financial Officer noted that the focus of the external support would now
shift from data gathering and analysis to working with CAG teams to
develop detailed plans. He also reminded Board members that corporate
directorates needed to lead by example and had to deliver savings as large
as those for the CAGs.
The Vice Chairman asked for further details as to how the proposed CIP
schemes would be reviewed to provide assurance that they would not
adversely impact on the quality and safety of patient care. The Chief
Financial Officer explained that, following CAG review, an independent
panel would review each scheme on behalf of the Medical Director and
Chief Nurse as part of a seven stage process in signing off a scheme as being
Green rated for implementation. The Chief Nurse added that it was also
essential to ensure that there was a robust approach to ongoing monitoring
of the impact on quality and safety of schemes as they were implemented.
The Safety Net tool would provide one element of this although for some
schemes there may be other specific metrics which were identified for
monitoring. Further details of the approach to assessing the quality and
safety impact of CIP schemes would be provided to the Quality Assurance
Committee at its meeting on 13 March 2013.
14

TB 24/13
The Vice Chairman asked to what extent CAGs had been able to focus on
starting to identify savings opportunities for years 2 and 3. The Chief
Financial Officer said that the current focus was on identifying CIPs for
2013/14 but CAGs would also be asked within the next month to outline
year 2 and 3 opportunities.
The Trust Board noted the report and agreed that any further points would be
covered at the Finance and Investment Committee meeting the following week.
29/13 FRANCIS INQUIRY
The Chief Nurse introduced TB 18/13, a paper outlining the Trust’s initial response
to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, and
highlighted the following points:
This was likely to be one of the most important reports that any Board
member would read in their career in the NHS and there should be a clear
expectation that the Board would return to the key themes and findings of
the public inquiry on a regular basis.
The learning from the failings in care at Mid Staffordshire had begun with
the publication of the first Francis inquiry report in February 2010 and the
Board had recently reviewed the actions taken in response, covering the
domains of standards, compliance, culture and compassion.
The key challenge going forward would be to embed the learning
throughout the organisation, from Board to ward. While the Executive
Team would be undertaking a review of the individual recommendations
from the public inquiry, the consensus of detailed discussions at the Trust
Executive and the Trust Management Board was that the Trust’s response
to Francis should focus on the key learning for the organisation rather than
the development of multiple action plans.
The paper outlined a set of proposals developed by the Trust Executive and
the Trust Management Board including holding ‘Learning from Francis’
conversations across the organisation; supporting every team to identify
the top three things they are going to do differently in the light of the
report; reporting back on progress against these commitments; reinforcing
the key messages of Francis through First Fridays, Clinical Fridays and Board
visits; allocating Board Seminar and Board Development Programme time
to reflecting on the specific learning for the Trust Board; strengthening and
triangulating feedback from Board ward and department visits and
spending dedicated Board time reviewing and discussing visits; and
continuing to embed the Trust’s values and behaviours.
The following points were made in discussion:
15

TB 24/13
The Chairman emphasised the need to maintain the learning from the
Francis report at the top of the Board agenda, not least through Board
members constantly seeking out opportunities to talk directly to patients,
relatives and staff about their experiences and concerns. In doing so, the
Medical Director encouraged the use of simple techniques such as asking
open rather than closed questions.
The Chief Financial Officer felt that the paper provided a very good
summary of the report and fully supported the proposed actions. Thinking
back to the patient story at the beginning of the Board meeting, he asked
what changes would be required to ensure that such a story was not
repeated in future. The Chief Nurse felt that the single greatest focus
should be on building teams which felt empowered to address concerns or
problems on the spot and to escalate rapidly if necessary to secure
appropriate resolution. The Medical Director agreed, adding that it would
also be important to hold people to account for failing to raise concerns.
The Chief Executive suggested that the Board needed to develop a clear and
consistent message about the key priorities for every member of staff in the
organisation, focused on standards, values, accountability, engagement and
visibility. These should be constantly emphasised by Board members and
leaders in the organisation.
Ms Whitaker supported the approach outlined in the paper and suggested
that sharing and celebrating examples of people demonstrating effective
behaviours could be very powerful.
The Trust Board approved the approach and specific proposals set out in the paper
and agreed that it should review progress against the agreed actions on a regular
basis at both the Trust Board and the Quality Assurance Committee.
30/13 STAFF SURVEY 2012
The Director of Human Resources introduced TB 19/13, a report on the results of
the 2012 staff survey, and noted the following points:
Both the patient story and the paper on the Francis report provided
important and helpful context to discussion of the staff survey results.
The 2012 staff survey was the first to be conducted for Barts Health and
would therefore act as a baseline for measuring future progress. The Board
was grateful to the 5,000 members of staff who had taken the time to
complete the survey.
16

TB 24/13
The overall picture was one of being close to the national average, although
there were a few questions where the Trust was a relatively high performer
and a number where the Trust was among the lowest performers.
Corporate directorates, with the exception of Corporate Affairs and Nursing
and Governance, had generally poor results. While this might partly reflect
the fact that corporate functions were being restructured at the time of the
survey, it indicated that there was significant work to be undertaken to
build capability and confidence in corporate areas.
The paper sought to map the staff survey results to the four key levers or
enablers of staff engagement which the Board had previously discussed. A
potential fifth enabler was team working or ‘teamship’.
The final section of the paper outlined the proposed priority areas for
action. A number of these were already being progressed, such as the Barts
Health Improvement System which was due to be discussed by the Board in
April, leadership development work and the development of a new
performance appraisal system. However, there were other areas where
further consideration was needed on how to address the findings of the
survey, for example in relation to workplace stress and bullying, harassment
and discrimination. Of particular concern were the results that showed that
BME staff in the Trust were more motivated than other staff groups but felt
less able to progress.
The following points were made in discussion:
Ms James asked the Director of Human Resources whether he was
confident that the monthly Pulse surveys would generate a good response
rate. The Director of Human Resources said that he believed that they
would. The first Pulse survey had run for a week and generated 400
responses from a sample of 2,000 members of staff. However, he was
concerned that these surveys were being conducted by email and may
therefore not be effective in reaching certain groups of staff. This would be
given further consideration.
The Chief Executive said that he had found paragraphs 16‐18 of the paper
very powerful in relation to how to maintain the motivation of the already
engaged group of staff. He suggested that consideration should be given to
more frequent opportunities to reward staff and celebrate success,
including at local level. Equally, it was important to have early and frank
conversations with staff who did not want to be engaged.
The Trust Board noted the survey results, supported the planned actions described
in the paper and invited the Director of Human Resources to propose a process for
regular feedback, including through the Integrated Performance Report.
Action: Director of Human Resources
17

TB 24/13
31/13 MIXED SEX ACCOMMODATION
The Chief Nurse introduced TB 20/13, a paper on mixed sex accommodation
compliance to inform the required annual declaration of compliance.
It had been a difficult assessment to make given the challenges which had been
discussed earlier in the meeting in relation to meeting the critical care step down
requirements of the mixed sex accommodation standards. However, taking the
year as a whole and the fact that all hospital sites were compliant outside critical
care, it was proposed that the Trust should declare overall compliance as at 1 April
2013. It was understood that such an approach would be consistent with that of
other London trusts which were also struggling on the critical care step down
element.
The Trust Board approved making the declaration of compliance as at 1 April 2013
as set out at Appendix 1 of the paper, subject to inclusion of a specific reference to
the challenge in critical care in meeting the step down requirements.
Action: Chief Nurse
32/13 BOARD ASSURANCE FRAMEWORK
The Director of Corporate Affairs and Trust Secretary introduced TB 21/13, a paper
describing the approach taken to the development of the Board Assurance
Framework (BAF) for Barts Health and seeking the views of Board members on the
proposed risks for inclusion on the BAF.
He explained that the development of the BAF had awaited the completion of the
initial exercise to merge and cleanse the Trust risk register. This had enabled a
‘bottom up’ approach to be adopted to derive BAF risks based on the high risks on
the Trust risk register as grouped by strategic objective. The outputs had then
been tested in discussions with Executive Directors to introduce a ‘top down’
element. The paper included a proposed shortlist of BAF entries together with
potential longlist entries. The paper also included two examples of worked up BAF
entries.
The following points were made in discussion:
The Director of Human Resources questioned whether sufficiency of
staffing should be included as a separate entry on the BAF. The Chief
Executive felt that this was an issue to be managed rather than a risk for the
BAF.
The Deputy Chief Executive noted that the BAF was in many ways as good
as the Trust risk register and there was a strong focus on improving the
quality of risk identification and recording via the work of the Risk
Management Committee.
18

TB 24/13
The Trust Board:
Noted the update and approved the approach to the development of the
Board Assurance Framework.
Agreed to provide comments on the proposed risk entries to the Director of
Corporate Affairs ahead of the next Trust Board meeting where a full
version of the BAF would be presented for approval.
Action: All Board members
33/13 USE OF THE SEAL
The Director of Corporate Affairs and Trust Secretary introduced TB 22/13, a paper
seeking Trust Board ratification of the use of the Seal on the occasions listed.
The Trust Board ratified the use of the Seal.
34/13 ORAL REPORTS FROM BOARD COMMITTEES
(i) Audit and Risk Committee
The Vice Chairman reported that the Audit and Risk Committee had met on 20
February 2013. The Committee had discussed salary overpayments,
implementation of the Whistleblowing policy, confirmation that the Trust had not
made inappropriate use of confidentiality agreements, the Board Assurance
Framework and a number of internal and external audit reports.
(ii) Public Health and Equalities Committee
Ms Whitaker reported that the Public Health and Equalities Committee had met on
20 February 2013. The Committee had welcomed the Trust’s new Director of
Public Health and had discussed the north east London convergence programme,
ways of strengthening liaison with the GLA, local authorities and Health and
Wellbeing Boards, the public health vision, local employment initiatives and ways
of promoting healthy living to staff.
35/13 SINGLE OPERATING MODEL
The Trust Board reviewed and retrospectively approved the February 2013 Single
Operating Model (SOM) self‐certification return reporting December 2012 data.
36/13 ANY OTHER BUSINESS
There was no other business.
19

TB 24/13
37/13 QUESTIONS FROM MEMBERS OF THE PUBLIC
Questions and comments were received from members of the public and the
questions were duly answered by members of the Trust Board as follows:
Concern was expressed that patients and patient groups were not being
adequately consulted by London Cancer on the emerging proposals for
specialist cancer provision in north east and north central London. The
recommendations on urological cancer appeared to involve a diminution of
choice and accessibility and a number of patient groups would be pressing
for a full statutory consultation. It had also been suggested that the Trust
had been pre‐occupied by the merger and had taken its eye off the ball on
specialist cancer services.
The Chief Executive explained that the decision on whether there would be
formal consultation would be one for specialist commissioners in London.
The London Cancer tumour groups charged with making proposals were
clinically led and their proposals would be reviewed by an independent
body which would present recommendations to commissioners.
It appeared that a large part of the cancer services at Barts were being
given away to competitors. This raised questions as to how the Trust would
manage the resulting loss of income, what the impact would be on patient
access, how it would be possible to maintain a seamless care pathway for
cancer patients and what cancer services would ultimately remain on the
Barts site.
The Chief Executive noted that the Integrated Cancer System (ICS)
proposals were not expected to impact on the location of the vast majority
of cancer services at Barts and there was therefore a clear expectation that
the investment in the Barts Cancer Centre would continue to derive strong
value and Barts would continue to have a key role to play in providing
cancer care for the ICS population of some 3 million people and the
Academic Health Sciences Network population of around 6 million people.
There might be some changes in how income flowed into the system
without a relocation of services. But for any services that did relocate,
there would be a loss of both income and cost and the Trust was currently
assessing the potential scale of these for the specialist areas where there
was the potential for relocation. It was also important to recognise that
any changes would take time to implement and there would therefore be
time for provider organisations to manage the impact.
20

TB 24/13
On access, the Chief Executive noted that London Cancer was seeking to
take decisions on the long‐term configuration of services for the benefit of
patients. He believed that The Royal London was well placed
geographically to serve the populations of north east and north central
London and Essex.
In terms of care pathways, the Medical Director explained that the focus
would be on delivering the best possible outcomes for patients by
concentrating the surgical element of the pathway in a smaller number of
centres but providing the rest of the care locally, including working with
GPs on prevention. This had the potential to save a large number of lives.
The Chief Executive added that he saw a clear, long‐term role for the Barts
site centred around leading edge cardiovascular and cancer services (both
as part of wider systems) and also a strong heritage focus.
Questions were raised as to why the control weaknesses referred to during
the meeting had not been tackled earlier in the year and whether the Trust
would be waiting for the outcome of the NHS Medical Director’s review of
emergency medicine before redesigning the Trust’s own emergency
medicine pathway.
On control issues, the Chief Executive noted that the new clinical
management structure had only been in place for around five months.
Progress was being made on addressing control weaknesses but would take
time as information requirements were addressed.
On service redesign and reconfiguration, the Chief Executive explained that
all such changes would be approached from the perspective of quality of
care. Some changes might be possible in the relatively short term while
others would take longer to deliver. The Medical Director noted that the
review being undertaken by the NHS Medical Director was based on the
methodology used for the earlier review of emergency care by the Medical
Director of NHS London. Based on the London work, CAGs were reviewing
how they worked together to deliver the best standards of emergency care
in order to achieve the best possible patient outcomes.
38/13 DATE OF NEXT MEETING
The next meeting of the Trust Board (Part 1) in public would be held on
Wednesday 10 April 2013 at 11.00 in the Main Lecture Theatre, Education Centre,
The London Chest Hospital, Bonner Road, London E2 9JX.
21

TB 24/13
39/13 RESOLUTION
The Board resolved that representatives of the press and other members of the
public be excluded from the remainder of this meeting having regard to the
confidential nature of the business to be transacted, publicity on which would be
prejudicial to the public interest (section (2) Public Bodies (Admissions to
Meetings) Act 1960).
Signed ……………........................................
Dated …………………………………
Ian Walker
Director of Corporate Affairs and Trust Secretary
Barts Health NHS Trust
020 7092 5212
22

TB 24/13
ACTION LOG
Trust Board meeting (Part 1): 6 March 2013
Page Action Lead Status update
no.
2 Mental health ‐ provide an update on work
with the mental health trust at the next
meeting.
Chief Operating
Officer
Completed – matter
arising on April 2013
Board agenda.
6 Patient story – there would be further Chief Nurse
Completed.
discussion at the Quality Assurance
Committee meeting the following week as
part of the item on learning disabilities.
The outcome of this discussion would then
be reported back to the Board.
8 Chief Executive’s report ‐ a paper providing
details of the Information Governance
Director of Corporate
Affairs and Trust
Completed ‐ on April
2013 Board agenda.
Toolkit submission would be presented at
the next meeting of the Trust Board.
Secretary
9 IPF – circulate CCP compliance details
following Board meeting.
Deputy Chief
Executive
Completed – circulated
on 11 March 2013.
10 IPF ‐ a separate session would be arranged
with the Chief Information Officer to
increase familiarity with the IPF.
12 SHMI ‐ an update on work to understand
reasons for low SHMIs should be provided
to the Trust Board in around three months’
time.
17 Staff survey ‐ propose a process for regular
feedback, including through the Integrated
Performance Report.
18 Mixed Sex Accommodation compliance
declaration – include a specific reference to
the challenge in critical care in meeting the
step down requirements.
19 BAF ‐ provide comments on the proposed
risk entries to the Director of Corporate
Affairs ahead of the next Trust Board
meeting
Trust Board meeting (Part 1): 6 February 2013
23
Director of Corporate
Affairs
Medical Director and
Chief Information
Officer
Director of Human
Resources
Chief Nurse
Completed – arranged
for Board Seminar on
10 April 2013.
Scheduled for July
2013 Trust Board
meeting.
Process to be
confirmed.
Completed and
published.
All Board members Completed –
comments received
incorporated into BAF
on April 2013 Board
agenda.
Page Action Lead Status update
no.
4 Patient story ‐ prepare a briefing on the
current arrangements and future plans for
volunteering to be brought back to the
Board in three months’ time. Also look at
how staff are encouraged to volunteer
outside the Trust in the local community.
Chief Nurse
Scheduled for May
2013 Board meeting.

TB 24/13
9 Quality and safety – consider reporting on
complaints per 1,000 beds.
10 Quality and Safety – Quality Assurance
Committee to review ‘Red’ rated survey
indicators from the latest CQC Quality and
Risk Profile.
10 Quality and Safety – provide an update to
the Quality Assurance Committee on the
timetable for reporting on surveys.
13 Royal College of Surgeons – confirm by
when it will be possible to report on
emergency surgery waiting times across the
whole Trust.
16 Safeguarding – issue a reminder to all staff
on security arrangements and challenging
visitors to wards and clinical areas.
Chief Nurse
To report back at next
Board meeting.
Chief Nurse Completed ‐
considered at March
2013 QAC meeting.
Chief Nurse Completed ‐
considered at March
2013 QAC meeting.
Medical Director Outstanding.
Chief Nurse and Chief
Operating Officer
Completed.
Trust Board meeting (Part 1): 28 November 2012
Page Action Lead Status update
no.
5 Patient story – draw up an action plan to
address both systemic and behavioural
Chief Operating
Officer and Chief
Scheduled for May
2013 QAC meeting.
issues. Patient to review action plan and
progress to be reviewed by the Quality
Assurance Committee in three to four
months’ time.
Nurse
7 King George Ilford renal satellite unit ‐
provide a report in due course on the
operation of the new unit.
Chief Operating
Officer
Scheduled for summer
2013.
16 Patient food ‐ taste patient food at a future
Board meeting.
Trust Board meeting (Part 1): 31 October 2012
Chief Operating
Officer
Completed – patient
food being served at
April 2013 meeting.
Page Action Lead Status update
no.
7 Chairman’s report – identify ways of sharing
positive news and developments.
Chief Nurse and
Director of
Currently under
review.
Communications and
Engagement
8 Circulate GMC report to Board members
when available.
Director of Academic
Health Sciences
Awaiting final report.
24

TB 24/13
Trust Board meeting (Part 1): 26 September 2012
Page Action Lead Status update
no.
6 Governance arrangements with Director of Corporate Will maintain on the
commissioners ‐ this should be included
explicitly on the action log.
Affairs
action log until
resolved.
Trust Board meeting (Part 1): 25 July 2012
Page Action Lead Status update
no.
3 Patient story ‐ the Chairman proposed that
the Board should discuss the Trust’s
Chief Operating
Officer and Chief
Completed – feedback
from COO at April 2013
relationship with local mental health Nurse
Board meeting.
services during the autumn.
8 Chief Executive’s Report – raise issue of
Charity name with the Barts and The
London Charity.
Chairman
Completed – outcome
reported in April 2013
Chief Executive’s
report.
Trust Board meeting (Part 1): 30 May 2012
Page Action Lead Status update
no.
8 Serious Incidents – consider inviting Chief
Executive of Salford Royal NHS Foundation
Trust to speak to the Board about patient
Chairman In progress –
discussing dates for a
wider Trust event.
safety culture.
15 Trust objectives – present advice to the
Board on a Trust improvement system.
Trust Board meeting (Part 1): 25 April 2012
Chief Executive and
Deputy Chief
Executive
Completed – on April
2013 Board Seminar
agenda.
Page Action Lead Status update
no.
15 New Hospitals Programme ‐ the New Deputy Chief Completed.
Hospitals benefits realisation programme
was being refreshed and would be brought
to the Trust Board in the next two months.
Executive and
Development Director
15 New Hospitals Programme ‐ produce a
consolidated estates report covering all of
Barts Health from the third quarter of the
year.
Director of Strategy
and Chief Operating
Officer
Now scheduled for
2013/14 Q1.
25

Report to the Trust Board: 10 April 2013 TB 25/13
Title
Sponsoring Director
Author(s)
Purpose
Previously considered by
Chief Executive’s Report
Chief Executive
As above
To report on key issues and developments
Not applicable
Executive summary
The report sets out current key issues for the Trust Board to note and discuss.
Related Trust objectives
All objectives
Sub‐objectives
Risk and Assurance
Related Assurance
Framework entries
Legal implications/
regulatory requirements
n/a
n/a
None identified.
Action required by the Board
The Trust Board is asked to note and discuss the issues raised in the report.
1

TB 25/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
CHIEF EXECUTIVE’S REPORT
1. Francis Report
Conversations are continuing across the organisation about how we respond to the
findings and recommendations of the Francis report, with a particular focus on
values, culture and leadership. Since we last met, the Government has published its
initial response to the report. A copy has been circulated to Board members.
2. Operational performance
The main areas of concern remain emergency care performance (at The Royal
London and Whipps Cross), mixed sex accommodation breaches at The Royal London
and 62 day cancer pathways (focusing on uro‐ and gynae‐oncology) and VTE
assessment (as the target moves to 95% from 1 April) across most of our sites. We
are on track to deliver the RTT position from Q1 and have maintained the
improvement in MRSA. Whipps Cross recently passed the one year mark with zero
MRSA bacteraemias.
On financial performance, there was a small surplus at the end of Month 11
compared to a target surplus of £5.7 million. We continue to forecast breakeven for
2012/13.
Looking forward, from a forecast £50 million CIP delivery at year end (an undershoot
of £14 million on the 2012/13 target) we face a requirement to increase CIP delivery
by around 50% for 2013/14. We must also further strengthen financial information
and controls in the relatively new CAG management structures.
3. Property Transfers
As part of the NHS reforms, a number of properties have been transferred to the
Trust from 1 April 2013. These include the majority of the Mile End Hospital site and
a small number of GP surgeries ‐ Steels Lane, Spitalfields Health Centre, St Peter’s
Street and Leopold Street.
4. Sir Ludwig Guttmann Health and Wellbeing Centre
Following our success in the pre‐qualifying stage, we have submitted our bid to
provide primary care services from the health and wellbeing centre on the Olympic
park site. The shortlisted bidders will be announced in mid April and the final
selection will be made in early May.
2

TB 25/13
5. Newham Urgent Care Centre (UCC)
The Newham UCC, located next to the Newham A&E department, is operated by East
London NHS Foundation Trust. Commissioners are retendering the service which will
stream patients to appropriate services and reduce pressure on the A&E department.
With the Board’s support, we will bid to run this service in partnership with a primary
care team in Newham. The bid will be submitted by 7 June, the preferred bidder will
be selected by 11 July and the service is due to begin operating from 13 November.
6. Baby Friendly accreditation
A partnership between The Royal London Hospital, Tower Hamlets public health and
Tower Hamlets council has become the first in London to be awarded the prestigious
Baby Friendly Initiative accreditation from UNICEF (United Nations Children's Fund)
for implementing recommended standards to promote and sustain breastfeeding in
both hospital and community settings.
7. Royal London Renal team
The Renal Supportive and Palliative Care Team at The Royal London and St Joseph’s
Hospice in Hackney have won an award from The International Journal of Palliative
Nursing and Macmillan Cancer Support for caring for end‐of‐life kidney patients. The
award recognises their work on Symptom Control Guidelines.
8. Maternity services at King George Hospital
The NHS North East London and the City Board decided last month to move forward
with the planned transfer of maternity birthing services from King George Hospital,
Ilford. Barts Health has worked closely with commissioners and colleagues at
Barking, Havering and Redbridge University Hospitals NHS Trust and Homerton
University Hospital NHS Foundation Trust over the past year to enable the transfer of
antenatal, birth and post natal services for around 1,700 women. For Barts Health,
this has included increasing capacity at Newham, including opening the Barking
Birthing Centre.
9. National Clinical Director appointments
I am delighted to report that Director of Academic Health Sciences, Professor Jo Martin,
has been appointed as the new National Clinical Director of Pathology Services at the
Department of Health from April 2013, and Consultant Gastroenterologist and
Hepatologist, Dr Michael Glynn, has been appointed as the new National Clinical Director
for Gastrointestinal and Liver Diseases.
3

TB 25/13
10. Barts Charity
The Barts and The London Charity has decided to adopt ‘Barts Charity’ as its name.
As Board members are aware, we are in the process of transferring the Newham and
Whipps Cross charitable funds from the corporate trusteeship of Barts Health NHS
Trust to Barts Charity. The target date for the transfer is 1 May.
11. Joint application for British Heart Foundation (BHF) Centre of Excellence
Unfortunately the joint application (Barts Health/QMUL/UCLH/UCL) for BHF Centre of
Excellence funding was not successful this time, but related grant applications have
been requested in recognition of the potential for major steps forward in
cardiovascular research in the partnership, and this will help pump prime further
research funding and development.
Peter Morris
Chief Executive
April 2013
4

Report to the Trust Board: 10 April 2013
TB 26/13
Title
Sponsoring Director
Author(s)
Purpose
Previously considered by
Integrated Performance Framework (IPF) –
Februaryy 2013
Chief Information Officer
Chief Information Officer and
Deputy Director of Informationn
To summarise the organisation’s in‐month and year to
date performance to
the end of February 2013.
Trust Management
Board, 9 April 2013
Executive summary
The performance
report is shown in its new format. A parallel report on
Quality and Safety
is also presented.
Regulatory performance remains of concern. The deterioration since s
October 2012 was noted last month. There is a clear plan to grip each off the
indicators and drive improvement.
VTE performance has recovered to meet
the requirement in February.
A training session
has been set for
understand this report.
members
of the Board to further
Work on the Partners’ View within the report is progressing.
Related Trust objectives
All Trust objectives.
Legal implications/
regulatory requirements
None
Action required by the Board
The
Trust Board is asked to: t
Note performancee for February 2013.
Comment on format, inclusions and exclusions to t support
development of this report.
the continued

TB 26/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
INTEGRATED PERFORMANCE FRAMEWORK
CONTEXT
1. In April 2012 the new organisation’s Board committed itself to a series of
principles about performance management. These were evidently intended
to enshrine a different culture within Barts Health. In particular, we sought
to confirm that information about performance would travel transparently
from ward to boardroom, and that what was meant by performance in the
organisation would include in equal measure safety and quality, workforce,
finance, operational minimum standards, education, research and
development.
2. In December 2012, the Board’s Quality Assurance Committee accepted the
recommendation that the Integrated Performance Framework should replace
other forms of data routinely presented to the Board. We agreed that our
focus would be in eight areas:
KEY performance
indicators………………
What do our patients think of us?
What do our staff and students think
of us?
What do our regulators think of us?
What do our partners think of us?
Performance indicators
about…………….
Quality, safety and innovation
Workforce information
Efficiency and productivity
Research, education and
communication
3. The task of constructing this approach was never underestimated and a
substantial amount of work remains to be done to complete the promise.
The substantial work is in five key elements:
i. Ensuring that the data is available not less frequently than monthly,
and in some cases weekly, for use by frontline leaders and with
availability to the Executive and the Board. Wherever feasible, this
dataflow would be automated.
ii. Ensuring that the data quality of the information is understood, and
is, in time, uniformly of high standard. This task is complicated by the
still merging nature of some indicators’ supporting data systems.
2

TB 26/13
iii. Agreeing what success would be for an indicator, especially in those
areas where no national measure is prescribed. The threshold needs
to be agreed there not later than the end of March for the 2013/14
annual plan, which will be supported by this IPF for measurement.
iv. Creating a rhythm of performance assurance by CAG, by service
group, by ward or department across our new organisation. A system
by CAG has been in place for some months. Looking into 2013/14 it is
important we set a trajectory by which this can deepen, and of course
can be matched by the performance assessment of each corporate
function. Performance management based on managing the opinions
of others – our KPIs – is a new and perhaps different skill to be
mastered.
v. While maintaining data availability and individuals’ capability to query
data sources themselves, beginning the process of ruthlessly retiring
other reports which show information herein either in a different
format or at a different time period.
REPORT
4. The report provides data in a broadly standard format across six of the eight
areas. The exception is the partnering domain where there is a need now to
grip how we plan to track reputation. Where the format is non‐standard it is
because the data is not yet available with the regularity needed to make a
graph over time useful.
5. The data provided takes members to the most recent information – from
February 2013 (month 11). How far back the data displayed goes relates to
availability and a measured view of past data quality. However, it does not
indicate that a full data quality review of the current data has been
completed.
6. The RAG system is deliberately rudimentary. Above the line performance is
green. Below the line performance is red. A future iteration can consider
what portion of green performance should be considered fragile and amber.
Perhaps brutally, where a composite judgement is needed across areas or
indicators, the lowest performing judgment governs the colour shown.
7. The report includes some description of the data. This is provided by the
relevant Executive lead. We need to discuss further (i) how that is assured
across all domains and (ii) how other qualitative information and opinion is
not lost from our reporting. In particular this is a valued part of the Quality
and Safety report.
3

TB 26/13
WHAT DOES THE REPORT TELL US?
8. We have far further to go in systematically collating feedback monthly from
staff, students, patients and partners. Nonetheless we are now able to do
that for staff (through our new monthly pulse survey) and for patients (not
only through RTF but now through the Friends and Family test).
9. We need to set some stretching goals in the workforce, efficiency and quality
performance indicators, which give us all a clear indication of what we are
striving to achieve. Without those expectations, our performance
conversation will focus on whether a data point has gone up or down.
10. While our annual staff survey provided some positive indications of
performance, and whilst we are not an outlier for patient opinion, we need
to actively seek to manage the underlying valence issues if we are to see
these two Key performance indicators move towards green. There is a real
opportunity here for teams to learn from each other: CAG to CAG, service to
service, ward to ward.
11. Our Regulatory performance in February has not yet recovered from the
deterioration reported in quarter 3. After two quarters of Department of
Health indicator compliance, we are now in the performance under review
category. Likewise our SOM is not green. We have indicators – cancer waits
and MRSA – which have not been compliant for three successive quarters.
We are, however compliant, with our Cooperation and Competition Panel
(CCP) obligations. VTE has shown recovery in February 2013.
12. A key question for the Trust Board to consider is the need for any preceding
dialogue in addition to that contained within the report itself.
Luke Readman
Chief Information Officer 5 April 2013
4

BARTS HEALTH NHS TRUST
February 2013 Integrated Performance Report
Luke Readman
Chief Information Officer
26 th March 2013

BARTS HEALTH INTEGRATED PERFORMANCE
HOW ARE WE DOING?
2

What do staff & students think?
Workforce
Overall; Permanent staffing is at 89.5%, down from 89.8% in Month 10. In some cases,
vacancies are being held in order to secure a return to budgeted pay spend this. Focus on our
time to hire has led to a median rate of 12.8 weeks at 22 nd March from 17 weeks at end
January. A workforce planning process has been agreed and completed first for ACCU. This
includes advanced recruitment authorisation in high volume areas.
Bank & Agency; Of concern, 26% of filled temporary staffing being via agencies. ECAM
remains the highest spender in temporary staffing, accounting for 17.44% of its pay budget in
month (15.95% YTD). Driven by unfunded beds, reductions will be seen as these beds are
closed. High spend within Surgery also remains and, Trauma and Orthopaedics; driven by
additional clinics inpatient list at RLH.
Turnover; Turnover is stable at 10.8%. Attributed to limited opportunities for career
progression. Turnover of staff appointed within the last 12 months is high in Cardiovascular
at 35.1% and Surgery at 24.9%. Cardiovascular is introducing a 6 month retention survey to
better understand how new staff have settled into their roles. In Surgery within ITU at the
RLH are high levels of vacancies &opportunities for promotion elsewhere and a lack of
support and development.
Sickness Absence; Highest are Women’s Health and Ambulatory. Across both, efforts are
being prioritised for management action via the new process. Occupational Health capacity
to support this is being increased.
What do our partners think?
Communication, R&D and Education
Work is underway with the Director of Communications to define an approach to
obtaining regular feedback from partners. A number of options are being explored.
Research and development metrics are presented showing overall good
performance, although expenditure and income recovered are down.
Executive Summary – Feb
What do our patients think?
Quality, Safety and Innovation
SHMI is unchanged at 0.84 which is a lower than expected for the Trust.
There were 33 SIs raised in the month
There was 1 case of MRSA bacteraemia for a patient at Newham (NUH
There were 8 cases of C. difficile infection across four sites but no severe harm falls
One patient in the community had 3 separate grade 4 pressure ulcers and 2 grade 2
One Never Event was reported but the care episode in which it occurred was in January 2013,
this was a retained swab associated with an obstetric delivery
84 incidents have exceeded their investigation completion dates. These comprise of legacy
incidents (12) and incidents raised since 1/10/12 (72). A plan is in place. While clearing the
oldest incidents more recent SI cases become overdue within the month. The CAGs with
central support are working together to resolve these.
CAS Alert performance indicates there are no alerts currently overdue for action.
34 legacy complaints outstanding. The central and CAG teams are working to resolve these.
The Friends and Family Test (FFT) continues to be rolled out across the organisation and is on
target for all wards/departments to be asking the FFT question by end of February, prior to
national implementation in April 2013. Response rate is currently disappointing
CQC activity in February and early March included 2 new unannounced compliance reviews
one at St Bartholomew Hospital (SBH) and the other Mile End (MEH). The CQC also carried
out a follow up visit to Intercare Services at Whipps Cross (WX) in March.
What do our regulators think?
Efficiency and Productivity
Headline regulatory performance in month reflects the difficult position although VTE has
come back in line in February. Key issues are
Cancer 62 day standard; The backlog of cases to be treated is reducing & we plan to be back
on track in April 13‐we are delivering the recovery plan
18 week treatment standard; On plan to recover the admitted position from April 2013‐We
are delivering the recovery plan
Mixed sex accommodation breaches; We are outliers in terms of performance in London and
have put in place revised controls to improve the April 13 position
4hr emergency access; Now managed through the Emergency Care Board, there are several
work streams (Infants and young people, assessment model at Wx, admission, Length of stay
and discharge)
Infection control; Our current rate has improved on the position over the last year however
we remain with challenging targets next year
We are about to report Q3 performance against the CCP standards. We met those standards
overall in Q1 and in Q2. From 2013‐14 the CCP standards start to anticipate performance gains
arising from our merger, around provision of services such as chemotherapy locally, acute
care rotas and workforce distribution in paediatrics and acute oncology, and productivity gains
on length of stay and re‐admission rates where the Trust aims to achieve organisation wide
what we achieve in our best performing hospital.
3

What do our regulators think?
BH Level Summary
DH Score
Feb13
1.92
YTD
2.38
Q3
2.42
Year to date
DH Monitoring Framework
DH
Scale 0
1 2 2.4 3
4
5
Q3
3.5
Q3 adjusted
4
GRR Score
GRR
Foundation Trust Single
Operating Model
Scale
0
1 2 3
4
5
GRR Score
Q3
2
FRR
Scale 1
2 3
4
5
Co-operation and
Competition Panel
Dashboard
Q1 Q2 Q3
provisional
Care Quality Commission
Compliance
compliant
4

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Patient Experience Real Time Feedback (RTF)
DH Friends and Family Test
A threshold has not yet been set
5

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Incidents, Serious Incidents and Never Events
6

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Saving Lives
7

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Falls (BH Quality Priority)
8

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Pressure Ulcers (BH Quality Priority)
Reference / Benchmark for Total Pressure Ulcers:
TBD per 1,000 OBD
9

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Maternity
*
* Note: validation of February data is not yet complete
10

Safety, Quality and Innovation
BH Level Detailed PI Tracking
Complaints
11

What do our regulators think?
BH Level Detailed KPI Tracking
18 weeks
Accident and Emergency
Cancer Access – Provisional Feb
12

What do our regulators think?
BH Level Detailed KPI Tracking
VTE, DTOC, MSA, Diagnostics
Infection Control
13

Efficiency, Productivity and Finance
BH Level Detailed PI Tracking
Inpatient Activity
Outpatient Activity
14

What do our partners think?
BH Level Detailed KPI Tracking
Work is underway with the Director of Communications to define an approach to
obtaining regular feedback from partners.
The following approaches are being considered:
• GPs – regular temperature checks
• CCG, CSUs and stakeholder groups – annual 360° feedback, regular
temperature check
• General - reputation tracker
15

R&D, Education and Communications
BH Level Detailed PI Tracking
R & D Financial Metrics
R & D Non-Financial Metrics
R & D Project Metrics
Actual YTD
Target
Forecast > target
Note: Only Four data points available in year
16

What do our staff and students think?
BH Level Detailed KPI Tracking
Staff Pulse Survey
NOTE: Baseline represents results from 2012 National Staff Survey engagement questions 17

What do our staff and students think?
BH Level Detailed KPI Tracking
Post Graduate Medical Trainees – 2012 Survey
Overall Mean of survey responses
Overall satisfaction
Access to education resource
Adequate Experience
-1.8%
+0.1%
-2.7%
+1.1%
Clinical Supervision
Education Supervision
Feedback
Handover
-0.5%
-4.3%
-5.0%
+1.9%
Induction
Local Teaching
Regional Teaching
Study Leave
-6.8%
+1.1%
-2.2%
-0.6%
Undermining
Work Load
-0.4% -4.8%
18

Workforce
BH Level Detailed PI Tracking
Statutory and Mandatory Training
19

Workforce
BH Level Detailed PI Tracking
Human Resources
*
* NOTE: Target (represented by------) is equal to 95% of budgeted establishment 20

Workforce
BH Level Detailed PI Tracking
Human Resources
* NOTE: Annualised sickness absence is calculated one month in arrears
21

Report to the Trust Board: 10 April 2013 TB 27/13
Title Quality and safety performance report ‐ Month 11
Sponsoring Director
Chief Nurse
Author(s)
Deputy Chief Nurse Quality Governance, Barts Health
Head of Governance Standards and Risk Management
Head of Patient Safety
Purpose
To report to the Trust Board on safety and quality indicators
and issues across all sites of Barts Health.
Previously considered by Trust Management Board, 9 April 2013
Executive summary:
This report provides a summary of performance against key quality and safety indicators
for SHMI, hospital acquired infections, falls, pressure ulcers, serious incidents, CAS alerts,
CQC assurance and patient feedback for Barts Health for Month 11, February 2013.
Risk and Assurance
Related Assurance
Framework entries
Legal implications/
regulatory requirements
This report provides assurance of the quality and safety of
services provided ensuring the best outcomes for patients.
This report provides assurance against the following CQC
Essential Standards:
Outcome 4 ‐ care and welfare of people who use the services
Outcome 8 ‐ cleanliness and infection control
Outcome 16 – assessing and monitoring the quality of service
Action required:
The Trust Board is asked to review and discuss 2012/13 Month 11 quality and safety
performance.
1

TB 27/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
QUALITY AND SAFETY PERFORMANCE REPORT – MONTH 11
INTRODUCTION
1. This report highlights performance against key quality and safety indicators for hospital acquired
infections, falls, pressure ulcers, serious incidents, CAS alerts and patient feedback across all of the
six Barts Health hospital sites. It also provides an update on recent CQC compliance review activity
and action planning.
Executive Summary for Month 11 (February 2013)
The SHMI is unchanged at 0.84 which is a lower than expected for the Trust.
There was 1 case of MRSA bacteraemia for a patient at Newham (NUH).
There were 8 cases of C. difficile infection across four sites.
There were no severe harm falls incidents.
One patient in the community had 3 separate grade 4 pressure ulcers and 2 grade 2 pressure ulcers.
There were 33 SIs raised in the month.
One Never Event was reported but the care episode in which it occurred was in January 2013, this
was a retained swab associated with an obstetric delivery.
There remain a high number of incidents (84) that have exceeded their investigation completion
dates. These comprise of legacy incidents (12) and incidents raised since 1/10/12 (72). A recovery
plan is in place but while clearing the oldest incidents more recent SI cases become overdue within
the month. The CAGs with the support of the central Patient Safety and Governance and Standards
Teams are working together to resolve these.
CAS Alert performance indicates there are no alerts currently overdue for action.
The number of legacy complaints outstanding (34) remains a concern for the organisation. The
central and CAG teams are working to resolve these.
The Friends and Family Test (FFT) continues to be rolled out across the organisation and is on target for all
wards/departments to be asking the FFT question by the middle of February, prior to national
implementation in April 2013.
CQC activity in February and early March included 2 new unannounced compliance reviews one at
St Bartholomew’s Hospital (SBH) and the other Mile End (MEH). The CQC also carried out a follow
up visit to Intercare Services at Whipps Cross (WX) in March.
2

PERFORMANCE AGAINST SELECTED INDICATORS
TB 27/13
Standardised Hospital Mortality Indicator (SHMI)
2. Barts Health’s SHMI at 0.84 places it 10 th position in a list of relevant healthcare organisations in
England which measure the indicator of deaths associated with hospitalisation. This is derived from
the last quarterly reported SHMI data for hospitals in England published in January 2013 for the
period up to June 2012.
3. Sixteen trusts had a ‘significantly lower than expected’ SHMI (between 0.71 and 0.87) indicating a
13% to 29% lower than expected mortality rate. Barts Health is in this group and is also the largest
organisation in the sample with 159,820 hospital cases. Given the size of Barts Health, there were
717 less deaths than expected in comparison for example to 424 at UCH with 64,972 cases.
Infection Control
Table 1: Summary of Barts Health Infection data at 28 February 2013
February
2013
Barts Health
Targets
Period
April
2012 to
March
2013
Non Trust
Apportioned
'Pre'
Trust
Apportioned
'Post'
3
YTD Non
Trust
Apportioned
'Pre'
YTD Trust
Apportioned
'Post'
Trust
Apportioned
'Post'
Date since
last +ve
Specimen
MRSA BC 8 1 1 10 11 06/02/2013 22
C difficile 99 1 8 43 84 18/02/2013 10
The London Chest
MRSA BC 6 * 0 0 0 2 14/07/2012 229
C difficile 59 * 0 0 0 2 17/05/2012 287
Newham
MRSA BC 2 0 1 3 2 06/02/2013 22
C difficile 6 0 1 10 12 11/02/2013 17
The Royal London
MRSA BC 6 * 0 0 4 6 10/11/2012 110
C difficile 59 * 0 3 13 33 18/02/2013 10
St Bartholomew's
MRSA BC 6 * 0 0 1 1 05/12/2012 85
C difficile 59 * 0 2 5 6 04/02/2012 24
Whipps Cross
MRSA BC 0 1 0 2 0 16/03/2012 349
C difficile 34 1 2 15 31 18/02/2013 10
No. of
days
since
last
+ve
Case

TB 27/13
Mile End Hospital is not counted in total for Barts Health as attributed to Commissioners
MRSA BC 0 0 0 0 ‐ ‐
C difficile 0 1 1 2 27/02/2013 1
Narrative for MRSA bacteraemia and C/diff acquisition after 72 hours
MRSA Bacteraemia
4. One case of MRSA Bacteraemia was attributed to NUH (see Table 1. The MRSA admission screen was
completed on the 21/12/12 but skin wounds present were not screened. The admission screen was
negative. Subsequent screening for MRSA colonisation was positive on the 11/2/13. At this time the
sores on various part of the body were swabbed for MRSA (grade 2 pressure ulcers had also developed
on the heel and sacrum and a leg laceration). The patient also developed C. difficile during the
admission. Decolonisation therapy protocol was prescribed on the 13/2/13.
MRSA RCA findings
5. The skin wounds were not screened on admission but on 07/ 02/13; the results which came back as
MRSA positive. It is therefore difficult to state whether the patient had acquired MRSA whilst an
inpatient or the wound may had been colonised prior to admission. The patient's skin condition made
it difficult for venous access; takes multiple attempts hence possibility of contamination of the blood
culture bottles.
6. Once results for MRSA bacteraemia was confirmed patient’s treatment plan was reviewed and it was
confirmed that patient was not septic therefore antibiotics therapy was not required.
7. The blood culture positive for MRSA was taken from a newly inserted cannula this is not a normal
recommendation. However, considering the patient’s condition this practice was deemed acceptable.
8. Monthly MRSA screening as the Trust’s policy recommends was not adhered to, it is possible that a
positive screening result would have prompted protocol and could have prevented this incident.
Clostridium Difficile
9. Nine cases were reported in February: eight post 72 hours and one pre 72 hours of the patient’s
admission (see Table 1). The target for Barts Health is 99. At the end of February there have been 127
cases: eighty four post 72 hours and forty three pre 72 hours.
The London Chest reported no cases. Total year to date is two post 72 hours.
Newham reported one post 72 hours. Total year to date is twenty two: twelve post 72 hours and
ten pre 72 hours.
Royal London reported three post 72 hours. Total year to date is forty six: thirty three post 72
hours and thirteen pre 72 hours.
St Bartholomew's reported two post 72 hours. Total year to date is eleven: six post 72 hours and
five pre 72 hours.
Whipps Cross reported two post 72 hours and one pre 72 hours. Total year to date is forty six:
thirty one post 72 hours and fifteen pre 72 hours.
Mile End (Community) reported one post 72 hour. Total year to date is three: two post 72 hours
and one pre 72 hours, the case at Mile End is on the Commissioners trajectory.
4

TB 27/13
Newham Hospital
10. There was a single case of C. difficile in a patient admitted to the stroke unit. The patient was
commenced on laxative treatment as well as antibiotics for different infections. The patient developed
diarrhoea 05/02/13 was sampled and it tested positive to C. difficile. Since the patient has been taking
both antibiotics and laxatives since admission it is not clear whether this was medication induced
infection.
11. Action taken: Medical, pharmacist and nursing staff to review/ monitor the use of laxatives and
antibiotics. Staff to be educated, on when to isolate patients and test for c. difficile.
Royal London Hospital
12. Three cases of C. difficile were reported in February the following issues were reviewed:
One patient was a recurrence (CDT positive 11 months earlier)
All three patients were on antibiotics; these were deemed as appropriate despite poor
documentation around reason for medication and duration.
Two of the patients had PPI’s
Hand Hygiene scores were above 95%
One patient was critically ill and died not related to C. Difficile infection.
In ACCU staff were unable to isolate patients when on 4F (HDU) due to staffing
Two of the cases were isolated on 4E, when investigated they were found not to be linked.
Action taken: Medical, pharmacist and Nursing staff to review/ monitor the prescribing of antibiotics.
St Bartholomew’s Hospital
13. Two cases of C. difficile was reported the following were RCA issues were reviewed:
Both patients were oncology patients and received multiple courses of antibiotics. However all
were prescribed in line with the Antibiotic Policy.
Hand Hygiene scores were above 95% in the areas
In ward 4A both patients were initially isolated when symptoms commenced, one was de isolated
to accommodate another known infectious patient. They were re‐isolated on receipt of positive
samples
The two cases did occur on one ward but when investigated they were found not to be linked.
Action taken: Medical and Nursing staff are to review care of patients with diarrhoea, and must not be deisolated
while symptomatic.
Whipps Cross Hospital
14. Two cases of hospital C. difficile were reported during February, the following issues were reviewed
Clinical Infection deemed unlikely in 1 patient as clinically well but treatment was started due to
mild neutrophilia. The second patient admitted to ICU had clinical infection.
Antibiotics were prescribed for uro‐sepsis and LRTI. One case was deemed not to be in line with
WX antibiotic guidelines
Hand hygiene compliance and environment cleaning audit results were good on both wards >97%
Patient was not isolated from the onset of diarrhoea but isolated on receipt of results
One patient was not isolated from the onset of diarrhoea but isolated on receipt of results
Action taken: Where non‐compliance with the antibiotic policy identified this has been addressed during
the RCA. A copy of the RCA form has been sent to the ward manager and matron to identify learning and
to agree actions to improve practice. Isolation of patients remains a challenge at the WX site and the
importance of isolating patients with diarrhoea is being continuously reinforced as a priority
5

TB 27/13
Patient Falls
Table 2: Patient Falls February 2013
Patient Falls
Period
Site
B&L NUH WX
Q1: April‐June 208 96 165
Q2: July‐Sept 232 92 152
No Harm
Low Harm
Moderate Harm
Severe Harm/Death
LCH MEH RLH SBH
Q 3: Oct ‐ Dec 11 20 130 20 88 121
January 2013 9 20 59 8 38 61
February 2013 5 19 55 8 40 68
YTD: 2012‐2013 804 354 567
Inpatient Falls
Period
Site
B&L NUH WX
Q1: April‐June 124 20 62
Q2: July‐Sept 130 22 37
LCH MEH RLH SBH
Q3: Oct ‐ Dec 15 7 61 14 28 74
January 2013 3 6 38 4 4 29
February 2013 3 3 25 5 12 18
YTD: 2012‐2013 438 86 220
Inpatient Falls
Period
Site
B&L NUH WX
Q1: April‐June 7 3 1
Q2: July‐Sept 6 2 2
LCH MEH RLH SBH
Q3: Oct ‐ Dec 0 1 3 4 2 3
January 2013 2 0 0 0 0 0
February 2013 0 0 2 0 0 1
YTD: 2012‐2013 25 7 7
Inpatient Falls
Period
Site
B&L NUH WX
Q1: April‐June 1 0 0
Q2: July‐Sept 0 2 1
LCH MEH RLH SBH
Q3: Oct ‐ Dec 0 0 0 0 0 0
January 2013 0 0 0 0 0 0
February 2013 0 0 0 0 0 0
YTD: 2012‐2013 1 2 1
All Falls – February 8 22 82 13 52 87
Falls per 1,000 Bed Days (Feb) 1.4 3.8 14.3 2.3 9.1 15.2
/denotes an increase or decrease in number of incidents this month compared to last month
6

TB 27/13
15. As can be seen in Table 2 there were no severe falls Injuries in month 11.
Pressure Ulcers
Table 3: Pressure Ulcers February 2013
Pressure Ulcers
Site
Timescale
B&L
LCH MEH RLH SBH
NUH WX
Q1: April‐June 17 16 9
Q2: July‐Sept 27 7 12
Q3 Oct‐Dec 1 6 21 3 10 16
January 2013 0 0 3 0 8 2
February 2013 1 0 3 2 12 10
YTD: 2012‐1213 84 53 49
Pressure Ulcers
Site
Timescale
B&L
LCH MEH RLH SBH
NUH WX
Q1: April‐June 85 26 50
Q2: July‐Sept 85 21 44
O3: Oct‐Dec 9 8 61 12 45 36
January 2013 6 1 28 4 24 11
February 2013 1 0 18 3 19 25
YTD: 2012‐1213 321 135 166
Pressure Ulcers
Site
Timescale
B&L
LCH MEH RLH SBH
NUH WX
Q1: April‐June 4 3 6
Q2: July‐Sept 9 4 4
O3: Oct‐Dec 0 2 2 0 10 14
January 2013 0 0 2 0 4 4
February 2013 0 0 1 0 2 4
YTD: 2012‐1213 20 23 32
Pressure Ulcers
Site
Timescale
B&L
LCH MEH RLH SBH
NUH WX
Q1: April‐June 9 0 0
Q2: July‐Sept 7 2 0
O3: Oct‐Dec 0 0 1 2 1 2
January 2013 0 0 0 0 0 1
February 2013 0 0 0 0 0 0
YTD: 2012‐1213 19 3 3
All PU February 2 0 22 5 33 39
Rate per 1,000 bed
days (Feb)
0.3 0 3.8 0.9 5.8 6.8
/denotes an increase or decrease in number of incidents this month compared to last month
Grade 1
Grade 2
Grade 3
Grade 4
7

TB 27/13
16. As shown in Table 3 there were no severe harm grade 4 pressure ulcer incidents in February 2013.
Tissue Viability Service led Quality Improvement
The Tissue Viability (TV) nurses are participating in the Patient Safety Forum to facilitate the
champions for the Quality Improvement Collaborative (QIC) in pressure ulcer reduction. This will
ensure ward champions are trained and PU link nurses identified in all areas that will cascade
training re risk assessment, implementing care plans and ensure investigatory pathways for
pressure ulcer incidents.
An e‐learning module on standardised pressure ulcer prevention and management is being
developed and will be made accessible via the Learning and Development intranet.
TV Service has gained assistance from the Education Academy to include pressure ulcer care
pathways as mandatory training for all nurses attending the Induction programme and update days.
The QIC pressure ulcer reduction programme continues. Tayberry (NUH), 5A (SBH), Neonatal
Intensive Care Unit (RLH) all continue to trial different tools/ methods to reduce avoidable pressure
ulcers. Improvements made will be rolled out across BH.
The TV nurses now support the Preceptorship Nurse Facilitators’ training programme for newly
qualified Registered Nurses by teaching them the pressure ulcer prevention care pathway and
processes and wound management.
Table 4: Adult Community Nursing reported pressure ulcers February 2013
Adult Community (District ) Nursing
Grade
Period
Grade 1 Grade 2 Grade 3 Grade 4
Q1: April‐June 3 17 13 5
Q2: July‐Sept 4 20 5 0
Q3: Oct‐Dec 6 9 3 0
January 2013 0 3 1 0
February 2013 0 3 0 3
YTD: 2012‐1213 13 52 22 8
17. One patient had 5 pressure ulcers which consisted of 3 grade 4 pressure ulcers on their foot, 1 x grade
2 also on the foot and a grade 2 on leg. This patient was known to tissue viability team and there was
underlying ischemia with comorbidities. The full RCA investigation is to be completed. The Wound
Care Team continue to work closely with district nurses in providing joint visits and reviewing grade 3
and 4 pressure ulcer patients on a weekly/twice weekly basis.
8

Serious Incidents
TB 27/13
Table 5: Serious Incidents (SI) by category February 2013
SI
Reported
Serious Incidents
Category
Number
in Pressure Ulcers 9
February Delays in Care 7
2013 Obstetrics (includes 1 Never Event) 5
Treatment 3
Safeguarding Adults 2
Equipment 1
IT related 1
Medication 1
Safeguarding Children 1
Tracheostomy 1
Anaesthetics/Theatres/SSD 1
Appointments and Clinics 1
Totals 33
18. There were 33 new SIs reported in February 2013
19. There was one Never Event reported but the incident happened in January 2013. This was a maternity
case where 2 vaginal swabs were not removed after suturing. The Women’s CAG have subsequently
published a ‘hot topic’ memo to all staff to remind them of checking for swabs at the end of all suturing
procedures.
20. As of 15 March 2013, there were 84 overdue SIs. This comprised of 12 legacy incidents (down from 27
last month) and the central Patient Safety and Governance & Standards Teams are working with the
CAG teams to complete the overdue investigations and reports. The aim is try to achieve closure of all
the legacy incidents by 31 March.
21. There are 72 overdue SI reports identified since 1/10/12 and the CAG teams are working hard to
conclude and finalise the investigations.
Moderate severity incidents reported in February
22. In March TMB and QAC discussed a paper which recommended changes to the SI process including
how other non‐SI but potentially ‘of concern’ incidents and complaints are triangulated and reported
going forward (e.g. those of moderate severity and/or resulting in actual harm and/or which identify
omissions in basic care). This recommendation (number 7) was supported and approved by QAC.
23. Table 6 reports moderate severity incidents by category and CAG reported in February and should be
viewed as a precursor to further analysis, reporting and eventual triangulation with moderate/high risk
rated complaints going forward. It does not drill down to sub category level but this is intended and
individual incident reports were reviewed.
24. The most frequently reported (top 3 moderate) incident categories are;
Tissue ulcers (22)
Obstetric incidents (15)
Staff injuries / illness (13)
25. Further work is being undertaken to understand some data anomalies identified from this initial review
of moderate incidents by category and of the individual incidents themselves. Firstly it indicated a high
degree of variability of actual harm to patients even though coded as moderate severity. For example
9

TB 27/13
for pressure ulcers 22 coded as moderate harm should have been recoded as no harm as 10 were
acquired outside of BH care and 1 case was an unavoidable end of life skin change. Four of these had
received final approval without the severity being modified.
26. Seven needle stick injuries in the Staff Injury/Illness category were graded as moderate harm. In no
case was there significant immediate harm to the staff member and in only one case was there a
significant risk of blood borne infection. In some cases high risk situations which had been handled
without harm arising were reported as moderate harm. In others review of the incident had indicated
no Trust fault although the patient had suffered harm as a result of ill health.
27. Less than a third of the moderate incidents had received final approval (all of them should have done,
according to the dates). Inappropriate grading seemed as common amongst those with final approval.
as without, indicating that grade is not being picked up either by the incident handlers or at final
approval as it should be.
Table 6: Moderate Severity Incidents in February 2013
Incident Category
Ambulatory
Cancer Services
Cardiovascular
Children’s Services
Clinical Support Services
Corporate
ECAM
Surgery
Women’s Health
Totals
% all MIs. This incident
type
Anaesthetics/Theatres/SSD 1 3 4 4%
Appointments and Clinics 1 1 1%
Blood Transfusion 1 2 3 3%
Communication Issues 1 1 1%
Delays in Care 2 1 1 2 1 1 8 8%
Equipment 2 1 3 3%
Infection Control 1 1 2 2%
Medication 1 1 1%
Obstetrics 1 14 15 16%
Pathology/Specimen 1 1 1%
Patient Falls 1 2 1 4 4%
Pressure Ulcers 4 14 4 22 23%
Safeguarding Adults 1 1 2 2%
Skin Trauma 1 1 1%
Staff injuries/illness at
work 2 2 1 3 1 2 2 13 14%
Staffing Issues 1 1 2 2%
Tracheostomy 1 1 2 2%
Transport 1 1 1%
Treatment 2 1 1 1 1 3 9 9%
Totals 11 6 3 2 3 3 28 14 25 95 100%
% all MI's, this CAG 12% 6% 3% 2% 3% 3% 29% 15% 26% 100%
Central Alerting System (CAS), Alert Assurance and Performance
28. Table 7 shows that of the six new CAS alerts received in February all have been closed.
10

TB 27/13
29. Regarding the remaining open alerts, actions to ensure compliance with the Estates & Facilities (tamper
free window restrictors) alert are nearing completion and on track to be completed by the target of
23/05/13.
NPSA Safer Intrathecal devices alert Part B
30. The remaining open NPSA alert relates to the introduction of safer intrathecal devices and action by
relevant clinical leads in each CAG, this is currently overseen by the Medical Director (MD) and the
Clinical Procurement Group. The MD has requested that each CAG using intrathecal devices undertakes
a risk assessment. Not all CAGs have responded and the requested risk assessments are outstanding. It
is highly probable that procurement and clinical recommendations regards the selection and
introduction of suitable devices across the Trust will not have been completed by the target date of 1
April 2013.
Table 7 Central Alerting System (CAS) Assurance and Performance
CAS Alerts Received February 2013 and (year to date since 1 April 2012)
MDA NPSA Estates & Facilities Total
6 (78) 0 (0) 0 (3) 6 (81)
All open alerts (as at 28 February 2013)
MDA NPSA Estates & Facilities Total
1 1 1 3
Overdue CAS Alerts, Barts Health, pre & post 1 April 2012
MDA NPSA Estates & Facilities Total
0 0 0 0
Patient Experience
Legacy Complaints
31. In October, the Trust had a total of 122 legacy complaints, which progressively exceeded the timescales
negotiated with complainants. A number of contributory factors were identified as the reason for the
delays. Some of these included:
Difficulties accessing ICT systems across different hospital sites post the 1 October
Delays with accessing records across different hospital sites
Limited knowledge of complaints management on the part of a significant number of staff who
were new to their roles
Inadequate handovers due to staff absence pre and post the merger
It was subsequently agreed that:
The CAG Governance Teams would contact all the complainants to give them an update and agree
reasonable deadlines for providing responses to complaints
The Patient Experience Team would support the CAGs with drafting response letters
Al legacy complaints would be responded to and closed by the 31 st of January
The Patient Experience Team would provide specific training for the appropriate staff
32. At the end of February, a total of 88 legacy complaints had been closed and 34 remain open at the time
of reporting, (see Tables 7 and 8). Staff absence due to sickness and a high number of incoming
complaints is cited by the CAGs as some of the reasons why a number of legacy complaints remain
11

TB 27/13
open. In addition to this, difficulties with ICT systems and accessing records across sites remain a
problem.
Training and Developments in Complaints Management
33. Training has been provided to staff that required it and on‐going support from the Patient Experience
Team. This has included additional training, shadowing, drafting response letters and providing advice
about how to manage complex complaints
34. The Patient Experience Team continue to work closely with all the CAG Governance Managers and their
teams and CAGS have provided assurance to the corporate Patient Experience Team that all open
legacy complaints will be closed by the 31 st of March.
35. However The Trust board should note that some staff in CAGs with a key role in the management of
complaints remain on leave and further organisational changes might impact on the progress of
meeting the set deadline.
Table 8. Number of legacy complaints currently open
Mile
End Newham
Royal
London Barts
Multiple
sites
2 2 28 1 1
CAG
No. of legacy
complaints currently
open
Ambulatory 8
Cancer 1
Corporate 3
Clinical Support Services 0
ECAM 7
Surgery 12
Women’s 3
Total 34
Table 9: Complaint Performance Report by Clinical Academic Group
Clinical Academic Group
Number of
complaints
Ack. within 3
working days Percentage
Ambulatory 22 21 95%
Cancer 2 1 50%
Cardiovascular 5 4 80%
Children's 6 6 100%
COO 3 2 67%
CSS 10 8 80%
Nursing & Quality
Governance 1 1 100%
ECAM 44 28 64%
Surgery 23 22 96%
Women's 16 16 100%
Total 132 109 83%
12

TB 27/13
CAG
Number of
complaints
Response
performance Percentage
Ambulatory 22 13 59%
Cancer 2 2 100%
Cardiovascular 5 5 100%
Children's 6 2 33%
CSS 10 8 80%
COO 3 2 67%
Nursing & Quality
Governance 1 0 0%
ECAM 44 38 86%
Surgery 23 18 78%
Women's 16 13 81%
Grand Total 132 101 77%
36. Top areas of complaints for service users are detailed in Table 10.
Consistent with previous months, the top 3 areas of concern for service users have been;
Diagnosis and Treatment ‐ 34% (43) of the total number of complaints closed during the month
Communication ‐ 23% (30) of the total number of complaints closed during the month
Delays in care ‐ 14% (18) of the total number of complaints closed during the month
Table 10: Top areas of concerns by site
Diagnosis /
Treatment
Communication ‐ verbal /
written / electronic Delays in care Total
London Chest 1 0 0 1
Mile End 1 0 1 2
Newham 0 3 4 7
Royal London 25 15 5 45
St. Bartholomew's 1 3 0 4
Whipps Cross 15 9 8 32
Total 43 30 18 91
Parliamentary Health Service Ombudsman Cases
37. During the year to date, the PHSO has indicated interest in 61 complaints concerning Barts Health see
Graph 1. Of the cases concerned:
‐ 30 are currently active (24 at the request for information stage 6 referred back for further local
resolution and are currently being considered by the services)
‐ 31 have been closed with no further action required of the Trust
‐ 1 complaint (not included in the summary above) from last financial year remains open at the time
of reporting, has been investigated and is currently in the action planning stage.
38. Cases are returned to the Trust by the PHSO where it is considered that further dialogue or a local
resolution meeting could resolve the issues a complainant has reported to PHSO. In some case,
complainants go straight to the PHSO before contacting the Trust about the response they have
received.
39. Usually the PHSO refer such cases back to the Trust and recommend that: a clarification of policies,
providing copies of policies or other relevant documentation or a sum of money for minor
inconveniences would suffice as a form of local resolution
13

Graph 1: Distribution of complaints reported to PHSO
TB 27/13
No. of active PHSO cases by site
1
1
10
5
13
Newham
Whipps Cross
Royal London
Mile End
Barts
Patient Advice and Liaison Service (PALs)
40. In February, the Trust managed 484 contacts, compared with 420 in January and 344 in December. Of
these, 89% (432) came under ‘issues & concerns,’ (see Table 10. As well as outlining the “type” of work
the service has been engaged in, the adjacent chart demonstrates that a high proportion of PALS work
involves supporting people to resolve issues and concerns they have about services across the Trust.
This emphasises the important role of PALS as an early warning system, which identifies potential
complaints, and supports service users to resolve these before they escalate any further.
Table 11: Number of PALS Contacts by Site
Site
Total number
Another hospital 14
London Chest 5
Mile End 14
Newham 139
Royal London 161
St. Bartholomew's 16
Whipps Cross 135
41. As indicated in the bar chart on page 15 the Trust’s service users contact the PALS service for various
reasons ranging from requests for advice and information about Trust services, to concerns about the
care they received.
42. This demonstrates the pivotal role PALS plays in delivering the organisation’s patient experience
agenda. By being available for patients and their families, PALS represent a service which patients and
their relatives can contact independently of their clinical care providers whenever they wish to alert
the Trust to issues or if they wish to raise concerns relating their care needs. As indicated below, the
highest area of activity for the PALS has been around providing advice and information.
43. With regard to actual issues and concerns service users presented with during the month, the three
highest areas of concern have been about:
Communication (24%), which is consistent with reportable complaints, where the second highest
reason for complaints was communication
Appointments and clinics (19%)
Diagnosis / Treatment (14%)
14

TB 27/13
Graph 2: PALS contact by Themes
No. of PALS contacts by subject
140
120
122
116
100
93
80
69
60
40
26
18
20
1
2 1 1
0
Diagnosis / Treatment
Advice and Information
Appointments / Clinics
Blood and Blood products
Communication ‐ verbal / written / electronic
Delays in care
Environment
Equipment and supplies
Fire Safety
Medication / Radiation
Healthcare records / X‐rays / Scans
10 12
6
1 1
Obstetrics
Patient falls
Privacy and dignity
Surgical / Invasive procedures
Security and unacceptable behaviour
1 4
Transport
Friends and Family Test (FFT)
44. Barts Health achieved 100% coverage (asking the Friends and Family question) in all appropriate areas
at the beginning of February. Results for this month show a high percentage of the patients who
responded would be extremely likely (64%) to recommend the ward or area to their friends and family
(Graph 3 and Table 11).
45. Although gradual improvement in uptake is evident from December to February, this is not reflective of
the total number of eligible discharges across Bart’s Health. In order to assist in embedding the
process, Patient Experience facilitators under the guidance of the team leaders continue to support the
CAGs by ensuring that they have all the materials to deliver the process successfully.
46. Facilitators are visiting the wards across all the sites on a weekly basis along with a Team leader
attending a number of committees to further raise awareness of FFT.
47. Staff awareness of and engagement in the process at discharge is of paramount importance to the
success of achieving at least the 15% target which will come into place when the FFT goes live
nationally from the 1 April. The Chief Nurse has raised the issue of staff engagement at Trust
Management Board and information has been sent out to staff via the weekly bulletin.
48. The other important element is to raise awareness amongst patients and their families and carers that
they will be asked on their discharge to answer the FFT question. Leaflets for staff and patients along
with posters have been produced by the DH which has just been received by the Trust. These are
15

TB 27/13
currently being distributed around the wards and areas carrying out the FFT. The FFT agenda has
CQUIN monies attached and also will provide the trust with valuable feedback from our patients
therefore it is imperative that everyone takes responsibility for its success.
Graph 3 Friends and Family Test Responses for Recommendation of ward to family/friend
Barts Health overall response
2% 2% 2%
30%
64%
Extremely likely Likely Neither likely nor unlikely Unlikely Extremely unlikely
Table 12: Numbers of Patients Participating in Friends and Family Test
Dec‐12 Jan‐13 Feb‐13 Total
Base 42 114 248 404
49. Snapshot of comments made by patients:
Extremely likely ‐ “Service was first class. All staff were very friendly and kind. Food was very bad”
Extremely likely ‐ “I would recommend the ward due to the care treatment not only of doctors but of
the nurses and staff. Clean caring helpful polite”
Likely ‐ “Discharged takes too long. Have to wait too long for medication. Otherwise good”
Likely ‐ “It was all good but took a while to be attended at the main entrance/reception”
Neither likely nor unlikely ‐ “There is a v marked difference between the quality of nursing during
the week (great) and at the weekends”
Unlikely ‐ “A few good reasons. The nurses have no thought about patients trying to sleep at night;
laughing & talking loud & banging things about. It was a nightmare”
Real Time Feedback (RTF)
50. Real time feedback collected for February is available through the Integrated Performance Framework
by site and CAG and reported to the Trust Board. CAGs receive a monthly report as part of their
monthly review information.
16

TB 27/13
CARE QUALITY COMMISSION (CQC) ESSENTIAL STANDARDS
Update on the recent CQC inspection visits and reports
51. The Care Quality Commission carried out unannounced compliance reviews at three registered Trust
locations in February and the beginning of March.
Mile End Hospital
52. On 18 February CQC carried out an unannounced compliance review. The assessors visited two elderly
service wards Gerry Bennet and Jubilee and assessed compliance with eight Outcomes. These were;
Outcome 1 Respecting and involving people
Outcome 4 Care and welfare of people who use services
Outcome 5 Meeting nutritional needs
Outcome 7 Safeguarding people who use services from abuse
Outcome 13 Staffing
Outcome 14 Supporting Staff
Outcome 16 Assessing and monitoring the quality of service provision
Outcome 21 Records
53. The Trust has received the draft report which judged 3 Outcomes as non‐compliant with moderate
impact on patients or safety. These are Outcomes 5, 13 and 21. The ECAM CAG will factual accuracy
checks the report and the Trust will respond to the CQC within the specified time of ten working days.
St Bartholomew Hospital
54. A further compliance review was carried out over two days at SBH 27 and 28 February consecutively.
The assessors visited wards 5A, 5B, 4A, Percival Pott and the Macmillan Vicky Clement Jones Cancer
Information Centre.
55. The Trust has received a draft report and the positive findings and fully met judgements are consistent
with the verbal feedback given after the visit. The main areas of focus in the Cancer Services visited
were;
Outcome 1 respect and involvement( fully met)
Outcome 8 infection control (fully met)
Outcome 13 staffing ( fully met)
Outcome 17 complaints management (fully met)
Whipps Cross Hospital
56. On 1 March the CQC inspected the Ainslie and Hingham’s Intercare Unit. This was a follow up visit from
an initial compliance review in August 2012. The following Outcomes were re assessed along with
evidence of progress and the changes introduced by implementation of the action plan developed after
the visit in August when 3 Outcomes were judged non‐compliant. The verbal feedback and draft report
both provided positive assurance and evidence that quality, safety and patient experience have
improved in this service. The CQC judges that three Outcomes previously not met are now compliant.
Outcome 4 Care and welfare of people who use services now fully met (noncompliant
in August)
Outcome 5 Meeting nutritional needs fully met
17

TB 27/13
Outcome 13 Staffing now fully met (non‐compliant in August)
Outcome 14 Supporting Staff now fully met (non‐compliant in August)
Outcome 21 Record keeping not met minor concern (Outcome 21 was not assessed
previously)
57. The Trust is yet to respond formally with a factual accuracy check and action plan to address the new
issue identified in relation to nursing documentation.
Care Quality Commission Quality Risk Profile (QRP) for Barts Health
58. An updated version of the Quality and Risk Profile (QRP) was issued on 6 March. It highlighted no
significant changes to risk estimates for the 16 Outcomes since the previous version. There are no high
(red or amber) risk estimates.
59. Outcome 13 Staffing (R22) – the risk slightly decreased from “high yellow” to “low yellow” as a result of
a recent inspection visit. The Trust was found compliant with this outcome following a visit at London
Chest Hospital in November 12.
60. Outcome 16 Assessing and monitoring the quality service provision (R10) – the risk estimate rating has
slightly increased from “high green” to “low yellow”. There are no significant changes to any
performance indicators except that previous QRP versions still had some indicators separated for the 3
legacy trusts.
61. The Trust is still rated “much worse than expected” for an indicator that relates to “Proportion of alerts
acknowledged within deadline out of total number of alerts issued to the organisation for the period
01/02/12 ‐18/02/13”. However, this issue has been addressed by new systems and controls
implemented since 1 October 2012 and all alerts are acknowledged within the expected time frame.
62. Below are the ‘red’ indicators extracted from the latest version of the Barts Health QRP. These
indicators are a selection which are used to estimate risk with a high number of the 16 Outcomes
18

Table 13: Summary of Red RAG rated items
Indicator information relevant to many Outcomes
Data source Item description Data Value Site
Adult inpatient
survey
Adult inpatient
survey
Adult inpatient
survey
Adult outpatient
survey
2011
Adult outpatient
survey
2011
NHS staff
survey2011/12
NHS staff
survey
2011/12
NHS staff
survey
2011/12
NHS staff
survey
2011/12
Respondents stating they waited
more than 5 months to be
admitted from the time they were
first told they needed to be
admitted
Respondents stating they did not
have confidence and trust in the
nurses treating them
Respondents stating that they did
not get enough emotional support
from hospital staff during their stay
Respondents stating they did not
have confidence and trust in the
doctor examining and treating
them
Respondents stating that the main
reason they went to the
Outpatients Department was not
dealt with to their satisfaction
Staff job satisfaction
% of staff experiencing
discrimination at work in the last 12
months
Effective team working
Percentage of staff witnessing
potentially harmful errors, near
misses or incidents in last month
Much worse than
expected
Much worse than
expected
Much worse than
expected
Much worse than
expected
Much worse than
expected
Lowest (worst)
20% when
compared to
other trusts
Highest (worst)
20% when
compared to
other trusts
This trust was in
the lowest
(worst) 20%
when compared
to other trusts
for this key
finding
This trust was in
the highest
(worst) 20%
when compared
to other trusts
for this key
finding
NUH
BLT
NUH
WX
NUH
BLT
NUH
NUH
BLT
NUH
WX
NUH
NUH WX
TB 27/13
19

TB 27/13
RECOMMENDATION
63. The Trust Board is asked to
Note the contents of the report.
Identify areas that the Quality Assurance Committee should examine further.
Kay Riley
Chief Nurse 26 March 2013
20

Report
to the Trust Board: 10 April 2013
TB 28/13
Title
Sponsoring Director
Author(s)
Purpose
Previously considered by
Finance Report – 2012/13 Monthh 11
Chief Financial Officer
Senior Finance Staff
To providee the Board
with the Trust’s financial performance
report for Month 11 and the key risks to the achievement of
the financial plan for 2012/13.
Trust Management Board, 9 April 2013
CFO Message
At Month 11 the Trust continues to forecast overall breakeven for the year end. This has
been achieved after planned financial support relating to the merger business case and in
year financial support for contract overperformance.
The overall position for patient treatment income shows overperformance on Ambulatory
Care, Paediatrics and Cancerr services, with underperformance on Emergency Care and
Acute Medicine, Cardiovascular, Women’s Health and Surgery. The expenditure position
remains
of concern, as all CAGs are overspent against budget. Pay expenditure has
remained largely static acrosss the year, with bank and agency spend s increasing in February
compared to previous months (see tablee 4). The Trust is undertaking a specific initiative to
review and improve the controls on variable pay.
The overall CIP achieved in 2012/13 wass in line with the merger FBC, butt below the
more
ambitious target we set ourselves. This is disappointing, and is an unsustainable position
going forward. We
have therefore engaged external consultancy support to help CAGs and
corporate areas to
deliver the
CIPs for 2013/14.
The Trust’s capital programme has been revised
down to £41.7m with year‐to‐date
expenditure at £22.6m, £15.6m less than plan. A number of large projects are still at the
pre‐approval stages and the Finance and Investment Committee will bee asked to review r
the capital programme this month aheadd of seeking
Board approval in May.
In summary, while
we will achieve ourr overall financial targets for 2012/13, the more
urgent priority is to address the t underlying financial position. This requires a step‐change
in our CIP delivery
and a significant improvement in budgetary control during 2013/ /14, in
order to ensure the Trust’s overall strategy and service improvement plans for patients
can be realised.
Mark Ogden, Chief
Financial Officer

TB 28/13
Related Trust objectives
6. Deliver the Trust’s 2012/13 financial plan, and cost improvement target, and develop a
sustainable long term financial plan (LTFM).
Risk and Assurance
Related Assurance
Framework entries
Legal implications/
regulatory requirements
Key risks to the delivery of the plan
n/a
No direct legal implications identified.
Action required by the Trust Board
The Trust Board is asked to review and discuss the 2012/13 Month 11 financial
performance, including the key risks identified in this report.
2

TB 28/13
Report Structure
1 Overview of financial Comprehensive Statement of Income. Commentary on income,
performance pay/non‐pay and CAG and corporate performance. Financial risk
rating and summary CIP.
2 Capital expenditure Performance against plan.
3 Cost improvement Performance against plans and commentary on
underachievement.
4 Income Income analysed by sectors (commissioners), point of delivery.
5 Balance sheet Balance sheets since start of the year, aged debt analysis and cash
flows details.
3

TB 28/13
1.0 Overview of Financial Performance
1.1 Comprehensive Statement of Income and Expenditure
Table 1 below summarises the financial position of the Trust by income and expenditure
categories and Table 2 shows the position by CAG and Corporate.
Table 1 – Analysis of Income and Expenditure by income/expenditure category
In Month
Year to Date
Trust Financial Performance
Year End
February 2013
Budget
£m
Actual
£m
Variance
£m
Budget
£m
Actual
£m
Variance
£m
Budget
£m
Income 104.8 109.8 5.0 1,153.5 1,180.0 26.5 1,264.7
- -
Expenditure
Pay 60.0 61.8 (1.8) 649.9 659.3 (9.3) 715.7
Non-Pay 35.5 41.0 (5.5) 401.9 441.6 (39.7) 439.8
Internal Trading (0.0) 0.0 (0.1) (0.6) (0.4) (0.1) (0.6)
Central Expenditure & Reserves 1.7 (0.0) 1.7 2.5 (0.9) 3.3 6.3
Total Expenditure 97.2 102.8 (5.6) 1,053.8 1,099.6 (45.9) 1,161.2
EBITDA 7.6 6.9 (0.6) 99.7 80.4 (19.3) 103.5
Interest, Tax and Depreciation 8.4 7.7 0.7 92.3 85.1 7.3 101.6
Donated Assets Adjustment 0.2 (0.6) 0.8 1.7 (5.0) 6.7 1.8
Retained Surplus / (Deficit) Before IFRS (1.0) (0.1) 0.9 5.7 0.3 (5.4) 0.0
Included in the non-pay above:
Pass Through Costs - Drugs 3.5 4.8 1.3 40.7 46.9 6.2 44.5
Pass Through Costs - Devices 1.6 1.7 0.1 18.7 18.9 0.2 20.4
CIPs Achieved 6.7 5.1 (1.7) 56.9 42.2 (14.6) 63.3
The Trust is showing a small surplus against a year to date target of a £5.7m surplus. There is
a favourable income variance of £26.5m, offset by an adverse operating expenditure
variance of £45.9m. Most of the expenditure variance relates to non‐pay, this is partly on
the costs of drugs, (overspent by £7.1m), clinical supplies (overspent by £8.5m) and an
£8.2m underachievement of non‐pay CIPs.
Interest and depreciation have a favourable variance against budget, mainly due to the
impact on the asset base, of impairments at the Royal London. In addition a donated asset
adjustment is applied, to exclude the impact of donated assets, in the Trust’s financial
performance, as required by the Department of Health.
4

TB 28/13
Table 2 – Analysis of Income and Expenditure by CAG
I&E by CAG
In Month
Year to Date
Year End
February 2013
Budget
£m
Actual
£m
Variance
£m
Budget
£m
Actual
£m
Variance
£m
Budget
£m
Income
Ambulatory Care 18.9 19.8 0.9 212.0 215.1 3.1 231.5
Cancer Services 4.4 4.9 0.5 50.6 58.0 7.3 55.2
Cardiovascular Services 7.0 6.7 (0.3) 80.8 79.8 (1.0) 88.2
Children's Health 4.6 4.7 0.1 54.3 59.0 4.7 59.3
Clinical Support Services 6.4 7.3 0.8 74.8 75.7 0.9 81.6
Emergency Care & Acute Medicine 18.0 18.6 0.5 210.1 207.7 (2.5) 229.3
Surgery 15.3 14.4 (0.9) 175.2 167.9 (7.3) 191.1
Women's Health 7.9 7.6 (0.3) 91.8 90.8 (1.0) 100.2
Corporate 5.2 5.6 0.4 52.9 57.5 4.5 57.1
Central Income 17.0 20.3 3.2 150.8 168.7 17.9 171.1
Total Income 104.8 109.8 5.0 1,153.5 1,180.0 26.5 1,264.7
Expenditure
Ambulatory Care 12.8 13.7 (0.9) 142.8 146.6 (3.8) 156.2
Cancer Services 3.6 4.1 (0.5) 38.7 42.9 (4.3) 42.3
Cardiovascular Services 5.3 6.1 (0.8) 58.7 61.8 (3.1) 64.0
Children's Health 3.9 4.2 (0.2) 42.9 45.1 (2.2) 46.9
Clinical Support Services 12.0 12.6 (0.6) 134.7 139.6 (4.9) 147.0
Emergency Care & Acute Medicine 13.7 13.8 (0.1) 142.4 148.5 (6.1) 155.3
Surgery 14.1 14.9 (0.9) 142.2 149.9 (7.8) 156.1
Women's Health 5.2 5.6 (0.4) 57.4 59.8 (2.4) 62.6
Corporate & Central Expenditure 35.2 35.1 0.1 388.7 386.0 2.8 434.9
Total Expenditure 105.9 109.9 (4.0) 1,148.4 1,180.1 (31.8) 1,265.3
Internal Trading
Ambulatory Care 0.7 0.8 (0.1) 8.5 8.4 0.1 9.3
Cancer Services 0.5 0.7 (0.2) 5.8 6.4 (0.6) 6.3
Cardiovascular Services 0.4 0.3 0.1 4.1 3.9 0.1 4.4
Children's Health 0.2 0.2 0.0 1.8 1.7 0.2 2.0
Clinical Support Services (3.4) (3.7) 0.2 (39.8) (39.5) (0.3) (43.6)
Emergency Care & Acute Medicine 0.8 0.9 (0.1) 9.5 9.7 (0.2) 10.4
Surgery 0.6 0.6 (0.0) 6.9 6.7 0.1 7.5
Women's Health 0.2 0.2 0.0 2.7 2.2 0.5 3.0
Total Internal Trading (0.0) 0.0 (0.1) (0.6) (0.4) (0.1) (0.6)
Retained Surplus / (Deficit) Before IFRS (1.0) (0.1) 0.9 5.7 0.3 (5.4) 0.0
Table 3 – Analysis of Corporate and Central Expenditure
Corporate & Central Expenditure
In Month
Year to Date
Year End
Budget
£m
Actual
£m
5
Variance
£m
Budget
£m
Actual
£m
Variance
£m
Budget
£m
Chief Executive 0.1 0.2 (0.1) 2.8 3.6 (0.8) 2.9
Development 13.6 14.7 (1.0) 157.1 162.1 (5.0) 176.9
Human Resources 0.6 0.7 (0.2) 6.3 7.5 (1.2) 6.9
Finance 0.8 1.1 (0.3) 9.2 9.8 (0.6) 10.2
Payroll 0.1 0.1 (0.0) 1.1 1.2 (0.1) 1.2
Procurement 0.2 0.2 (0.0) 1.9 2.8 (0.9) 2.1
Strategy 0.2 0.1 0.0 1.6 1.5 0.1 1.8
Medical Director 0.3 0.4 (0.0) 3.6 3.6 0.1 4.1
Chief Nurse 2.5 2.7 (0.2) 29.0 29.6 (0.6) 31.5
Academic Health Sciences 4.4 4.4 (0.0) 42.8 42.3 0.5 46.3
Chief Operating Officer 1.5 1.7 (0.2) 20.5 21.4 (1.0) 22.1
Central Income & Expenditure 0.3 -0.2 0.0 2.9 1.1 1.8 3.1
Reserves 1.0 (0.2) 1.3 0.9 (0.2) 1.0 5.5
BLT/NUH/WUH Merger 1.4 1.2 0.2 16.9 14.6 2.2 18.7
Interest 3.0 3.1 (0.1) 32.8 33.3 (0.5) 35.8
Dividends 0.5 0.2 0.4 5.9 2.0 3.9 6.5
Depreciation 4.8 4.4 0.4 53.5 49.7 3.8 59.3
Sub Total 35.2 35.1 0.1 388.7 386.0 2.8 434.9

TB 28/13
In month & YTD performance
Expenditure analysis
Pay expenditure
Actual pay expenditure during month eleven was £61.8m, which is £1.5m higher than
month ten. At month eleven, there was an adverse variance against budget of £1.8m in
month and £9.3m year to date. This was mainly the result of non‐delivery of CIPs, which
continues to demonstrate that pay expenditure is not reducing at a sufficient rate to
deliver the recurrent CIPs. In addition, the Bank and Agency expenditure was at £7m,
which is £1.3m higher than bank and agency spend in the preceding two months.
The run rate of pay expenditure is shown by month in table 4.
Table 4 – Analysis of ‘run rate’ pay expenditure (including bank and agency)
Pay Spend by Month
Apr 2012
£m
May 2012
£m
Jun 2012
£m
Jul 2012
£m
Aug 2012
£m
Sep 2012
£m
Oct 2012
£m
Nov 2012
£m
Dec 2012
£m
Jan 2013
£m
Feb 2013
£m
YTD
Total
£m
Pay Spend
Medical 16.5 15.9 16.4 16.3 16.7 17.0 17.2 17.2 16.7 17.6 17.6 185.2
Nursing & Midwifery 23.5 24.1 23.8 23.5 24.0 24.1 23.7 24.4 23.4 24.6 24.1 263.3
Scientific, Therapeutic & Technical 8.4 8.5 8.2 8.2 8.5 8.2 8.4 8.5 8.8 8.3 8.2 92.2
Directors & Senior Managers 2.8 2.6 2.9 2.7 2.8 2.7 2.8 3.2 3.1 2.8 3.1 31.5
Admin & Clerical 9.3 9.7 6.8 8.4 8.2 6.5 6.5 8.7 7.2 6.9 8.9 87.1
Total Pay Spend 60.5 60.9 58.0 59.1 60.3 58.6 58.6 61.9 59.3 60.3 61.8 659.3
Bank & Agency Spend
Medical 0.5 0.6 0.7 0.8 1.0 0.8 0.9 0.8 0.9 1.1 1.1 9.2
Nursing & Midwifery 3.8 2.9 3.3 2.8 3.4 3.6 3.4 4.3 3.8 3.6 3.6 38.4
Scientific, Therapeutic & Technical 0.3 0.4 0.4 0.3 0.5 0.3 0.3 0.5 0.4 0.3 0.4 4.1
Directors & Senior Managers 0.1 0.1 0.1 0.1 0.1 0.1 (0.0) 0.1 0.1 0.1 0.1 0.9
Admin & Clerical 1.9 3.3 (0.2) 1.3 1.3 (0.4) (0.7) 1.8 0.4 0.6 1.9 11.1
Total Bank & Agency Spend 6.6 7.3 4.2 5.3 6.2 4.3 3.9 7.5 5.7 5.7 7.0 63.8
An analysis of CIP underperformance is included in section 3.
Non‐pay expenditure
In month eleven, expenditure on non‐pay totalled £41m, with an adverse variance against
budget of £5.5m. The spend on drugs and clinical supplies in month was above trend to
date but this reflected the impact of winter pressures activity and working towards
achieving access targets by utilising the private sector for some work. The impact of
unidentified/unachieved CIPs continues to be a factor in continuing non pay overspends.
CAG Expenditure (year to date overspends)
Surgery. The year to date expenditure overspend is mainly on bank and agency, clinical
supplies and non achievement of CIPs.
Ambulatory Care. The year to date expenditure overspend is mainly due to high cost drugs
in Rheumatology and Infection & Immunology.
Cardiovascular. The year to date expenditure overspending is mainly on medical and nursing
staff, clinical supplies and underachieved CIPs.
Clinical Support Services. The year to date overspend is mainly on clinical supplies,
maintenance contracts and the underachievement of CIPs.
ECAM. The year to date expenditure overspend is mainly on nursing and medical staff,
mostly bank and agency and unachieved CIPs.
6

TB 28/13
Women Services. The year to date expenditure overspend is mainly on nursing and medical
staff, and unachieved CIPs
Cancer Services. The year to date expenditure overspend is mainly due to high cost drugs
and unachieved CIPs.
Children’s Services. The year to date overspend is mainly on nursing and medical staff, high
cost drugs and activity related clinical supplies costs.
Control Environment. The controls across the organisation are being improved and in
particular compliance with existing controls and polices. There is a working group
developing and implementing a new approach to the control of variable pay, which has
increased significantly compared to previous years. This is covering:‐
Banning overtime
Improved roster planning and review
Weekly analysis of bank and agency spend
Increasing the bank pool
More senior request and authorisation levels.
There are also a number of unfunded posts, which have been identified at budget setting,
which are being addressed.
In addition, steps are being taken to control non‐pay expenditure. The Trust is rationalising
the number of suppliers and driving compliance to ordering from preferred suppliers’ who
have been through a tendering and selection process. Fundamental to this though is the
need to improve the use of the Trust’s purchase ordering system.
7

1.2 Key Metrics – By
Month
TB 28/13
The tables below
show the actual income/expenditure per month.
Table 5 ‐ Key Financial Metrics – By Month
Table 6 – Actual Monthly ‘Run Rate’ (£m)
Ref. Category
3. Monthly I& &E
3.1 Incom me
3.2 Pay
3.3 Non Pay - Clinical
3.4 Non Pay - Non Clinical
3.5 Central Support and Reserves
3.6 Interest, Tax and Depreciation
3.7 Surplus / (Deficit)
Type
Apr 20122 May 2012 Jun 20122 Jul 2012
£m £m £m £m
Aug 20122 Sep 2012 Oct 20122 Nov 2012 Dec 20122
£m £m £m £m £m
Jan 2013
£m
Feb 2013
£m
In Month Actual
In Month Actual
In Month Actual
In Month Actual
In Month Actual
In Month Actual
In Month Actual
97.99 60.5
16.9
17.0
(0.3) 8.4
(4.6) 106.1
60.9
19.0
17.8
(0.2)
8.1
0.6
103.4
58.0
18.4
23.4
(0.2) 8.2
(4.4) 108.5
59.1
16.5
23.0
0.7
8.1
1.1
105.6
60.3
17.77 20.9
(0.2) 8.88 (2.0) 101.8
58.6
17.1
18.8
(0.0)
8.3
(1.0)
111.2
58.6
17.77 27.5
(0.6) 8.0
(0.2) 112.9
61.9
20.5
22.2
(0.3)
8.3
(0.3)
106.9
59.3
18.2
19.3
(0.0) (0.3) 10.5
115.8
60.3
19.9
28.6
(0.1)
6.9
0.2
109.8
61.8
18.88 22.22 (0.0) 7.1
(0.1) 1,180.0
659.3
200.8
240.8
(1.3)
80.1
(0.3)
YTD
Total
£m
8

1.3 Financial Risk Rating
TB 28/13
Table 7 – Financial risk rating
Metric
Year End
Plan
Year to
Date
YTD
Rating
Forecast
Outturn
Commentary
EBITDA margin 3 3 ● 3
EBITDA margin is obtained by dividing EBITDA by
total income. The year to date score is in line with the
plan.
EBITDA; % achieved 5 3 ● 5
EBITDA % achieved is calculated by comparing the
actual EBITDA with that planned. The full year
forecast score is in line with the plan.
Return on Assets 2 2 ● 2
Return on Assets is essentially the surplus divided by
average net assets. The year to date score is in line
with the plan.
I&E surplus margin 2 2 ● 2
I&E surplus margin is the Trust’s surplus (exclusive of
IFRS IFRIC 12 costs) as a percentage of total
income. The Trust would need a 1% surplus in order
to achieve a 3. The current plan is breakeven.
Liquidity 3 2 ● 2
Liquidity is net current assets, excluding inventory,
divided by operating expenses.
Weighted Average 2.8 2.4 ● 2.6
The 5 measures above are subjected to a weighted
average calculation which returns an overall score.
Overall Rating 2 2 ● 2
A score of 3 is mandatory to achieve Foundation Trust
status.
The financial risk rating provided to our external regulators requires the Trust to report all measures on an in year
basis. The Board should note that this position is more favourable compared to the underlying situation, which has
required additional non‐recurrent support as part of the merger FBC.
9

TB 28/ /13
2.0
Capital Expenditure
Table 8 – Capital expenditure analysis by site
Table 9 – Capital expenditure analysis by CAG
Capital Plan
The Trust’s capital programme has been revised to £41.7m
from the previous plan of £64.6m. This
revised budget represents the outcome of discussions with CAG and Corporate teams to prioritise
schemes for 2012‐13. Year to date spend s is £22.6m, whichh is a £15.6mm underspend against the year to
date plan.
On
a specific scheme basis, the most significant underspends relate to t the following schemes:
Table 10 – Under‐spending capital schemes s
10

Report
to the Trust Board: 10 Aprill 2013
TB 29/13
Title
Sponsoring Director
Author
Purpose
Previously considered by
NHS Trust Development Authority 2013/14 Annual Plan
–
Final Submission
Director of Strategy
FT Programme Lead
To note thee final submission of the 2013/14 Annual Plan to the
NHS Trust Development Authority (NTDA)
FT Project Board, 13 March 2013
Trust Executive, 2 April 2013
Trust Management Board, 9 April 2013
Executive summary
This paper sets out
our response to the 2013/14 annual planning requirements in terms of:
1. NTDA requirements.
2. Our 5 April 2013 final submission. s .
3. Key risks.
4. Further work.
Related
Trust objectives
Achievement of foundation trust status within agreed timeline. .
Risk and
Assurance
Related
Assurance
Framework entries
Legal implications/
regulatory requirements
See the risks table at paragraph 14. 1
n/a
Health and Social Care
Act 2012
Toward High Quality, Sustainable
Services (NTDA), requirement
to submit an annual plan.
Action required:
The Trust Board is asked to receive the final 2013/ /14 annual plan as submitted to the NHS
Trust Development
Authority on 5 April 2013.

TB 29/13tt TB 29/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
NATIONAL TRUST DEVELOPMENT AGENCY 2013/14 ANNUAL PLAN
INTRODUCTION
1. The ‘Toward High Quality, Sustainable Services’ planning guidance from the NHS Trust
Development Agency (NTDA) sets out the expectations for NHS trusts to deliver in the
coming year and how the NTDA will support them to achieve high quality and
sustainable care for the patient and communities they serve. The FT Project Board
reviewed a detailed second draft submission of the Trust’s Annual Plan at their meeting
on 13 March 2013.
2. As was noted during that discussion, the final draft submission was required to be
submitted to the NTDA on 5 April 2013. This submission has been made and this paper
therefore outlines next steps and risk mitigation
3. This planning guidance sets out clear expectations on:
Quality – that agreed CQUIN schemes are delivered in full and the basic
standards on quality are adhered to;
Delivery – that all the core standards are met and that all contracts are
delivered in full;
Sustainability – that all NHS trusts show an improvement trajectory for
surpluses and Financial Risk Ratings for 2013/14 linked to their overall medium
to long term financial plans in their Long Term Financial Model.
4. The Trust was required to submit a final plan by the 5 April 2013 deadline, responding
to written and verbal NTDA feedback in relation to the 25 January and 7 March draft
submissions. They key components of the plan are:
Overarching presentation ‐ to capture the narrative on the last year and the
year ahead, set out the key challenges and development needs and the plans
for the year ahead, alongside the areas of variation where improvement is
expected.
Annex A and B – to identify development and improvement priorities for the
coming year.
Annex C, D and E – to present triangulated activity, workforce and finance
plans.
Annex F Planning checklist ‐ to confirm (self‐certify) that we meet key
requirements in relation to quality, financial planning, workforce planning,
CQUINs, QIPP and the FT pipeline. Action plans are required for areas of noncompliance
2

TB 29/13tt TB 29/13
5. Based on the delegated authority provided at the March Foundation Trust Project
Board, the final submission of the plan was reviewed in detail by the Trust Executive on
the 2 April.
6. The Board is asked to note that the submitted plan is a final draft and that further
iterations and discussions are expected with the NTDA throughout April. It is
anticipated that a final version, agreed between the Trust and the NTDA, will be
available in early May.
7. The robustness of the annual plan will form the basis of the Trust’s agreed FT trajectory
with the NTDA, replacing the earlier process of the Tripartite Formal Agreement (TFA).
PROCESS TO DATE
8. Barts Health submitted an initial annual plan to the NTDA to meet the 25 January 2013
deadline. This plan was still in development, given that our workforce plan (Annex E)
and our improvement and development priorities (Annex A & B) required further work.
9. A second version of the plan was submitted on 7 March including our finance plan
(Annex D) to reflect feedback from the NTDA and to reconcile fully with current
iterations of our CIP plans, workforce and activity plans. We also submitted the
outstanding information from the 25 th January submission (Annex A, B and E).
10. Additional information was also requested from the NTDA on the 28 February and this
was collated and submitted on 7 March 2013. This focussed primarily on
demonstrating improvement plans and trajectories for our key operational
performance targets and clarifying processes for engaging stakeholders in our annual
planning process.
11. A meeting took place between the NTDA and key Trust Executives on 19 March and
feedback was provided around the finance and operational performance elements of
the annual plan. Subsequently, additional queries regarding some of the detail behind
quality arrangements have been raised by the NTDA which have been addressed in the
final, submitted version.
12. Significant work has taken place to generate robust and aligned financial, workforce
and activity plans for submission. The 5 April plan incorporated the latest work on the
quantum and phasing of cost improvement plans and all plans have been reviewed by
a small sub‐group to ensure that they read across to each other.
3

TB 29/13tt
TB 29/13
KEY AREAS TO NOTE
13. The Trust Board is asked
to consider the following:
The NTDA has set s out clear expectations on quality, delivery and sustainability
in the planning
guidance. . It needs to be recognised that from itss current
position, Barts Health has a number of areas where it is challenged in meeting
these expectations.
Specifically the NTDA and commissioners have highlighted:
o The challenging cost improvement
plan for the coming year
o Commissioner supportt and engagement in agreeing a our operating plan is
still at an early stage. At the time of writing, we have not yet agreed our
2013/14 contract. As such, the activity and finance plans which we have
submitted in Annexes C and D remain provisional andd we have not been
able to fully
describe our planning processes for Commissioner QIPPs and
innovation (CQUINs)(
inn the Annex F Planning Checklist.
o Our operational performance, particularly inn relation to A&E waits which
has resulted
in the request for the
submission of improvement trajectories
and action plans to address this area.
We have been prudent inn our responses to thee planning checklist (Annex F).
Where we have
identified actions to ensure compliance in 2013/14 but are not
yet compliant at the timee of submitting our plan, we have recordedd ‘partial
compliance’ and have set out our
planned actions too move towards a
compliant position.
Our improvement and development
priorities in Annex A & B have been
iterated from the versions seen at the
13 March FT Project Board although the
broad themes remain r the same. It is
intended that t these now translate into a
set of formal corporate objectives which the Board will review in May
4

TB 29/13tt
TB 29/13
The Trust is planning a £1m
(0.1%) surplus for the financial year 2013/14 on a
turnover of £1,256m. The key financial assumptions are:
Income:
o 1.3% tariff deflator has been applied to all Paymentss by Resultss income.
This is the national standard
o There iss underlying demographic and non‐demographic growth of
£22m which has largely been
recognised in discussions to date along
with decommissioning of activity for £7m.
o We willl agree QIPP (Quality, Innovation, Productivity, Prevention)
deductions where the evidence base is strong andd this is likely to be
around £30m.
o There will be a £7m increasee for counting and coding improvements
and business rules.
o Commissioners will fund £28m tenders and service development
growth in i year.
o Non‐recurrent income will include merger transitional funding of
£23.8m and £18.1m
for PFI and Project Diamond.
Expenditure:
o Inflationn will be 1.8% for pay, 6.5% for drugs, d 2.7% for clinical supplies,
3.1% forr other operating expenses and 5% % PFI inflation.
o We will deliver £77.5m in recurrent CIP savings.
o We will improve itss cost control by £20mm and theree will be no material
unbudgeted expenditure.
o We will have an £32m capital programme.
Delivering the plan will require robust implementation plans, a programme
management approach inn key areas and an unrelentingg focus on
driving
improvement.
5

TB 29/13tt TB 29/13
Wider engagement and communications around the annual plan is still to be
addressed. We need to ensure that the plan is clearly aligned to our other
plans (Integrated Business Plan, clinical strategy work) to ensure that messages
to internal and external stakeholders are consistent). This process will be
supported by the agreement of the set of corporate objectives referred to
earlier.
KEY RISKS
14. The following table summarises the key risks to delivery of the annual plan.
Risk Mitigation Lead
1 Delivery of cost improvement
plan falls short of the financial
challenge.
2 CIP plans require a step
change in delivery on a
monthly basis and failure to
achieve that from month one
will risk the ability to deliver
the financial position.
Focus by executive team. High
quality programme management
and support programme. Early
action on slippage. Short‐term
non‐pay controls to be designed to
reduce spend to ensure the Trust
remains within the overall budget
within year.
PWC are facilitating discussions
with CAGs to ensure CIP schemes
exist. TX to look at top down
schemes. Additional support posts
from the recovery team to work
with CAGs on design, control and
delivery.
Mark Ogden/
Stephen
Bloomer/ Mark
Cubbon
Trust Executive
3 Workforce CIPs will require
lead‐in time to begin realising
savings
4 Delay in agreeing contracts
with commissioners will mean
that activity plans are not set
at the point of submitting the
annual plan.
TX to look at alternative non‐pay
schemes to be brought forward to
keep the integrity of the CIP
profile.
Contracting team are working with
commissioners and working in an
escalated manner. The annual plan
is based on realistic income
assumptions some of which are
already agreed with
commissioners.
Michael Pantlin/
Len Richards
Mark Ogden
6

TB 29/13tt TB 29/13
Risk Mitigation Lead
5 Lack of alignment between the
annual plan and Integrated
Business Plan (IBP) and Long
Term Financial Model (LTFM).
6 Performance improvement not
delivered in line with annual
plan.
7 Annual plan poorly
communicated to and agreed
with key stakeholders and
CAGs.
8 Internal budgetary control
must be improved to ensure
CAGs deliver to budget. This
requires a £20m improvement
across the organisation.
Ongoing reference to annual plan
in IBP and LTFM preparation.
Performance improvement
strategy and underlying processes
to support delivery of identified
priorities and address operational
performance issues.
Communications plan for sharing
annual plan with CAGs and other
stakeholders. Annual plan and
associated activity to be used as
basis for CAG plans.
Control breaches and issues being
highlighted with suggested
solutions. Basic controls at the
front line level being examined
with rectification plans put in
place.
Frances
O’Callaghan/
Stephen
Bloomer
Len Richards
Frances
O’Callaghan/
Adrienne Noon
Len Richards
FUTURE WORK ON THE ANNUAL PLAN
15. The NTDA will review the annual plan with the Trust to agree a final plan during April
and that CAG plans support the overall delivery requirements in the Trust. Work will
continue on the plan to include:
Communication of the annual plan to inform CAG plans.
Translation of activity and workforce plans into CAG plans.
Ongoing liaison with commissioners regarding the annual plan and its
implementation.
Alignment of the annual plan to finance, workforce and activity assumptions
underpinning the Integrated Business Plan (IBP) and Long Term Financial Model
(LTFM).
RECOMMENDATION
16. The Trust Board is asked to receive the final 2013/14 annual plan as submitted to the
NHS Trust Development Authority on 5 April 2013.
7

TB 29/13tt TB 29/13
Frances O’Callaghan
Director of Strategy 5 April 2013
8

Annual Plan
Overarching presentation
5 April 2013

Purpose
• Stronger together: a reminder why creating Barts Health NHS Trust
was the right decision for the local health and social care economy
• To celebrate our success as Barts Health NHS Trust
• To highlight our progress against our Trust objectives
• Demonstrate our approach to our emerging Trust strategy and
requirements for FT authorisation
• To ensure a common understanding of the challenges and
developments needs for our journey

Stronger together: our case for change
• The need to sustain performance: health needs are
challenging; people living longer with more complex illnesses, a
diverse and changing population; some of the most deprived and
unhealthiest communities; big health inequalities (17 years’
difference in life expectancy compared to national average).
• Financial challenge: growing population; cost of drugs,
techniques and technology outstripping income; foundation trust
status required; historical deficits; estate investment required; the
need to achieve cost improvement plans to contribute to the NHS
£20bn efficiency savings over five years.
• The need to improve: patient experience could be much better;
some services are excellent but far too many needed to improve;
the changing face of healthcare. New understanding of best
practice requires a fresh look at services e.g. ensuring senior
doctors are on site for more hours of the day.

Benefits of creating Barts Health NHS Trust
• A healthcare system that is committed to preventing ill-health as
well as providing excellent health care
• Locally accessible, excellent quality, sustainable and
comprehensive health services that are focused on each
individual’s needs
• Better access to high-quality specialist care when it is needed
• Benefits to staff would benefit patients: staff can gain experience
across the whole patient journey; a bigger trust offers more career
progression, retention of staff; being part of the Academic Health
Sciences Network offers more interesting and rewarding roles for
staff, making recruitment easier e.g. to persistent vacancies

Barts Health NHS Trust
Changing lives together from 1 April 2012

Barts Health at a glance
Waltham Forest
Population 270,702
• 1.25 billion turnover
• 15,000 employees
• Serving over one
million people – our
population is growing
faster than London
and national averages
• 15,000 births
• 1,300,000 outpatient
attendances
Hackney
Population
272,906 (includes
City)
City of London
Barts
Tower
Hamlets
Population 242,618
Whipps Cross
London Chest
Royal London
Mile End
Newham
Newham
Population 333,256

Investing in our community
2012/13 has been an exceptional year of investment across our Trust:
• The brand new Royal London hospital became fully operational
• The second phase of the St Bartholomew’s build remains on
schedule with the London Chest hospital services due to move in
2014
• Brand new maternity services opened at Newham Hospital
• Newham Hospital emergency department underwent a £7m
refurbishment ahead of the Olympic and Paralympic Games
• Our merger secured the necessary capital funding for a larger and
refurbished maternity unit at Whipps Cross Hospital and £23m was
invested in a new emergency department
• Newham Hospital received a brand new CT-scanner
• We started offering maternity services from Barking Birth Centre
• Barts Health NHS Trust was highly commended in the Health
Service Journal Award in the ‘Workforce’ category for its
Community Works for Health programme which aims to boost
local recruitment and retention of key groups of staff

Investing in our people
• Our new structure is based on eight Clinical Academic Groups which
went live on 1 October 2012 alongside the supporting corporate
functions
• A dedicated development programme is underway to ensure we
build our leadership capacity and deliver on the key themes we have
heard from our stakeholders during our merger engagement:
‣ ensuring financial stability for future generations
‣ providing patient choice, bringing care closer to home and
improving patient outcomes
‣ taking our staff on the journey
‣ Improved engagement and communications; and
‣ working in partnership with statutory leaders, public and
private organisations and the wider community

Achievements in our first few months
• Our Clinical Academic Groups went live on schedule
• Our new Trust vision to change lives, and our values and
behaviours were developed in partnership with staff, patients and
our partners
• We are investing in our staff with a
new education academy and
dedicated organisational
development team
• Our organisational development
programme has seen us survey all
of our staff to secure a baseline for
improvement, host our first Barts
Health Heroes awards ceremony
reward and develop an emerging
staff reward and recognition
programme

• We have established a Patient and
Public Forum, with members of the
public sitting on our Clinical Academic
Groups from February and a Local
Authority Forum to guide us. Both will
be our base to build our Board of
Governors when we attain Foundation
Trust status
• We are currently developing our brand
standards to articulate the level of
consistent service that our patients can
expect
• The patient experience is a standing
item in our Trust Board meetings, with a
patient story shared at each meeting

• We are actively engaged in the Academic
Health Sciences and UCL Partners
reviews to improve services to local people
• Our public health strategy was launched in
August and our Community Works for
Health employment team were highly
commended at the HSJ awards
• Shortly we will be launching our innovative
Integration Performance Framework based
on four premises: what do our patients,
staff, partners and regulators think of us?
In time we will be able to report this down
to each service we offer

• Recognised as a leading Trust
nationally in Standardised Hospital
Mortality (SHMI) one of the key
recognised indicators on the quality of
care that hospitals provide
• Hyper Acute and Acute Stroke Unit
recognised as best organised in Royal
College of Physicians national audit
• First London Trust to be awarded the
prestigious Baby Friendly Initiative
accreditation by UNICEF to promote
and sustain breastfeeding in both
hospital and community settings

What we have achieved in Year 1
Changing lives

Objective
Our outcomes
Deliver minimum national
standards set out in our
Operating Framework
including A&E, 18 weeks
RTT, cancer access and
MRSA
Lead Executive:
Chief Operating Officer
Trust Objectives 12/13
• The Barts Health Standardised Hospital Mortality (SHMI) continues
to indicate ‘better than expected’ comparative performance and we
are in the top ten in the country.
• MRSA bacteraemia – the Trust’s year to date total is 11, three
above the Barts Health combined target of 8
• Clostridium Difficile – year to date total is 68. Performance remains
within the monthly and end of year trajectories.
• Targeted infection prevention and control training continues as a
key improvement priority objective, e.g. Non Aseptic Non-Touch
Technique training is now being rolled out at both Newham and
Whipps Cross Hospitals.
• Stop and Wash social marketing campaign across the Trust
• Agreed internal Barts Health divert process with the London
Ambulance Service
• Recruitment to a full consultant establishment at WX for the first
time in at least three years
• Demonstrable reduction in grade 3 and 4 pressure ulcers
• We continue to miss 62 day cancer wait targets but we have a
clear improvement plan in place.

Objective
Our outcomes
Achieve the three quality
improvement priorities to
keep patients better
informed about their care,
to improve feedback given
to staff whey they raise
quality and safety
concerns, and to improve
our patient administration
systems
Lead Executive:
Chief Nurse / Medical
Director / Chief Operating
Officer
• The Outpatient Transformation Board is reviewing patient letters
and information
• All Barts Health staff (15,000) have been invited to participate in
the staff survey
• CRS upgrade at three of our six hospitals
• Working with primary care to integrate some of our electronic
patient records
• Patient literature review underway
• Revised interpreting and advocacy arrangements
• Friends and Family Test phased roll out from December 2012
• We are launching our Caring and Compassionate Campaign on 8
March 2013
• We have a Quality Collaborative underway across the Trust
• Our Trust Board dedicates the first hour of its business every
month to hear a patient story
• Since the establishment of our CAG structure our senior nurses
have undertaken Clinical Friday where they are all in uniform and
working on the wards across the Trust. This is complemented by
the First Friday of the month when all Barts Health leaders are
visible throughout our hospitals.

Objective
Our outcomes
Implement a plan to improve
patient experience and
satisfaction, including a focus on
outpatients appointments
Lead Executive:
Chief Nurse /Chief Operating
Officer
• The Outpatient Transformation Board led by a CAG Group
director is reviewing all patient letters and literature
• A Patient Forum has been established to represent patient
views, reporting directly to the Trust Management Board.
• Patient representatives are sitting on each of our CAG
Boards
• We have built closer relationships with the local BME media
to promote health messages and we are now producing
bilingual press releases
• We have created a new Bilingual Health Advocacy and
Interpreting Service (BHAIS) to provide patients, relatives
and carers with easy access to translators, sign language
interpreters and support those with learning disabilities
• Newham Language Shop provides us with a 24/7
interpreting telephone service
• We work closely with all of our Local Involvement Networks
and look forward to working with Healthwatch

Objective
Our outcomes
Implement a plan for improved
communication and joint working
with GPs
Lead Executive:
Medical Director
• Barts Health has a director of primary care and two
associate directors, all of which are GPs in our local area to
act as a link with primary care
• Monthly quality review meetings are undertaken in each of
our boroughs
• Quarterly general meetings are coordinated in every
borough and used as networking events
• We have hosted two GP / consultant dinners to build
relationships
• We attend CCG and LMC meetings regularly throughout the
year
• CCGs and Barts Health are actively engaged in the
Integrated Care agenda with local authority partners
• We are working on a joint ICT system to share patient
records
• A GP specific section has been developed for our new Trust
website and we have a monthly GP News publication
• Barts Health also has a public health team who regularly
engage with primary care.

Objective
Our outcomes
Deliver Transforming Community
Services objectives for three
improvement areas in Tower
Hamlets
Lead Executive:
Chief Operating Officer
• Improving care for children with long-term conditions at
home following discharge and improving the coordination of
care for children
• Continuing to reduce unnecessary referrals where care can
be provided in the community and in primary care
• Improving pathways in specific care pathways such as
obesity and incontinence
• Complex children’s community services will be moved into
the Children’s CAG from April 2013
• Launched consultation with staff and stakeholders in
February 2013 into a delivery model for the integrated care
programme for frail elderly
• Developing how we share patient information across the
care pathway through improved informatics
• Establishing a strategic partnership group to agree a joint
vision, system objectives and support joint working on end
of life care.
• Taking part in "Communicate My Care" - a system which
allows clinicians ease of access to care plans and patient
preferences

Objective
Our outcomes
Provide an environment that
supports staff to embed the
Trust’s values
Lead Executive:
Development Director
• All of our 15,000 staff were surveyed in order to have a
benchmark results for our first year; this information can be
cut by professional group, CAG and hospital etc
• Our staff developed our vision and values, with 1500 taking
part in shaping these and our behaviours
• We hosted our first Barts Health Heroes Awards in January
2013 after a campaign across the Trust celebrating individuals
and teams that embody our Trust values and behaviours
• Our OD team is developing a leadership development
programme (360 appraisals have commenced for our top
250); we have a new Trust wide appraisal process launching
in April 2013 – this will include a talent management
approach; and we have a ‘you said, we did’ campaign in the
making, matching our staff and patient survey results
• We have a full embedding programme for our OD
programme, working with leaders throughout the organisation
to empower their staff.

Objective
Our outcomes
Deliver the Trusts 2012/13
financial plan, and cost
improvement target, and
develop a sustainable long term
financial plan (LTFM)
Lead Executive:
Chief Financial Officer / Chief
Operating Officer
• Our new finance team is now completely in place after a
lengthy recruitment process to find the very best staff
• We have integrated our legacy Trust financial teams and
reconciled the Trust budgets into a single Barts Health ledger
• We have leveraged major non-pay savings e.g. £1m on
cardiac implants, £750k on hip and knee joints.
• £50m in efficiency savings have been made in 2012/12
• We are forecasting to breakeven for 2012/13
• 120 management and administrative posts have been made
redundant in this year
• Our efficiency savings target for 2013/14 is £77.5m with
similar annual requirements going forward
• The Trust is current going through a robust challenge session
with our CAGs to ensure we have CIP schemes that will
deliver in 13/14, including Independent Assurance Panels,
consisting of peers.

Objective
Our outcomes
Develop service line
management, ownership and
capability through Clinical
Academic Group (CAG)
structures
Lead Executive:
Chief Operating Officer / Chief
Financial Officer
• We have an established Clinical Academic Group (CAG
structure) which went live on 1 October 2012.
• Each CAG is led by a Group Director, Operations Director
and a Director of Nursing and Governance
• Clinical Directors have been appointed across all specialties
• Our teams work across Barts Health and the six hospitals that
we operate.
• Each of the CAGs has a central location within one of our
hospitals who also provide leadership alongside their
deputy/associate chief operating officer and deputy/associate
chief nurse colleagues
• Service line reporting is being rolled out across the Trust
• We have developed an Integrated Performance Framework
based on four quadrants: What our patients, staff, partners
and regulators think of us. Each speciality will have a monthly
report but can review the information on a daily basis if
necessary.
• Each CAG is subject to a monthly performance review.

Objective
Our outcomes
Deliver the post-merger
integration plan including the
clinical due diligence action plan
and corporate and clinical
services management
integration
Lead Executive:
Development Director
• Our integration plans are complete at the end of 31 March
2013 when we move into our service improvement phase.
• The actions from our merger clinical due diligence review
have now all been closed or are being taken forward in our
service improvement programme, care quality collaborative or
are now part of our mainstream priorities.
• We are also working with all staff to implement the Francis
Review recommendations and to engage with our 15,000
strong workforce
Prepare a growth plan for
clinical trial take-up and an
ambitious but realistic growth
plan for R&D income
Lead Executive:
Director of Academic Health
Sciences
• We have increased the numbers of patients participating in
NIHR adopted research by 10%
• We have increased the numbers of active researchers by
over 10%
• We have increased externally funded research project
expenditure by over 5%
• Strong commercial clinical trial activity has been developed to
support local and national wealth creation
• We are founder members of UCL Partners Academic Health
Sciences Centre and have helped shape the new network.
• We have been working hard with our local communities since
October 2012 to demystify and explain the importance of
clinical trials, and to get patient input into trial design.

Objective
Our outcomes
Agree a Foundation Trust
authorisation trajectory and
achieve all milestones
Lead Executive:
Director of Strategy
• We have just appointed to our FT programme Lead who will
join Barts Health in April 2013
• We intend to enter the formal FT progress in October 2013
with a view to authorisation in April 2016, if not before
• We are in active discussions with the NTDA about our
timescale for authorisation and milestones
• We are already making good progress against many of the
elements required to achieve FT status
Develop a comprehensive
strategy for Barts Health
Lead Executive:
Director of Strategy
• The Barts Health Board reviewed our emerging strategy at
our Board meeting in February
• All of our CAGs have engaged in this process: fact,
judgement, choice. We have completed phase one of our
process and our clinical leaders are now making their
judgement on their strategic directions. Our Trust Board
receives monthly updates through out FT Project Board and
we have an established FT Executive committee and an FT
Working Group to support our journey

Objective
Our outcomes
Agree a commercial strategy
and property development
programme
Lead Executive:
Development Director
• An appointment has just been made to the position of director
of redevelopment
• Progress on our property development programme requires
our Trust strategy to be defined
• This portfolio will now be led by the Executive Director of
Strategy
• We have started conversations with the London Borough of
Tower Hamlets over our joint vision for the Whitechapel area,
where the Royal London is located.
• The St Bartholomew’s phase two development is progressing
well and we have an agreement in principle with UCLH to
move the Heart Hospital to be located with the London Chest
on this site in 2014 (subject to consultation and regulatory
approvals)
• We have a maternity capital investment programme underway
at Whipps Cross Hospital, which will also support the
implementation of Health for north east London

Quality Objectives 12/13
Quality Objectives
1. To keep patients (and their carers) better informed about their care and treatment,
so that they feel safe and involved before and after they leave the hospital, and
able to make informed choices.
2. To improve the feedback given to staff when they report and raise quality and
safety concerns.
3. To improve our patient administration systems, with a focus on the quality
standard and timeliness of letters and discharge summaries that we send to GPs.
We will continue to work in partnership with GPs to deliver a high quality clinical
service with the best possible outcome for every patient

Quality Objective One 2012/13
To keep patients (and their carers) better informed about their care and treatment, so that they
feel safe and involved before and after they leave the hospital, and able to make informed
choices.
Outcomes to date
• Patient literature review underway
• Revised interpreting and advocacy arrangements
• Friends and family test phased roll out from December 2012
• We are launching our Caring and Compassionate Campaign on 8 March 2013
• We have a Quality Collaborative underway across the Trust
• Our Trust Board dedicates the first hour of its business every month to hear a patient story
• Since the establishment of our CAG structure our senior nurses have undertaken Clinical
Friday where they are all in uniform and working on the wards across the Trust. This is
complemented by the First Friday of the month when all Barts Health leaders are visible
throughout our hospitals.
• Intentional rounding – a check of the basic care needs of every patient every one to two
hours. We are delivering this already across all of our wards – but we need to ensure that
we do this consistently and to the same standards

Quality Objective Two 2012/13
To improve the feedback given to staff when they report and raise quality and safety concerns.
Outcomes to date
• Since the establishment of our CAG structure our senior nurses have undertaken Clinical
Friday where they are all in uniform and working on the wards across the Trust. This is
complemented by the First Friday of the month when all Barts Health leaders are visible
throughout our hospitals.
• Clinical Safety Net – this measurement tool supports our senior sisters and charge nurses
to see how issues such as changes to staffing levels affect quality indicators (e.g. pressure
ulcers, falls, and needle stick injuries). This information allows senior staff to gauge how
safe their environment is and to escalate concerns.
• All Barts Health staff (15,000) have been invited to participate in the staff survey and local
teams are being empowered to question behaviours which are not in line with those
agreed for Barts Health as well as supporting them to improve our engagement throughout
the organisation

Quality Objective Three 2012/13
To improve our patient administration systems, with a focus on the quality standard and
timeliness of letters and discharge summaries that we send to GPs. We will continue to work
in partnership with GPs to deliver a high quality clinical service with the best possible outcome
for every patient
Outcomes to date
• The Outpatient Transformation Board is reviewing patient letters and information
• We have had a major CRS upgrade at three of our six hospitals, with further upgrades
planned across Barts Health in the next year
• We are working with primary care to integrate some of our electronic patient records
• We meet primary care colleague on a monthly basis to discuss issues and we have a
dedicated primary care team who liaise with our partners on a daily basis.

Our plans for the future
Changing lives

Trust objectives 13/14
Our Trust objectives for 13/14 are currently being considered but have
not yet received Board approval.

Quality Priorities 13/14
Our Trust objectives for 13/14 are currently being considered and are awaiting Board
approval.
It is expected that these will build on our 12/13 priorities in the following areas:
Have Free Care within all our wards and departments
A quality improvement intervention via a single methodology – The Care Quality
Improvement Collaborative (QIC). The areas this will cover are:
• Falls Improvement
• Pressure Ulcer Improvement
• Acutely Ill (deteriorating patients)
• MRSA/C Diff
• Surgical safety Improvement to reduce the incidence of surgical related never
events
To ensure the patients gets to the right place, first time (lost patient)
• Reviewing the length of stay, via the Health Care Program . Defined metrics will
be agreed, aligned to best practice, benchmarking data and monitored.

Quality Priorities 13/14 continued…
Executive use of the SHMI
• To establish effective mortality review systems, to ensure learning is shared
and practice is evidence based.
Improving Standards of Care for older people via the Older Peoples Program
• This program is to encompass mental Health Care and Learning Disabilities
Improvement.
Patient experience
• To improve patient experience, enhance communication to families and carers
about their care. To enhance the actual giving of care to our patients, providing
care with dignity and compassion via the Care Campaign
Staff engagement
• To improve staff engagement and develop a culture whereby every individual
is valued and understands how they can improve quality of care, and that
when staff do raise concerns about quality and safety they are listened to and
we are open and transparent in the lessons that are learnt

How we will deliver a Barts Health Strategy
• It is acknowledged that a Trust wide strategy needs to be
embedded in our operational model, and it has been agreed that
all service lines will need to engage in the strategy process over
the next 12 months. To enable this, numerous conversations have
taken place with clinical leaders and will continue over the coming
months.
• All service lines are being asked to commit to brand standards of
excellence: all services have an opportunity to be involved in their
development through their clinical and CAG leaders.
• A first draft of our emerging strategy was shared with our Board in
February 2013. We will shortly be writing to our partners to ask for
their input.

How we are approaching our strategy development
Changing lives
An academically based health system
delivering excellent clinical outcomes and health improvement
Values
▪ Caring and Compassionate
▪ Listening and understanding
▪ Working together to achieve
ambitious results
▪ Improving and Innovating
▪ Valuing every member of staff
Strategic
initiatives
3
Selected clinical
distinctiveness
4 5 6 7
Integrated care Population
health
Research
excellence
Teaching and
training
excellence
Foundations
to become a
successful FT
1 Brand standards: Consistently excellent quality and delivery
2
Clinical and financial sustainability, enabled by SLR (achieved via basic cost
management & CIPs, commercial and partnership opportunities, service redesign)
Strategic enablers
a. Board and quality governance
b. Clinical Leadership
c. Informatics and Systems
d. HR, OD & Workforce
e. Performance management
f. Estates optimisation

Introduction to selected distinctiveness: Barts Health thinks
about its portfolio of services as falling into three broad categories
All services need to meet
brand standards on
▪ Quality, Safety and Patient Experience
▪ Delivery and Operational efficiency,
including finances
▪ Basic research and teaching
▪ Staff and patient engagement
Brand standard
performers
One or two globally
acknowledged truly
distinctive service lines, that
bring International renown
and acclaim for Barts Health
along the dimensions of
▪ Reputation and Recognition
▪ Research power
▪ Excellence in Teaching and
Training
▪ World class infrastructure and
investment levels
Deep local
impact, nationally
acclaimed, world
class
World
leading
A subset of services
which excel on all the brand
standards and also
▪ Are critical to addressing
local population needs
▪ Have significant
opportunity to develop a
nationally distinctive
profile within Barts
Health, through
partnerships
▪ Have healthy current
and future scale and
margins

Service improvement programme approach
Our service improvement approach is currently being refined and has
not yet received Board approval.

Our approach to Cost Improvement
• We have a clear approach established to ensure that we deliver on
our cost improvement programme for 2013/14
• We need to achieve a CIP of 6.5%, equating to £77.5m next year
and going forward
• Our CAG teams are working on the detail of our programmes with
support of our corporate services
• We will have a detailed programme management approach to
enable delivery
• Our control systems are also being firmed up to ensure that we
have a firm grip across the organisation to ensure CIP delivery and
efficiency whilst maintaining high quality levels of care.

The challenge ahead
• Our merger was only one step in the right direction and we knew
we would still need to work hard to improve services, reduce
health inequalities and would have to find the same efficiencies
over the next five years or attract more income or funding.
• We are almost through the first year of our roadmap: integration
and we have delivered on our ambitions.
• In our merger full business case we outlined year two as a focus
on service improvement, and delivery of our clinical and patient
experience improvements and financial benefits of our merger. To
enable this we have an established leaders forum, clear
expectations regarding cost improvement plans and an emerging
Trust strategy.
• Year three and beyond will be our transformation stage including
larger scale pathway redesign information by our finalised Trust
strategy.

Our merger five year plan…
In our merger full business case we outlined the following outcomes
that we intend to achieve within five years:
• Achieving among the lowest rates of hospital mortality
• Achieving among the lowest rates of defects and hospital
associated harm in the NHS
• Being a quality leader among NHS Trusts – consistently among
the highest ranking in national quality indicators and top
performers in national patient surveys
• Being the employer of choice for staff, supporting their health and
wellbeing and helping them to thrive in their work
• Achieving authorisation as a NHS Foundation Trust
…these remain our focus.

Annex A – Improvement priorities
Annex A – improvement priorities
Deliver a reliable Patient Administration System
Engage staff in the pursuit of high quality, compassionate services, as demonstrated by an improvement in the staff
survey results
Enhance the patient experience, as demonstrated by a significant improvement in the patient survey results
Drive consistency of clinical practice across the sites levelling up to the “best in Barts Health”
Achieve all the performance and quality standards set out by our regulators, commissioners and set out in our
annual Quality Priorities
Barts Health NHS Trust – Annex A – Improvement priorities v3.2 draft 5 April 2013

Annex B – Development priorities
Annex B – development priorities
Develop joined up informatics systems
Strengthen capacity and capability at all levels within the organisation
Working with partners to improve population health and reduce inequalities
Develop an innovative Integrated Care model to improve care for the local population
Develop a Barts Health improvement system
Barts Health NHS Trust – Annex B Development priorities – v3.2 draft 4 April 2013

Financial Briefing
2013/14 Annual Plan
Trust Board
10 th April 2013

Purpose of the Briefing
The briefing is based on a briefing given to the Trust
Development Agency and explains the annual plan moving from
the outturn of 2012/13 to the submitted plan covering the key
financial assumptions and areas of risk.
2

2012/13 forecast outturn to underlying position
The trust 2012/13 outturn
The Trust will achieve a break-even position
The trust will have an underlying
deficit of £46m at the end of
2012/13 (3.9% of income)
The 2012/13 underlying position
excludes £101.7m non-recurrent
income and £50.5m nonrecurrent
expenditure
The Trust’s underlying deficit has deteriorated from £11m to £46m during
2012/13 (a £35m deterioration) mainly due to:
1) Changes in SLA activity levels. Our lead commissioners have recently
agreed to a higher recurrent activity and income baseline in 2012/13 mainly
due to failed commissioner QIPP and increased non-elective activity.
Although this income has not been fully paid for in 2012/13 due to our block
contract arrangements, this is the revised income and activity starting
position for 2013/14 SLA negotiations.
2) Changes in planning assumptions, e.g. 1% coding benefit not achieved
3) Material reliance on transitional funding to deliver the in-year position
4) The trust set a challenging CIP program for 2012/13 to mitigate cost
pressures and changes in planning assumptions. The actual forecast
c£40m recurrent CIP delivery is marginally less than the £45m (3.9%)
recurrent CIP assumed in the FBC LTFM
The £101.7m non-recurrent income comprises of:
£10.5m Agreed additional commissioner support
£49.4m FBC merger funding
£18.8m NHS Bank PFI transitional funding
£ 9.2m Project Diamond (excluding MFF)
£ 8.3m Additional income related to the cost of PDC cash support
£ 5.5m Financial support to cover one-off year end expenditure pressures
The £50.5m non-recurrent expenditure comprises of:
£16.9m Merger costs
£18.6m NHS Bank PFI transitional costs
£10.5m Excessive use of bank and agency
£ 4.5m Additional asbestos provision
The underlying position has also been adjusted for the £7.8m CIP delivered
non-recurrently in 2012/13 and an £8.7m full year effect benefit generated by
the pay spend reduction program.
3

Bridge 3: 2012/13 forecast outturn to underlying position
4

4: 2013/14 Income and Expenditure plan
5

4: 2013/14 Income and Expenditure plan –
Income Assumptions
Key income assumptions • 1.3% national tariff deflator
• £22m SLA growth (demographic and nondemographic)
• (£30m) commissioner led QUIPP and productivity
schemes
• (£7m) commissioner decommissioning deduction
• £7m counting and coding improvements and business
rules impact
• £28m other growth (tenders and service
developments)
• There will not be a material PbR gain or loss from the
2013/14 tariff or grouper
• Non-recurrent merger transitional funding of £23.8m
• Non-recurrent other income of £18.1m (PFI and Project
Diamond)
Total income includes £42m of nonrecurrent
income
SLA growth and coding gains are
necessary to keep the cost savings target
at 6.5%
The £42m non-recurrent income comprises of £23.8m
merger funding and £9.2m NHS Bank PFI support, both in
line with the merger FBC and Project Diamond income of
£9.0m (2012/13: £9.2m).
SLA growth includes income for additional activity from
demographic growth, service developments in renal and
additional pass-through drugs income.
6

4: 2013/14 Income and Expenditure Plan –
Income Assumptions
There are significant risks in our plan due
to uncertainty around commissioner QIPP
(demand management and
decommissioning)
Our lead commissioners have indicated an annual SLA
QIPP/demand management pressure of £100m which is
20% reduction. Our 2013/14 draft plan assumes total SLA
demand management and decommissioning of £37m.
This is broadly in line with the £36m planned
commissioner QIPP in 2012/13. Further work is required
with commissioners to understand the reasonableness
and robustness of their proposed £100m QIPP target for
2013/14. The trust cannot accept any demand
management plans without robust evidence and
milestones for delivery. Evidence in 2012/13 is that
demand is not being managed, particularly at Whipps
Cross and The Royal London sites. SLA discussions with
commissioners are on-going and may require arbitration if
a satisfactory agreement cannot be reached.
7

4: 2013/14 Income and Expenditure Plan -
Expenditure Assumptions
Key expenditure assumptions • 1.8% pay inflation (incremental drift and wage
inflation)
• 6.5% drug inflation
• 2.7% clinical supplies inflation
• 3.1% other operating expenses inflation
• 5% PFI inflation
• £77.5m CIP savings requirement
• No material unbudgeted expenditure
• £25m capital expenditure
Total expenditure includes £16.1m of nonrecurrent
spend
The overall expenditure decrease of £4.9m
includes increases for inflation in line with
NHS national planning guidance, offset by
planned cost savings target of £77.5m
The plan assumes £16.1m non-recurrent
expenditure comprising of £10.1m FBC merger
transition costs and £6.0m NHS Bank PFI transition
costs, both in line with the FBC.
Identification and implementation of CIPs is being
led by the trust PMO supported by PwC. Work to
date has identified around £100m of savings
opportunities. The trust will embed CIP schemes
directly into agreed budgets and workforce planning.
The trust has been playing ‘catch up’ during 2012/13
because of the lack of identified schemes at the start
of 2012/13. Clinical engagement through the CAGs
has been strengthened and will be much stronger
than in 2012/13.
8

4: 2013/14 Income and Expenditure plan –
Cost Improvement Programme
Total Total
Q1 Q2 Q3 Q4 2013/14 2014/15
£000s £000s £000s £000s £000s £000s
Pay
Headcount recovery programme 2,356 2,356 2,356 2,357 9,425 10,800
Medical productivty 501 501 501 501 2,004 2,000
Other workforce productivity 465 465 465 465 1,860 2,000
Outpatient productivity 2,135 2,135 2,135 2,135 8,540 3,500
Pathways & service development 1,111 1,111 1,111 1,112 4,445 3,000
Reduction in LOS schemes 1,148 1,148 1,148 1,148 4,592 2,000
Skill mix/ structure 2,088 2,088 2,088 2,086 8,350 3,000
Theatre Efficiency 750 750 750 750 3,000 3,600
Unidentified CIPS 2,946 2,946 2,946 2,946 11,784 20,000
Pay Total 13,500 13,500 13,500 13,500 54,000 49,900
Non-Pay
Corporate (Estates) efficiencies 1,203 1,203 1,203 1,201 4,810 3,000
Diagnostics 2,544 2,544 2,544 2,544 10,176 4,000
Trustwide procurement savings 1,625 1,625 1,625 1,626 6,501 8,000
Unidentified CIPS 504 504 504 504 2,016 12,300
Non-Pay Total 5,876 5,876 5,876 5,875 23,503 27,300
Total 19,376 19,376 19,376 19,375 77,503 77,200
*The current submission to the TDA shows a backloaded CIP, but this will be changed to 1/12ths for the final submission
9

2013/14 Cost Improvement Programme
by CAG
Analysis of Targets
By Scheme Category
CAG - Existing Structure
Annual
Target
2012/13
Shortfall
FYE of
2012/13
New
Schemes Total
£m £m £m £m £m
Ambulatory Care 10.1 3.3 0.5 6.4 10.1
Cancer 4.1 1.8 0.0 2.2 4.1
Cardiovascular 4.8 1.6 0.6 2.6 4.8
Childrens Serivces 3.2 0.6 0.0 2.6 3.2
Clinical Support Services 10.3 2.4 0.5 7.5 10.3
ECAM 9.6 1.6 0.4 7.6 9.6
Surgery 12.2 3.4 0.4 8.4 12.2
Womens Services 5.9 2.2 0.0 3.7 5.9
Corporate 17.3 5.9 0.1 11.4 17.3
Total 77.5 22.7 2.5 52.3 77.5

4: 2013/14 income and expenditure plan –
key risks
SLA with our lead commissioners has not
been agreed
Development of the 2013/14 cost savings
program is behind schedule
Tighter cost control and budget monitoring
will be required in 2013/14
The main contracts for 2013/14 have not been
agreed with either our local or specialist
commissioners. The ability of the CAG’s to release
full costs in response to downward contract changes,
is limited in the short-term.
The finalisation and delivery of the Trust’s CIP plans
presents a key risk to delivery of the trust’s plan
surplus of £1m. The planned target at 6.5% of
income represents a significant challenge to the
CAGs, particularly bearing in mind performance on
the 2012/13 CIPs. Plans are being finalised under
the Trust’s Recovery Plan, which will be reported
separately.
Internal budget variances have been identified as
part of the budget setting process. However, further
work is required to determine the extent to which
these are attributable to poor budgetary control, or to
genuinely unavoidable cost pressures. The
assumption within the provisional budgets that have
been set is that internal cost pressures will be dealt
with by the CAGs and Corporate, as part of their
business planning process, rather than to increase
the CIP above £77.5m.
11

Statement of Financial Position

Statement of Financial Position Key
Assumptions
Key balance sheet and cash flow
assumptions
The plan assumes cash funding of £64.7m in
Q1
• £79m PFI addition for Royal London (Phase 2)
• £28m estimated PFI impairment
• £32m other capital expenditure
• £65m PDC cash funding receipts (see below)
• £62m pay down of loans and creditors to improve
liquidity position
• £88m closing cash balance target by 31 March
2014
The merger FBC outlined the need for cash funding.
The trust is seeking to draw-down the full entitlement
to funding as set out in the FBC. This comprises of:
• £26.7m funding that was due in 12/13
• £14.0m funding for the capital program
• £24.0m additional funding to improve liquidity

Report to the Trust Board: 10 April 2013 TB 30/13
Title
Information Governance (IG) Toolkit
Sponsoring Director Director of Corporate Affairs and Trust Secretary
Author(s)
Information Governance Manager
Purpose To ratify the IG Toolkit submission for 2012/13.
Previously considered by Trust Management Board, 9 April 2013
Executive summary
2012/13 has been a year of transition for the IG function. While we are confident that
standards of IG within Barts Health are as high as, and in some cases higher than, in the
pre‐merger legacy trusts, a single IG Team for the new organisation did not come into
place until 1 October 2012 and work is continuing to develop and implement unified IG
policies, procedures and systems across all our sites. A key consequence of this for an
assessment such as the IG Toolkit, which relies heavily on having evidence of embedded
systems and processes, is that the scores for the first year of the new Trust are lower
than those in the legacy organisations. Good progress has been made in many cases on
implementing a Barts Health wide approach but this is not yet universal. Moreover, we
need time to build up evidence that staff are aware of the new arrangements and they
are working effectively. A deliberately cautious approach has therefore been taken to
scoring this year. Compliance with 32 of the 45 IG Toolkit requirements has been
assessed at the required Level 2 or above. 11 requirements have been assessed at Level
1 and 2 requirements have been assessed at Level 0. This gives an overall rating for
2012/13 of ‘Not Satisfactory’ (with a corresponding percentage of 57%).
Related Trust objectives
9. Deliver the post‐merger integration plan including the clinical due diligence action
plan and corporate and clinical services management integration.
Risk and Assurance
Related Assurance
Framework entries
Key information governance risks are monitored by the
Information Governance Committee, which is chaired by the
Trust’s Senior Information Risk Owner.
n/a
Legal implications/
regulatory requirements
The Trust is required to make an annual submission to the
Department of Health by 31 March 2013.
Action required by the Board
The Trust Board is asked to:
Ratify the Trust’s 2012/13 Information Governance Toolkit submission.
Note the proposed key Information Governance priorities for 2013/14.
1

TB 30/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
INFORMATION GOVERNANCE TOOLKIT
INTRODUCTION
1. Information Governance covers the way in which the NHS manages all types of
information, in particular the personal and sensitive information of patients and
employees. Fundamentally, an effective Information Governance framework
gives organisations and individuals the confidence that personal information is
being dealt with legally, securely, efficiently and effectively, in support of
delivering the best possible standards of clinical care.
INFORMATION GOVERNANCE TOOLKIT
2. The Department of Health’s Information Governance Toolkit (IGT) is an annual
mandatory self‐assessment of how NHS acute trusts are performing against a
range of 45 separate requirements spanning the six initiatives of Information
Governance. Each standard must be rated on a scale of 0 to 3:
0 No compliance
1 Weak compliance
2 Adequate compliance
3 Full compliance
Trusts are required to meet a minimum of Level 2 for all 45 requirements in
order to achieve an overall ‘Satisfactory’ level of compliance on the Toolkit.
3. NHS organisations have had to make three toolkit submissions during 2012/13: a
July 2012 baseline assessment, an October 2012 performance update and the
final submission by 31 March 2013. At its meeting on 6 March 2013, the Trust
Board delegated authority to the Chief Executive to sign off the Barts Health final
submission. This was completed on 28 March 2013.
4. Trusts’ submissions are subsequently used by other organisations such as the
Care Quality Commission, the NHS Litigation Authority and the Information
Commissioner’s Office, to support the wider NHS compliance and information
management framework. For example, the CQC uses a number of the IG Toolkit
standards as indicators of potential non‐compliance for the Records Outcome
(Outcome 21) of the Essential Standards of Quality and Safety.
2012/13 PERFORMANCE
5. As in many other areas of Barts Health, 2012/13 has been a year of transition for
the information governance function. While we are confident that standards of
2

TB 30/13
information governance within Barts Health are as high as, and in some cases
higher than, in the pre‐merger legacy trusts, a single IG Team for the new
organisation did not come into place until 1 October 2012 and work is continuing
to develop and implement unified IG policies, procedures and systems across all
our sites.
6. A key consequence of this for an assessment such as the IG Toolkit, which relies
heavily on having evidence of embedded systems and processes, is that the
scores for the first year of the new Trust are lower than those in each of the
legacy organisations. Good progress has been made in many cases on
implementing a Barts Health wide approach but this is not yet universal.
Moreover, we need time to build up evidence that staff are aware of the new
arrangements and they are working effectively. A deliberately cautious
approach has been taken to scoring this year.
7. Each IG requirement has an assigned lead and a senior manager, generally at
Director level, who is responsible for signing off the proposed score and
confirming that it is supported by appropriate evidence. Their reviews of
compliance have been supported by the findings of an Internal Audit of a sample
of the IG Toolkit requirements, particularly in relation to information security.
The Internal Audit work to date has confirmed the IG Team’s own assessment of
the need to build a stronger evidence base for a number of the requirements as
further integration and embedding of systems and processes is completed.
8. Table 1 below sets out the 2012/13 IG Toolkit scores for Barts Health, as
endorsed by the Trust’s Information Governance Committee:
Total number of requirements
Level 0 Level 1 Level 2 Level 3 Total
Overall
Score
IG Management 0 2 3 0 5 53%
Confidentiality and
Data Protection
0 2 6 1 9 62%
Information Security 2 2 11 0 15 53%
Clinical Information 0 2 3 0 5 53%
Secondary Use 0 3 5 0 8 54%
Overall
Grade
Not
Satisfactory
Not
Satisfactory
Not
Satisfactory
Not
Satisfactory
Not
Satisfactory
Corporate Information 0 0 2 1 3 77% Satisfactory
Overall 2 11 30 2 45 57%
Not
Satisfactory
Key:
Satisfactory:
Not Satisfactory:
Achieved attainment Level 2 or above on all requirements
Not achieved attainment Level 2 or above on all requirements
3

TB 30/13
9. In summary, compliance with 32 of the 45 requirements has been assessed at
the required Level 2 or above. 11 requirements have been assessed at Level 1
and 2 requirements have been assessed at Level 0. This gives an overall rating
for 2012/13 of ‘Not Satisfactory’ (with a corresponding percentage of 57%).
10. For information, each of the three legacy trusts also scored ‘Not Satisfactory’ in
their 2011/12 submissions, albeit with a lower number of Level 1 and no Level 0
scores.
11. The main areas of non‐compliance are as follows:
IG Management: all staff to have undertaken annual mandatory IG
training and passed a test of comprehension (currently the figure is
under 50%); and all contracts to include robust IG requirements.
Confidentiality and Data Protection: consolidation of data flow
mapping work; and embedding a single Subject Access Request
process.
Information Security: all information assets are risk assessed and
managed, with up‐to‐date and tested business continuity plans; and
appropriate use of pseudonymisation and anonymisation techniques.
Clinical Information: monitoring, auditing and tracing clinical records
across all specialties.
Secondary Use: comprehensive data quality completeness and
validity checks.
2013/14 INFORMATION GOVERNANCE WORK PROGRAMME
12. A key priority for the 2013/14 Information Governance work programme will be
to raise the Level 0 and Level 1 scores to Level 2 and the IG Team will work with
the requirement leads to ensure that an appropriate evidence base is in place.
An action plan will be developed, informed by the final Internal Audit report, and
its implementation will be monitored by the Information Governance
Committee. Issues will be reported to the Trust Management Board by
exception.
13. Other key IG priorities for 2013/14 will be as follows:
Identifying and mitigating information governance risks by raising
awareness and undertaking spot checks across all sites.
Continuing to drive compliance with annual mandatory Information
Governance training, ensuring a flexible supply of both face‐to‐face and
e‐learning opportunities to undertake training.
4

TB 30/13
Initiating and completing the de‐identification project for all secondary
uses of patient information.
Preparing the Trust for the adoption of the European General Data
Protection Regulation which will supersede the current Data Protection
Directive in 2014.
Establishing a unified register of data flows and information assets across
Barts Health.
Providing specialist IG advice and support on a range of informatics
projects.
OTHER IG ISSUES
Information Governance Assurance Statement
14. The Information Governance Assurance Statement is the agreement between
NHS Connecting for Health and Approved Service Recipients that sets out the
terms and conditions for the use of NHS Connecting for Health services,
including the NHS N3 network, in order to preserve the integrity of those
services. The Information Governance Assurance Statement is supported by the
annual submission of the IG Toolkit and NHS organisations are required to attain
Level 2 for all the IGT requirements that feed into the Information Governance
Assurance Statement.
15. On the basis of the proposed 2012/13 IG Toolkit scores above, the Trust will not
meet all of these requirements at Level 2 or above. This requires the Chief
Executive to sign an action plan detailing how and when Level 2 or above will be
achieved. The action plan will be draw up and tabled at the next Information
Governance Committee meeting in May 2013 prior to being signed off by the
Chief Executive.
Freedom of Information
16. The volume of Freedom of Information requests received by the Trust continues
to remain high and to consume significant resources both centrally and across
the organisation. During this reporting period, the Trust has dealt with over 500
requests for information under the Act.
IG incidents and risks
17. During 2012/13, the Trust reported three IG‐related incidents to the Information
Commissioner’s Office. These were investigated as Serious Incidents and will be
disclosed in the Annual Report as required by Department of Health guidance.
The Trust and has not been subject to any Information Commissioner Data
Protection monetary penalties, enforcement notices or Freedom of Information
notices. The Information Governance team continues to work with colleagues
across the Trust to learn from these incidents and the Information Governance
Committee reviews all IG incidents and key risks at each of its meetings.
5

TB 30/13
RECOMMENDATIONS
18. The Trust Board is asked to:
Ratify the Trust’s 2012/13 Information Governance Toolkit submission.
Note the proposed key Information Governance priorities for 2013/14.
Remi Ogbe
Information Governance Manager
Ian Walker
Director of Corporate Affairs and Senior Information Risk Owner 28 March 2013
6

Report to the Trust Board: 10 April 2013 TB 31/13
Title
Sponsoring Director
Board Assurance Framework
Director of Corporate Affairs and Trust Secretary
Author(s)
Deputy Trust Secretary
Interim Risk Manager
Purpose
The Board Assurance Framework (BAF):
Provides an assessment of the principal risks to the
Trust’s strategic annual objectives.
Is used to assist the commissioning of assurances and
the development of work plans for the Board’s
assurance committees.
Is an essential requirement for trusts to produce,
demonstrating the Board’s oversight of the
organisation’s systems of control.
Previously considered by Audit and Risk Committee, 20 February 2013
Trust Management Board, 5 March 2013
Risk Management Committee, 4 April 2013
Related Trust objectives
All Trust objectives
Risk and Assurance
Related Assurance
Framework entries
Legal implications/
regulatory requirements
This report highlights proposed principal risks to the delivery of
the Trust’s annual objectives for 2012/13.
All
It is a requirement as part of the Trust’s Annual Governance
Statement (an element of the Trust’s annual report and
accounts) that the Trust evidences its systems of control, most
commonly through the development of a BAF. Its development
and use is reported on in the related Head of Internal Audit
Opinion.
Action required by the Board
The Trust Board is asked to:
Receive and approve the Board Assurance Framework for 2012/13 Q4.
Note and comment on the methodology used to develop the Board Assurance
Framework and proposed steps to refine this during 2013/14.
1

TB 31/13
BARTS HEALTH NHS TRUST
REPORT TO THE TRUST BOARD: 10 APRIL 2013
BOARD ASSURANCE FRAMEWORK
INTRODUCTION AND BACKGROUND
1. The Trust Board receives the Board Assurance Framework (BAF) on a regular basis to note
and discuss principal risks to the delivery of the Trust’s annual objectives. It is proposed that,
following its development, the Board Assurance Framework is presented to the Board at
least three times during 2013/14 following review by the Risk Management Committee.
2. The terms of reference for the Board’s principal assurance committees (the Quality
Assurance Committee and Audit and Risk Committee) establish that the respective
Committee will receive and review at each meeting the BAF entries allocated to it for
oversight. The BAF is intended to inform the development of annual work plans for these
committees and their role in commissioning assurances.
3. Immediate Barts Health priorities for risk management were identified by the Trust
Management Board and the Risk Management Committee following the merger on 1 April
2012 and during the transition from legacy site‐based units to the establishment of a Clinical
Academic Group (CAG) structure on 1 October 2012. These priorities included the
completion of clinical and financial due diligence exercises, the development of a risk
management strategy and policy and steps to consolidate and validate the Trust’s risk
register (taking into account the letters of representation exercises).
4. The development of a Barts Health BAF has followed on from the above steps and builds on
this work. The BAF entries set out in Appendix 2 have been developed based on the
approach outlined at the last meeting of the Trust Board on 6 March 2013. These seek to
take account of key national and local drivers, such as the Francis Report on events at Mid
Staffordshire NHS Foundation Trust, the Trust’s Foundation Trust aspirations and the
current financial environment.
BAF FORMAT
5. At an early stage, the proposed approach to developing the Board Assurance Framework
entries indicated an emphasis on the high risks identified in the risk register. It was felt that
a purely ‘top‐down’ assessment of principal risks to the Trust’s objectives (by the Board,
executive team or others) could result in gaps, given the size and scale of the new
organisation. There was also an important opportunity to build on other risk identification
work outlined in paragraph 3. It was also felt that previous BAF formats had proved weak in
terms of providing an established link between high risks on the risk register and BAF
entries. This is addressed in the new BAF format by explicitly referencing the related high
risks that appear on the risk register.
2

TB 31/13
6. The format of the current BAF (as at Appendix 2) reflects the decision taken to focus initially
on identifying the principal risks. A link to performance will be re‐established in later
iterations of the Board Assurance Framework – with the intention of reflecting the evolving
changes to performance reporting in the Trust. Other planned improvements in 2013/14
include a focus on revising the BAF in line with new 2013/14 objectives, mapping assurances
more systematically (with the involvement of Internal Audit and reflecting their forward
plan – the Internal Audit plan 2013/14) and establishing target risk scores which reflect what
the Board may consider to be an acceptable level of residual risk (risk appetite).
BAF DEVELOPMENT
7. Since the last meeting, steps have been taken to review the ‘shortlist’ and ‘long list’ of
possible BAF entries with lead executives (in meetings held jointly with Risk Management
and Trust Offices staff) and the Risk Management Committee to identify risk scores,
controls, assurances and gaps in controls and assurances. This iterative process of BAF
review will continue throughout 2013/14, with the continued advice and assistance of
colleagues from Risk Management and Internal Audit functions.
8. The BAF risks highlighted in this version reflect changes to the scores of related risk register
entries and progress against some risks previously appearing on the ‘shortlist’. Steps will be
taken to ensure that those risks identified on the ‘long list’ are reflected in the risk register
(if this is not already the case). The BAF risks have been assigned to lead executives who will
be responsible for reporting to the Board on progress against these entries. The BAF risks
have also been tentatively assigned to Board assurance committees to assist with planned
discussions on committee work plans for 2013/14 (the final committee allocation will be
discussed at scheduled planning meetings and committees during May).
9. The BAF was discussed and endorsed by the Risk Management Committee on 4 April 2013.
The Risk Management Committee agreed some changes, including the addition of risk 6
(relating to assessing team effectiveness). Other proposals for further developing the BAF
included an assessment of the risks relating to broader academic developments and to
signpost where BAF entries relate to recommendations in the Francis Report.
RECOMMENDATION
10. The Trust Board is asked to:
Receive and approve the Board Assurance Framework (BAF) for 2012/14 Q4.
Note and comment on the methodology used to develop the Board Assurance
Framework and proposed steps to refine this during 2013/14.
Sean Collins
Deputy Trust Secretary
Mark Rogers
Interim Risk Manager 4 April 2013
3

RISK HEATMAP
Board Assurance Framework (heatmap)
Trust Board meeting
10 April 2013
Current Score (consequence x likelihood, arrow indicates movement in
quarter)
Risk entry Page Outset Score =20 Target Score
1. Failure to identify or address safeguarding concerns impacts on the quality of services, safety of patients and the
Trust’s reputation. 1 5x4=20 5x4 tbc
2. As a result of skills and capacity constraints, a failure to manage acutely ill patients in a consistent way at all sites
and all times, could result in isolated incidents of delayed responses to deteriorating patients Insufficient emergency
care capacity and failure to address patient flow issues impacts on patient safety and experience and meeting
national targets. 2 5x3=15 5x3 4x4 tbc
3. Insufficient emergency care capacity and failure to address patient flow issues impacts on patient safety and
experience and meeting national standards. 3 4x4=16 4x4 tbc
4. Lack of a robust infection prevention framework for eliminating avoidable health care associated infections
impacts on patient safety and experience. 4 4x4=16 4x4 tbc
5. Absence of an integrated informatics infrastructure to ensure that the ‘right information at the right time’ is
available adversely impacts on patient treatment or flagging safety issues. 5 5x3=15 5x3 tbc
6. A failure to systematically assess the health of teams, in particular team cultures, and the effectiveness of
individual services adversely impacts on quality of care. 6 5x3=15 5x3 tbc
7. Underachievement of CIPs and other expenditure controls leads to increased challenge to LTFM in subsequent
years and to ongoing financial sustainability. 7 4x5=20 4x5 tbc
8. Cost improvement plans involve workforce changes and temporary staffing controls that adversely impact on
quality and safety. 8 5x3=15 5x3 tbc
9. The lack of sufficiently robust workforce information impairs decision‐making and the optimal use of workforce
resources to deliver safe patient care efficiently. 9 5x3=15 5x3 tbc
10. Non‐compliance with mandatory systems and policies and a failure to engage staff on its importance adversely
impacts on safety and efficiency. 10 5x4=20 5x4 tbc
11. A failure to develop a Clinical Strategy consistent with the LTFM and delivery of merger full business case
benefits impacts on the organisation’s Foundation Trust trajectory. 11 5x3=15 5x3 tbc
TB 31/13a
Period covered: 2012/13 Quarter‐4
12. Statutory and mandatory training non‐compliance results in patient safety risks and impairs quality of care. 12 3x4=12 3x4 tbc
Highlights by exception: (Going forward to highlight changes to the previous version)
Addition of new risk 1a(v) above. Deletion of previous risk 8(i) which stated 'Failure to satisfactorily resolve issues relating to non‐recurrent funding to support the PFI and support for Barts site costs has an adverse impact on the
Addition of new risk 1a(v) above. Deletion of previous risk 8(i) which stated 'Failure to satisfactorily resolve issues relating to non‐recurrent funding to support the PFI and support for Barts site costs has an adverse impact on the
Trust’s financial outlook'.
Notes: Shading indicates risks for which a Board committee has an assurance role: ARC QAC FIC FT Project Board

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: n/a
PRINCIPAL RISKS
Description of risk
1. Failure to identify or
address safeguarding
concerns impacts on the
quality of services, safety of
patients and the Trust’s
reputation.
Executive lead: Chief Nurse
Subcommittee role: Quality
Assurance Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x4=20)
Outset risk: Mar
13 (5x4=20)
Essential
Standard:
Outcomes 4, 7,
13, 20
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Unified Barts Health safeguarding adults and children team in
place. Safeguarding policies and processes in place (risk 162).
Focus on safeguarding adults at risk:
Joint working group with 5 Local Authorities to agree
standard processes for alerts , referrals and Mental
Capacity Act implementation
Learning disabilities strategy to address risks of
inequality of access or treatment. Additional resources
for this strategy supported by the Board.
Older People’s Services improvement programme with
well integrated support from safeguarding.
Statutory and mandatory training programme in place and
staff must attend appropriate level of safeguarding children's
training for their role. Training for level 1 and 2 is provided on
a monthly basis and Level 3 on bi monthly basis (risk 162 and
931).
Safeguarding adults training programme in place with focus in
April/May 2013 on increasing training take‐up and provision.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Reporting to Trust Board twice yearly on safeguarding
children.
Safeguarding Board monitors performance information.
External assurance:
Clinical Due Diligence phase 2 reviews.
Pan‐London Local Safeguarding Children’s Board monitors
serious case reviews and key data.
Management assurance:
Reporting to Trust Board on Mental Health Act compliance.
Progress against learning disabilities strategy objectives
monitored regularly.
Older People’s Services improvement programme
governance mechanisms.
External assurance:
Clinical Due Diligence phase 2 reviews.
External reviews of Older People’s Service (MEH/RLH) in
2011 and 2012.
CQC reviews of Ainslie and Highams; Beech Ward
arrangements.
Pan‐London Safeguarding Adults Board group monitors
serious case reviews and key data.
External membership on Older People’s Services
independent assurance panel.
Management assurance:
Reporting through the Integrated Performance Framework
and focus at Performance Reviews
External assurance:
RED
RD
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Incidents in Older peoples’ services and
findings from external reviews indicates the
need for further review of controls.
Action: QAC agreed Health Check review
process for Older People’s Services
Detail: Lack of a consistent and integrated
approach with social care to managing patients
with mental health issues or learning disabilities
Action: Regular liaison with social care partners
Detail: Absence of a systematic Barts Healthwide
approach to flagging patients with
learning disabilities to identify needs and target
resources.
Action: Steps to improve and harmonise
patient administration systems across Barts
Health
Detail: As a result of non‐compliance as
stipulated by NHSLA, CQC to achieve a rate of
95% compliance in Safeguarding particularly,
the Trust could face a negative report and an
improvement notice (risk 931)
Action: Additional training sessions being
provided based on training needs analysis.
Communicating with CAGs re compliance
requirements and the need to release staff to
attend training (risk 931)
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
98 ‐ Assessment, treatment & discharge of under 16s in ED with urgent primary care needs (risk score ‐ 16, lead ‐ ECAM CAG)
162 – Management and compliance with regional and national policy and legislation for safeguarding children (risk score – 16, lead Children’s CAG)
931 – Statutory and Mandatory Trust wide safeguarding children training coverage below commissioners requirements (current risk score 9 [was 15] – lead Director of AHS)
1

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: n/a
PRINCIPAL RISKS
Description of risk
2. As a result of skills and
capacity constraints, a failure
to manage acutely ill patients
in a consistent way at all sites
and all times, could result in
isolated incidents of delayed
responses to deteriorating
patients.
Executive lead: Medical
Director
Subcommittee role: Quality
Assurance Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 4, 16
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Role of matrons in routine ward reviews and identifying issues
particularly the systematic use of Early Warning Scores.
Managing acutely ill patients policies and dedicated critical
care outreach team in place to assist frontline staff.
Mortality and Morbidity reviews by clinical teams.
Serious Incident reporting mechanisms.
Root cause analysis and staggered audits (through the Global
Trigger Tool) provides management information.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Resus team carries out frequent audits.
Risk Management Committee tracks risks and issues
escalated to TMB as required
External assurance:
Management assurance:
A Trust‐wide Critical Care Board, with cross‐CAG
representation, which has a Managing the Acutely‐Ill
Patient workstream.
RED
RD
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Quality Assurance Committee agreed in
March plans for further focused work at The
Royal London.
Action: Increased multidisciplinary team
meetings and education sessions.
Detail: No natural forum where cross‐CAG
themes in failures of care are discussed. No
obvious early trigger‐point when episodes of
harm are on the rise.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
99 Management of the Acutely ill patient (risk score – 15, lead – ECAM CAG)
B
2

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: A1.Deliver minimum national service standards set out in the Operating Framework including A&E, 18 weeks RTT, cancer access and MRSA
PRINCIPAL RISKS
Description of risk
3. Insufficient emergency
care capacity and failure to
address patient flow issues
impacts on patient safety and
experience and meeting
national standards.
Executive lead: Chief
Operating Officer
Subcommittee role: Quality
Assurance Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (4x4=16)
Outset risk: As
above
Essential
Standard:
Outcomes 4, 13,
16
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
A&E and site management teams in place. Bed management
protocols identified for admissions and discharge with
escalation plans.
Introduction of additional measures at Whipps Cross to
improve throughflow and reduce length of stay including,
weekend consultant‐led discharge and escalation
arrangements (risk 9).
Emergency Department facilities: move to an integrated
ED/Urgent Care Centre on a new site with a single point of
access at RLH. Similar improvements at Whipps (risk 98).
Introduction of Patient At Risk (PAR) scoring, revised
escalation and security arrangements to reflect changes to
ways of working. (risk 100)
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance: Daily operational team reviews of
performance and weekly reviews by Trust Executive. Chief
Executive more directly involved from March 2013 in A&E
performance monitoring. TMB and Board monthly
reporting via the Integrated Performance Framework.
External assurance: TX commissioned an independent
review of A&E flows at all sites to identify variances in
attendances and admissions rates. Initial results fed back in
March 2013 and further work now being undertaken.
Management assurance: Daily and weekly operational
team reviews of performance. TMB and Board monthly
reporting.
External assurance:
Management assurance:
New Hospital planning group for A&E developed flow
models. CAG Board oversight (risk 100).
External assurance:
RED
RD
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Failure to satisfactorily address issues
with managing within existing bed capacity,
responding to higher attendances and greater
acuity (risk 83).
Action: Ongoing performance monitoring.
Detail: Greater Information and analysis
required to minimise readmissions (risk 938).
Action: Readmissions data reviewed at PRs.
Detail: Issues with psychiatry team’s timeliness
of responses to complete joint assessments
(risk 120)
Action: Agreements identified with ELMHT and
steps to review consistency of application.
Detail: Insufficient resources to support
preferred levels of medical cover (risk 9, 98)
Action: Appointment of additional emergency
care consultants.
Detail: Changed layout and size of emergency
departments requires changes to ways of
working (risk 100).
Action: New controls implemented to respond
to new arrangements and the impact assessed.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
9 ‐ Failure to achieve reduction in Length of Stay at Whipps Cross site (risk score ‐ 16, lead – ECAM CAG)
83 ‐ Failure to achieve A & E 4 hour wait indicator (risk score 25, lead Len Richards/ECAM CAG)
98 ‐ Assessment, treatment & discharge of under 16s in ED with urgent primary care needs (risk score ‐ 16, lead ‐ ECAM CAG)
938 ‐ Cost of Readmissions (risk score – 16, lead Len Richards)
100 ‐ Introduction of new format of emergency care department – visibility / management (risk score – 20, lead – ECAM CAG)
120 ‐ Psychiatry liaison issues (risk score 16, lead – ECAM CAG)
3

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: A1. Deliver minimum national service standards set out in the Operating Framework including A&E, 18 weeks RTT, cancer access and MRSA
PRINCIPAL RISKS
Description of risk
4. Lack of a robust infection
prevention framework for
eliminating avoidable health
care associated infections
impacts on patient safety and
experience.
Executive lead: Medical
Director
Subcommittee role: Quality
Assurance Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (4x4=16)
Outset risk: As
above
Essential
Standard:
Outcomes 4, 8, 9,
10
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
A dedicated infection control team is in place with leadership
of Director of Infection Prevention and Control and Deputy
DIPC. Occupational Health department provides leadership on
workforce health and flu immunisation programmes.
CAGs have designated clinical directors as leads for infection
control. CAG‐level targets and dashboards for infection
control.
Interventions to support zero tolerance infection control
culture include infection control training, launch of IC
campaigns (including infection control day in May); post
infection reviews for C diff and MRSA cases. Targeted
executive walkrounds where MRSA bacteraemias occur
(Executive and lead consultant attend all MRSA case reviews)
meetings); and inclusion of infection control requirements in
all job descriptions.
Infrastructure improvements through construction of new
hospitals at The Royal London and Barts (designed to reduce
infections, with increased single room availability) and
refurbishment programmes at Whipps Cross.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance: Infection Control work plan RED
monitored regularly by Infection Control Committee.
CAG Boards monitor CAG‐level performance and
Performance Reviews.
External assurance:
CQC visits with focus on Outcome 8 (cleanliness and
infection control)
Management assurance:
Staff survey and other patient survey data.
Management assurance: Daily and weekly operational
team reviews of performance. TMB and Board monthly
reporting.
RD
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Interim arrangements in place pending
standardisation of nursing resources and
appointment of a Trust decontamination lead.
Action: Completion of recruitment processes.
Detail: Centralisation of laboratory systems
identified as a possible cause of reporting
delays.
Action: Monitoring to ensure predicted benefits
of centralisation are realised.
Detail: Isolation facilities and older wards,
including 9 at Whipps Cross, increases risk
profile (risk 3).
Action: Ongoing performance monitoring and
capital developments.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
3 Acacia Ward isolation ward facilities (risk score 15 – lead ECAM CAG)
35 Insufficient data on Surgical Site Infection (SSI) rates (risk score 16 – lead Surgery CAG)
77, 89, 165 Failure to implement effective infection control framework (risk score 20 – lead Medical Director)
119 Facilities for cystic fibrosis patients (risk score 16 – lead Medical Director)
131 Pseudomonas (ACCU) (risk score 16 – lead ECAM CAG)
4

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: A2. Achieve the three quality improvement priorities: to keep patients better informed about their care, to improve feedback given to staff when they raise quality and safety concerns, and to improve our patient
administration systems.
PRINCIPAL RISKS
Description of risk
5. Absence of an integrated
informatics infrastructure to
ensure that the ‘right
information at the right time’
is available adversely impacts
on patient treatment or
flagging safety issues.
Executive lead: Chief
Information Officer
Subcommittee role: Audit
and Risk Committee for data
quality and systems / Quality
Assurance Committee for
patient safety aspects
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 9, 16
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
ICT infrastructure in place and key Patient Administration
Systems (PAS) supported by a central team. Business case to
procure a single Electronic Patient Record system to replace
contracts expiring in next 18‐36 months endorsed by FIC in
March 2013. Whipps Cross to move across to Cerner CRS
system in 2013/14.
Information Governance and Information security teams in
place.
Upgrade of Millennium Cerner at former Barts and The
London sites in Dec 2012 to enhance functionality.
Work being piloted to join up CRS and EMIS.
Key policies including information governance, information
security, disaster recovery and Major Incident Plans in place.
Health records management with dedicated team.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Reports to TMB and the Finance and Investment
Committee on the informatics strategy and CRS route map.
Management assurance:
Information Governance Committee with oversight of IG
issues and escalation to TMB as required. Health Records
Committee being established.
External assurance:
IG Toolkit submitted and assessment processes reviewed
by Internal Audit.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Limitations on flagging in existing PAS
systems (risk 12).
Action:
Detail: PACs/RIS interface / reporting issues.
Action: Contract agreed for new PACs system.
Detail: Steps required to finalise single policy
and lack of a coordinated health records
management system.
Action: Policy drafted and in consultation.
Electronic Document Management project to
deliver improved health records access and
quality with intent to roll out beyond former
Barts and The London sites.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
12 Lack of ‘Target’ Flag on PAS (risk score ‐ 16, lead ‐ Cancer CAG)
66,121 Failure to capture all maternity clinical data and activity at point of care electronically (risk scores – 15, 16, lead – Women and Children’s CAG)
84 Diagnosis recording in Cerner Millennium (risk score – 15, lead – ICT Directorate)
105 EPR replacement (risk score – 15, lead – ICT Directorate)
111 ICT infrastructure (risk score – 15, lead – ICT Directorate)
129 CRS issues with consultant names (risk score – 16, lead – Surgery CAG)
1332 Delays in accessing patient letters on DMS system (risk score – 15, lead – Cancer CAG)
144,155 Health records management system (risk scores – 15, lead – ICT Directorate)
5

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: A. Service Quality and Development
Sub Objective: A3. Develop and deliver a plan to improve patient experience and satisfaction, including a focus on Outpatients appointments
PRINCIPAL RISKS
Description of risk
6. A failure to systematically
assess the health of teams, in
particular team cultures, and
the effectiveness of
individual services adversely
impacts on quality of care.
Executive lead: Chief
Executive
Subcommittee role:
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 4, 6,
10
Datix ref: tbc
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Incident reporting rates, staff survey results and complaints
data used at CAG, site and organisational level to identify
exemplars and areas of concern.
Health Check tool designed to look at different aspects within
wards /departments such as observation of practice, staff
behaviour, patient experience, SI’s alongside other metrics to
get a rounded picture of themes within an area /speciality.
Safety thermometer tool to asses harm free care within the
ward in patient areas and community services. A monthly
audit is undertaken looking at 6 areas and output forms part
of CAG Dashboards.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Risk Management Committee tracks key risks and issues
escalated to TMB as required.
RMC rolling programme of drill down reviews for CAGs and
Directorates.
QAC rolling programme of drill down reviews for CAGs.
Triangulation through Clinical Fridays, NED walkrounds.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: A lack of transparency regarding
possible team working arrangements or
working in silos.
Action: Focus at QAC and RMC on higher risk
areas (e.g. smaller, niche services such as
screening services)
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
Ward accreditation process to asses harm free care within the
ward in patient areas and community services. A monthly
audit is undertaken looking at 6 areas and output forms part
of CAG Dashboards.
Integrated Performance Framework with increased focus on
staff, stakeholder and patient perception of performance.
Staff engagement led by Chief Executive with support from
Human Resources, OD, Communications and Governance
functions. Professional leadership arrangements led by Chief
Nurse and Medical Director.
OD and leadership work to develop capability, team working
and succession planning arrangements
HR processes to support staff raising concerns
(whistleblowing).
Related high risks (>15 at outset) on the risk register – Datix refs:
137, 138 Failure to improve the organisational culture (Risk scores – 16,20, lead – Director of HR)
981, 988 Staff engagement (Risk scores – 15, 15, lead – Director of HR)
6

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: B. Financial management
Sub Objective: B6. Deliver the Trust’s 2012/13 financial plan, and cost improvement target, and develop a sustainable long term financial plan (LTFM).
PRINCIPAL RISKS
Description of risk
7. Underachievement of CIPs
and other expenditure
controls leads to increased
challenge to LTFM in
subsequent years and to
ongoing financial
sustainability
Executive lead: Chief
Financial Officer
Subcommittee role: Finance
and Investment Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (4x5=20)
Outset risk: As
above
Essential
Standard:
Outcome 26
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
CIP challenge identified in 3 year LTFM. Dedicated resources
including Director of Recovery post and PMO team in place to
support CAGs and Departments to identify and deliver CIPs.
Procurement of additional external support for identifying
and validating 2013/14 CIPs schemes.
CIPs risk assessment process to identify any efficiency, quality
or safety issues and to identify cross‐cutting themes.
Budgetary management controls supported by Finance and
embedded finance managers.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Trust Management Board and Finance and Investment
Committee oversight of CIPs and LTFM.
CIPs tracker tool.
Strategic Cost Improvement Board meets monthly chaired
by the Chief Executive.
External assurance:
Management assurance:
Framework being developed to quality assure CIPs
schemes
Management assurance:
Financial position and run rate monitored at performance
reviews.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Identification of 2013/14 CIPs
significantly behind schedule at Month 11,
2012/13.
Action: Steps being taken to identify additional
schemes and strengthen existing schemes RAG
rated as red or amber.
Detail: Framework not yet gone live for quality
assuring schemes
Action: Launch details to be confirmed.
Detail: Inconsistent application of budgetary
controls.
Action:
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
143, 157, 217 QIPP/CIP Plans delivery for 2012/13 (Risk Scores ‐ 16, 15, 16, lead – Chief Financial Officer)
164 Deliver the planned run rate as per the agreed plan for 2012/13 (Risk Score ‐ 15, lead – Chief Financial Officer)
7

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: B. Financial management
Sub Objective: B6. Deliver the Trust’s 2012/13 financial plan, and cost improvement target, and develop a sustainable long term financial plan (LTFM).
PRINCIPAL RISKS
Description of risk
8. Cost improvement plans
involve workforce changes
and temporary staffing
controls that adversely
impact on quality and safety
Executive lead: Medical
Director and Chief Nurse
Subcommittee role: Quality
Assurance Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 12, 13,
16
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Dedicated resources including Director of Recovery post and
team in place to support CAGs and Departments to identify
and deliver CIPs (with additional external support for
identifying the 2013/14 CIPs schemes).
CIPs risk assessment process to identify any efficiency, quality
or safety issues and to identify cross‐cutting themes. Process
includes clinical sign‐off on schemes (with escalation
arrangements in place). Identified arrangements to capture
any unintended consequences of schemes and revisit risk
profile of CIPs programme.
Embedded processes to capture staff and patient feedback
regarding suitability of staffing and experience.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Trust Management Board and Finance and Investment
Committee oversight of CIPs and LTFM
External assurance:
Deloitte review of quality governance framework.
Management assurance:
Trust Management Board and Finance and Investment
Committee oversight of CIPs and LTFM.
Framework being developed to quality assure CIPs
schemes
External assurance:
CQC inspections covering Outcome 12
Management assurance:
Clinical Fridays and NED walkrounds using 15 Steps tool
help to triangulate formal feedback mechanisms.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Framework not yet gone live for quality
assuring schemes
Action: Launch details to be confirmed.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
143, 157, 217 QIPP/CIP Plans delivery for 2012/13 (Risk Scores ‐ 16, 15, 16, lead – Chief Financial Officer)
142 Workforce reduction and service changes (Risk Score ‐ 15, lead – Chief Operating Officer)
145, 147 Bank and agency staff spend (Risk scores – 16, 20, lead – ECAM CAG, Chief Financial Officer)
8

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: C. Achieving FT status/post‐merger integration
Sub Objective: C.8 Deliver the post‐merger integration plan including the clinical due diligence action plan and corporate and clinical services management integration
PRINCIPAL RISKS
Description of risk
9. The lack of sufficiently
robust workforce information
impairs decision‐making and
the optimal use of workforce
resources to deliver safe
patient care efficiently.
Executive lead: Director of
Human Resources
Subcommittee role: Audit
and Risk Committee
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 12, 13,
14, 16
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Development of the Electronic Staff Record as the key
resource for workforce information. Reconciliations to the
financial ledger carried out and exercises to capture
organisational structure changes to ensure accuracy of ledger
and ESR. Work to develop ESR’s OLM training functionality
and interim solutions in place to record statutory and
mandatory training.
Pre and post employment checks, policies and procedures in
place to ensure a safe workforce. Action plan in place
following look back exercise to address gaps on CRB checks.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Trust Management Board and Finance and Investment
Committee oversight of CIPs and LTFM
External assurance:
CRB external review (of Barts and The London sites).
Management assurance:
Workforce Resourcing Assurance Group established to
oversee delivery of action plan.
Audit and Risk Committee and Quality Assurance
Committee receives regular assurance reports on
workforce
Independent assurance:
Internal Audit reviews of employment checks
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Further work required to assess and
evidence completion of all pre‐employment
checks from legacy sites
Action: Manual checks of personnel files and
additional CRB processes implemented
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
1032 CRB checks (Risk score – 15, Lead – Director of HR)
926 Retention of key talent (Risk score – 20, Lead – Director of HR)
1034 Right to Work in UK (Risk score – 15, Lead – Director of HR)
1035 Safe Practice Assurance/Professional Registration Checks (Risk score – 15, Lead – Director of HR)
1036 Honorary contracts (Risk score – 15, Lead – Director of HR)
1037 Clinical observers (Risk score – 15, Lead – Director of HR)
1041 Overpayments (Risk score – 16, Lead – Director of HR)
i
9

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: C. Achieving FT status/post‐merger integration
Sub Objective: C.8 Deliver the post‐merger integration plan including the clinical due diligence action plan and corporate and clinical services management integration
PRINCIPAL RISKS
Description of risk
10. Non‐compliance with
mandatory systems and
policies and a failure to
engage staff on its
importance adversely
impacts on safety and
efficiency.
Executive lead: Chief
Executive
Subcommittee role: ‐
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x4=20)
Outset risk: As
above
Essential
Standard:
Outcomes 12, 14
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Performance management framework supported by policies
and procedures, OD and leadership development and
performance reporting (identifying objectives, quality
priorities and staff, patient and stakeholder perceptions).
Increasing focus of TMB, QAC and ARC on holding individuals
to account (for example on salary overpayments).
Development of brand standards for CAGs and Directorates
identifying service imperatives, expectations of staff and
escalation arrangements.
Barts Health Improvement System to develop culture of
continuous improvement and maximise resources.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Trust Board and assurance committee workplans prioritise
development of an effective Trust strategy and culture that
supports the vision and values of the organisation.
Management assurance:
Trust Management Board to receive regular updates and
drive delivery.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Lack of a comprehensive and consistent
approach to holding to account for noncompliance.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
137, 138 Failure to improve the organisational culture (Risk scores – 16,20, lead – Director of HR)
981, 988 Staff engagement (Risk scores – 15, 15, lead – Director of HR)
146, 1372 Failure to comply with statutory and mandatory training targets (risk score – 15, 16, lead ‐ Director of Corporate Affairs, Director of AHS)
77 Failure to implement effective infection control framework (risk score – 25, lead – Medical Director)
1099 Effective management of senior medical staff, supporting revalidation (risk score – 16, lead – Medical Director)
10

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: D. Strategy
Sub Objective: n/a.
PRINCIPAL RISKS
Description of risk
11. A failure to develop a
Clinical Strategy consistent
with the LTFM and delivery
of merger full business case
benefits impacts on the
organisation’s Foundation
Trust trajectory.
Executive lead: Director of
Strategy
Subcommittee role: Trust
Board (in capacity as FT
Project Board)
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (5x3=15)
Outset risk: As
above
Essential
Standard:
Outcomes 6, 10,
26
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Dedicated Strategy team led by Director of Strategy working with
CAGs to develop a Clinical Strategy for Barts Health.
FT programme structure and governance mechanisms to address
key workstreams.
Clinical engagement in development of the clinical strategy to
ensure that this is viable and patient‐focused.
Development of CAG strategies and brand standards for CAGs and
Directorates identifying strategic aspirations, service imperatives,
expectations of staff and escalation arrangements.
Regular updates of the LTFM to ensure clarity on the financial
envelope for developing clinical services.
Estates options appraisals being developed to inform commercial
plans.
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Trust Board and assurance committee workplans prioritise
development of an effective Trust strategy and culture that
supports the vision and values of the organisation.
Trust Board away day and challenge from McKinseys on
proposed approach.
External assurance:
External support for development of Clinical Strategy.
Management assurance:
Close involvement of clinical leaders in strategy
development through the Leadership Group and Strategic
Advisory Group.
Management assurance:
Staff survey
Management assurance:
Finance and Investment Committee oversight of LTFM and
commercial strategy. WDS Advisory Group led by NEDs
provides advice to the Board on estates options.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Potential for external reconfiguration/
designations to impact on the development of a
clinical strategy.
Action: Horizon scanning and development of
key partnerships including UCLP, AHS structures
and academic links.
Detail: Steps required to understand the cost
implications of CAG strategies and fit against
Service Line Management profitability analyses.
Action: Development of matrix to assess CAG
strategies, including costs and risks.
Detail: Potential for external factors to limit the
available options for the clinical strategy.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Related high risks (>15 at outset) on the risk register – Datix refs:
932 Medical workforce – failure to realise benefits of economies of scale on 24/7 cover (Risk score – 16, lead – Medical Director)
976 Non‐delivery of Full Business Case deliverables (Risk score – 16, lead – Development Director)
993 Public Health – lack of focus on health improvement (Risk score – 16, lead Medical Director)
11

APPENDIX 2 – BOARD ASSURANCE FRAMEWORK – QUARTER 4 2012/13 TB 31/13b
Objective Heading: E. Academic Health Sciences
Sub Objective: n/a
PRINCIPAL RISKS
Description of risk
12. Statutory and mandatory
training non‐compliance
results in patient safety risks
and impairs quality of care.
Executive lead: Director of
Academic Health Sciences
Subcommittee role: ‐
CURRENT RISK
SCORE
[CxL]
Current risk score,
and relevant CQC
Outcome;
Current risk –
Quarter 4 risk
score: (3x4=12)
Outset risk: As
above
Essential
Standard:
Outcomes 12, 14
KEY CONTROLS
(numbers in brackets indicate controls relating to
Identified related high risks)
Most significant controls/systems in place to assist in securing
delivery of objective and managing principal risks:
Capacity and delivery analysis.
Training Needs Analyses for all staff groups.
Monthly compliance report to CAGs and Directorates.
Changes made in terms of training delivery (more e‐learning).
Steps taken to identify particular areas of non‐compliance to
flag for priority notification to CAGs
ASSURANCES ON CONTROLS
Does the available assurance [process outlined below] provide
evidence that controls/systems, on which we are placing reliance,
are effective? (Indicate if management, internal audit or
independent assurance)
Management assurance:
Education and Training Board monitors progress.
Training compliance reported in Integrated Performance
Framework and reviewed at performance reviews.
Regular updates to QAC on
Internal Audit review provided significant assurance on
processes for training provision.
GAPS IN CONTROL / ASSURANCE
Where are we failing to a) put effective controls/systems
in place? b) gain evidence that controls are effective
Detail: Lack of a comprehensive and consistent
approach to holding to account for noncompliance.
Action: Monitoring at PRs. Links to appraisal
and individual performance assessments
established.
TARGET RISK
SCORE
Target (by Q4
unless stated)
Q4 2013/14
target to be
confirmed
Datix ref: tbc
Related high
risks >15 on the
risk register –
Datix refs:
(See table below)
Related high risks (>15 at outset) on the risk register – Datix refs:
56, 852 Statutory & Mandatory training ‐ access to & provision of training (Risk Score 16, Lead – Director of AHS)
931 Safeguarding children training coverage below commissioners requirements
146, 1372 Failure to comply with statutory and mandatory training targets (risk score – 15, 16, lead ‐ Director of Corporate Affairs, Director of AHS)
12

Report to the Trust Board: 10 April 2013 TB 32/13
Title
Sponsoring Director
Author(s)
Purpose
Previously considered by
Trust Board membership
Director of Corporate Affairs and Trust Secretary
As above
To note the reappointments of a Non Executive Director of
Barts Health NHS Trust.
n/a
Executive summary
The previous term of office of Professor Richard Trembath as University Nominated Non
Executive Director of Barts Health NHS Trust ended on 31 March 2013.
The NHS Trust Development Authority has confirmed Professor Trembath’s
reappointment to this position for a further term from 1 April 2013 to 31 March 2015.
Related Trust objectives
n/a
Risk and Assurance
Related Assurance
Framework entries
Legal
implications/regulatory
requirements
Sub‐objectives
The appointments have been made in accordance with the
Commissioner for Public Appointments Code of Practice.
n/a
See ‘Risk and Assurance’ above.
Action required by the Board
The Trust Board is asked to note the reappointment of Professor Richard Trembath as a
Non Executive Director of Barts Health NHS Trust.
1

Report to the Trust Board: 10 April 2013 TB 33/13
Title
Sponsoring Director
Author(s)
Purpose
Previously
considered by
Amendment to the Trust’s Standing Orders, Standing Financial
Instructions and Reservation and Delegation of Powers
Chief Financial Officer
Associate Director of Finance
Deputy Trust Secretary
The purpose of this paper is to seek Board approval to make minor
amendments to the Trust’s Standing Orders (SOs), Standing Financial
Instructions (SFIs) and Reservations and Delegation of Powers.
Audit and Risk Committee, 20 February 2013
Executive summary
The Standing Orders, Standing Financial Instructions and Reservations and Delegation of
Powers set out the delegated responsibilities of both individuals and/or Committees. The
paper sets out proposed changes to limits, thresholds and processes relating to
procurement within the Trust’s current Standing Financial Instructions (SFIs). A wider
review of the Standing Orders and Standing Financial Instructions will be conducted during
2013/14 to address any further improvements that may be required.
Related Trust objectives
6. Deliver the Trust’s 2012/13 financial plan, and cost improvement target, and develop a
sustainable long term financial plan (LTFM).
Risk and Assurance
Related Assurance
Framework entries
Legal implications/
regulatory requirements
n/a
n/a
The SOs and SFIs incorporate key legal and statutory
requirements in relation to corporate and financial
governance.
Action required by the Board
The Trust Board is asked to approve the amendments to the Trust’s Standing Orders,
Standing Financial Instructions and Reservations and Delegation of Powers.
1

TB 33/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
AMENDMENTS TO THE TRUST’S STANDING FINANCIAL INSTRUCTIONS
INTRODUCTION
1. The limits and thresholds relating to procurement within the Trust’s current
Standing Financial Instructions (SFIs) have been reviewed and this paper details
some proposed changes. A wider review of the Standing Orders and Standing
Financial Instructions will be conducted during 2013/14 to address any further
improvements that may be required.
2. The Audit and Risk Committee endorsed the proposed changes at its meeting on
20 February 2013. It was agreed that further review of e‐tendering arrangements
would be undertaken by Internal Audit during 2013/14 to provide additional
assurance.
Proposed amendment to section 16.5: Obtaining quotations and tenders.
3. The current limits are:
Goods & Services (including Capital)*
Less than £10,000 2 quotes
Between £10,000 and £50,000 obtain
minimum 4 quotes
Between £50,000 and £100,000 obtain
minimum 4 tenders
Between £100,000 and OJEU obtain
minimum 6 tenders
Above OJEU threshold use EU tender
Works (including Capital)*
Less than £50,000 3 quotes
Between £50,000 and £100,000 obtain
minimum 4 tenders
Between £100,000 and OJEU obtain
minimum 6 tenders
Above OJEU threshold: EU tender rules apply
4. The proposed limits are:
Goods and services (including capital)
Up to £5,000: 1 verbal quotation
(minimum)
Between £5,000 and £50,000: 2 written
quotations (minimum)
Between £50,000 and OJEU Limit: 3
written quotations (minimum)
Over OJEU Limit: EU directive applies
Works (including capital)
Up to £50,000: 3 written quotations
(minimum)
Between £50,000 and £100,000: 4 written
quotations (minimum)
Between £100,000 to OJEU Limit: 4 tenders
(minimum)
Over OJEU Limit: EU directives apply
2

TB 33/13
5. The OJEU limits are currently £113k for Goods and Services and £4,348k for
works.
6. For all quotations and tenders over £50,000, all employees involved in evaluating
and concluding contracts will continue to be obliged to complete a declaration of
interest form.
7. The rationale for the change is as follows:
The current procedures for quotations and tenders are too cumbersome
to ensure the timely delivery of contracts, which has resulted in a high
number of waivers being produced.
The reduction in the written quotations up to the OJEU limits is more
practicable whilst ensuring effective competition of all high value orders.
The majority of the contracts following merger have exceeded the OJEU
limit.
The proposed procedures have been benchmarked against similar Trusts
(UCL Hospitals NHS Foundation Trust, Great Ormond Street Hospital for
Children NHS Foundation Trust and Guy’s and Thomas’s NHS Foundation
Trust).
8. Guidance on commercial awareness will be issued to ensure that the Trust is
competitive with its requests for pricing.
Proposed amendments to section 16.6: E Tendering
9. As part of the e tendering regime the proposal is to amend the requirements on
opening of tenders, which is currently managed by the Trust Offices.
10. Currently the requirement is that a minimum of two Trust directors (or one
director plus the Deputy Trust Secretary) must be present for the opening of
tenders.
11. The proposal is that all Trust tenders conducted via the procurement e‐
tendering portal may be unlocked by procurement, with procurement
maintaining the tendering numbering system. For manual tenders, it is proposed
to add the Associate Trust Secretary to the list of those authorised to open
tenders.
3

TB 33/13
12. The rationale for the change and increased emphasis on e‐tendering is:
a. The current paper based system is an inefficient process.
b. All electronic tenders are locked by the system until the closing date and
time has lapsed.
c. The electronic system has a full audit trail with the forms being in PDF
format.
d. The Bravo e‐tendering system was audited by the internal auditors at
Whipps Cross University Hospital before the merger.
RECOMMENDATION
13. The Trust Board is asked to approve the above amendments to the Trust’s
Standing Orders and Standing Financial Instructions.
Tracey Leforte
Deputy Director of Procurement
Martin Botterill
Associate Director of Finance 5 April 2013
4

Report to the Trust Board: 10 April 2013 TB 34/13
Title
Sponsoring Director
Author(s)
Purpose
Previously considered by
Use of the Trust Seal
Director of Corporate Affairs and Trust Secretary
As above
To seek Trust Board ratification of use of the Seal, pursuant
to Standing Order 21.2
n/a
Executive summary
This paper documents the use of the Trust Seal on the following occasions:
27 March 2013
A Licence to Underlet relating to First floor, 51‐53 Bartholomew Close, London
EC1A 7HP between Barts Two Investment Property Limited, Barts Health NHS
Trust and The Secretary of State for Health. (3 copies)
A Sublease of Part of First floor, 51‐53 Bartholomew Close, London EC1A 7HP
between Barts Health NHS Trust and The Secretary of State for Health.
Related Trust objectives
n/a
Risk and Assurance
Related Assurance Framework entries
n/a
n/a
Legal implications/
regulatory requirements
The Trust’s lawyers were involved in drawing up the
documents requiring sealing.
Action required by the Board
The Trust Board is asked to ratify the use of the Seal on the occasions listed above.
1

SELF-CERTIFICATION RETURNS
Organisation Name:
Barts Health NHS Trust
Monitoring Period:
February 2013
NHS Trust Oversight self certification template
Returns to som@london.nhs.uk by noon on
15th April 2013

NHS Trust Governance Declarations :
2012/13 In-Year Reporting
Name of Organisation: Barts Health NHS Trust
Period: February 2013
Organisational risk rating
Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any
contractual issues and compliance with CQC essential standards:
Governance Risk Rating (RAG as per SOM guidance)
Key Area for rating / comment by Provider
Score / RAG rating*
R
Normalised YTD Financial Risk Rating (Assign number as per SOM guidance) 2
* Please type in R, AR, AG or G and assign a number for the FRR
Governance Declarations
Declaration 1 or declaration 2 reflects whether the Board believes the Trust is currently performing at a level compatible with FT authorisation.
Supporting detail is required where compliance cannot be confirmed.
Please complete one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand
written or electronic, you are required to print your name.
Governance declaration 1
The Board is sufficiently assured in its ability to declare conformity with all of the Clinical Quality, Finance and Governance elements of the Board
Statements.
Signed by : Print Name :
on behalf of the Trust Board
Acting in capacity as:
Signed by:
Print Name:
on behalf of the Trust Board
Acting in capacity as:
Governance declaration 2
At the current time, the board is yet to gain sufficient assurance to declare conformity with all of the Clinical Quality, Finance and Governance elements of
the Board Statements.
Signed by : Print Name :
Stephen O'Brien
on behalf of the Trust Board
Acting in capacity as:
Chairman
Signed by:
Print Name:
Peter Morris
on behalf of the Trust Board
Acting in capacity as:
Chief Executive
If Declaration 2 has been signed:
For each target/standard, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain
briefly what steps are being taken to resolve the issue. Please provide an appropriate level of detail. (Only 5 can be accommodated on this template - see
attached for full exception report)
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
Target/Standard:
The Issue :
Action :
3. All medical practitioners have met the relevant requirements.
The responsible officer and revalidation statute was enacted on 3rd December 2012 and all trusts are on a
The Trust is compliant with the relevant responsible officer legislation as of December 2012 and had
4. The trust will maintain a FRR ≥ 3 over the next 12 months.
The Trust's FRR is 2 in October 2012.
The Trust's FRR is currently at 2 due to the in year deficit. This position will improve to an FRR of 3 when
7. All current key risks have been identified and addressed.
Not currently possible to provide full assurance.
Currently, there is robust evidence, knowledge and quantification of current risks but insufficient
8. The board has considered all likely future risks.
Not currently possible to provide full assurance.
Our latest review of risk management integration as Barts Health re-confirmed our trajectory to have both
9. The necessary planning, management and mitigation plans are in place to deliver the annual plan.
Not currently possible to provide full assurance.
New arrangements currently being developed for implementation following planned go live of new

Board Statements
Barts Health NHS Trust
February 2013
For each statement, the Board is asked to confirm the following:
For CLINICAL QUALITY, that:
Response
The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the SOM's
1
Oversight Regime (supported by Care Quality Commission information, its own information on serious incidents, patterns
of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective
Yes
arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s
2 Yes
registration requirements.
The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on
3 No
behalf of the trust have met the relevant registration and revalidation requirements.
For FINANCE, that:
Response
4 The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.
No
5
The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards
in force from time to time.
Yes
For GOVERNANCE, that:
Response
6 The board will ensure that the trust at all times has regard to the NHS Constitution.
Yes
All current key risks have been identified (raised either internally or by external audit and assessment bodies) and
7 No
addressed – or there are appropriate action plans in place to address the issues – in a timely manner
The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,
8 No
likelihood of occurrence and the plans for mitigation of these risks.
The necessary planning, performance management and corporate and clinical risk management processes and
9 mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by No
the board are implemented satisfactorily.
An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance
10 framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury
No
(www.hm-treasury.gov.uk).
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the
11 application of thresholds) as set out in the Governance Risk Rating; and a commitment to comply with all commissioned No
targets going forward.
The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance
12 No
Toolkit.
The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,
13
ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or
plans are in place to fill any vacancies, and that any elections to the shadow board of governors are held in accordance
Yes
with the election rules.
The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and
14 skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, Yes
and ensuring management capacity and capability.
The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the
15 Yes
annual plan; and the management structure in place is adequate to deliver the annual plan.
Signed on behalf of the Trust: Print name Date
CEO Peter Morris Peter Morris 10-Apr-13
Chair Stephen O'Brien Stephen O'Brien 10-Apr-13

QUALITY
Information to inform discussion meeting
Barts Health NHS Trust
Insert Performance in Month
Criteria
Unit Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Board Action
1 SHMI - latest data Score 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8
This indicator remains consistent and positive for the whole trust. This figure is taken from
the NHS Information Centre (NHSIC) publication in January 2013 for the period up to June
2012. Barts Health’s SHMI at 0.84 places it 10th position in a list of relevant healthcare
organisations in England which measure the indicator of deaths associated with
hospitalisation.
Sixteen trusts had a ‘significantly lower than expected’ SHMI (between 0.71 and 0.87)
indicating a 13% to 29% lower than expected mortality rate. Barts Health is in this group
and is also the largest organisation in the sample with 159,820 hospital cases. Given the
size of Barts Health, there were 717 less deaths than expected.
2
Venous Thromboembolism (VTE)
Screening
% 90.31 91.06 91.04 91.13 91.13 92.09 90.65 89.83 87.56 88.58 90.25
Recording of VTE assessment has recovered to above the 90% level this month due to a
widespread daily focus on delivery and is on an upward trajectory for March. Recording at
Whipps Cross Hospital remains a problem, where we still rely on paper systems to record
VTE assessment. Our IT strategy aims to deal with this by implementing Cerner Millenium
Care records service as quickly as possible – though this will be at least 18-24 months away.
In the interim the Clinical Academic Groups (CAGs) are receiving the VTE data now by site
as well as by CAG. This data is now presented for each working date and can drill down to
ward level. The data is subject to monthly scrutiny at executive led performance reviews
and the accountability framework has been re-emphasised to support delivery . The cohort
basis for low risk patients is well established. A VTE Board to cover the whole Trust (taking
over from the separate arrangements prior to 1st October) has been established, chaired
by the Medical Director with a focus on all 3 aspects of the future CQUIN.
3a Elective MRSA Screening % 121 103 99 91 93 94.17 92.5 100.1 137.8 92.8 To follow
Significant work has been undertaken to develop a report that is based on combined
laboratory and admissions data in order to match at a patient level. The old report used to
take unmatched tests and admissions and it was therefore possible to get performance in
excess of 100% (due to multiple tests being undertaken on some patients).
Barts Health is co-locating its laboratory services at the Royal London site and
consolidating its admissions data on to a single platform which are a prerequisites to
proving accurate reporting.
3b Non Elective MRSA Screening % 128 99 94 112 96 111.35 101.8 100.9 78.4 89.5 To follow
Significant work has been undertaken to develop a report that is based on combined
laboratory and admissions data in order to match at a patient level. The old report used to
take unmatched tests and admissions and it was therefore possible to get performance in
excess of 100% (due to multiple tests being undertaken on some patients).
Barts Health is co-locating its laboratory services at the Royal London site and
consolidating its admissions data on to a single platform which are a prerequisites to
proving accurate reporting.
4 Single Sex Accommodation Breaches Number 3 31 29 3 1 0 0 24 129 125 124
5
Open Serious Incidents Requiring
Investigation (SIRI)
Number 31 37 26 40 41 25 24 39 27 21 33
6 "Never Events" occurring in month Number 1 3 1 1 2 0 0 0 3 0 1
7 CQC Conditions or Warning Notices Number 0 0 0 0 0 0 0 0 0 0 0
Increases in reported figures over the past few months reflects a reporting system within
critical care that was not as robust as it could have been. As a result of this, an increase in
reporting has been seen. Work is underway to address the causes of these breaches.
Pressures on critical care beds/ lack of step-down beds, including an increase in
tracheostomy patients has had a significant impact. Remedial action is in place to address
the causal factors.
There were 33 new SIs reported in February 2013. As of 1 March 2013, there were 81
overdue SIs. This comprised of 19 legacy incidents (down from 27 last month) and the
central Patient Safety and Governance & Standards Teams are working with the CAG teams
to complete the overdue investigations and reports in line with our recovery plan. The aim
is try to achieve closure of all the legacy incidents by 31 March.
There are 62 overdue SI reports identified since 1/10/12 and the CAG teams are working
We have undertaken a review of all never events in the last year, we have focused work on
the retention of foreign object never event on all sites. There was one Never Event
reported but the incident happened in January 2013, relating to a maternity case. The
Women’s CAG have subsequently published a ‘hot topic’ memo to all staff to avoid future
incidents.
A draft QCQ compliance report for the Whipps Cross Q&E and Older Person's Services
review in November, indicated one area of minor non-compliance in respect of outcome
14, supporting staff.
On 18 February CQC carried out an unannounced compliance review at Mile End Hospital,
visiting two elderly service wards and a further compliance review at St Barts Hospital
(cancer services). The Trust has received a draft report with positive findings and fully met
judgements.
8
Open Central Alert System (CAS)
Alerts
Number 38 43 50 30 19 20 23 27 3 1 0
Since end Oct, we made a concerted effort to get all overdue alerts actioned/closed off and
managed to acheive our target of zero overdue alerts.
Six new CAS alerts received in February all have been closed.
The remaining open alerts, and actions to ensure compliance with the Estates & Facilities
(tamper free window restrictors) alert are nearing completion and on track to be
completed by the target of 23/05/13.
9
RED rated areas on your maternity
dashboard?
Number 1 0 0 0 0 0 0 0 0 0 0
Maternity dashboard in development across all BH sites however this work is not yet
complete.
10
Falls resulting in severe injury or
death
Number 0 0 2 1 0 0 0 0 0 0 0 Reducing falls is a BH 2012 quality improvement priority
11 Grade 3 or 4 pressure ulcers Number 7 16 9 8 13 14 9 8 16 11 7
This is a BH 2012 quality priority, focus on reducing all grades, particularly grade 4, working
to a zero tolerance approach
12
100% compliance with WHO surgical
checklist
Y/N N N N Y Y N N N N N N
A report considering never events at BH and legacy organisations, has recommendationed
a review of the WHO checklist approaches adopted so far and work to identify a new coordinated
programme of action to promote consistent practice.
The medical Direcotr has circulated a joint communication with the President of the Royal
Colelge of Surgeons to all surgeons and procedure leads. The Chief Nurse has likewise
emphasised the importance to all other staff groups.
13 Formal complaints received Number 115 182 155 191 150 111 89 184 144 178 132 The reduction in formal complaints received has continued.
14
Agency as a % of Employee Benefit
Expenditure
% 5.10% 4.47% 4.81% 4.43% 4.54% 5.28% 4.58% 5.00% 5.10% 5.58% 4.99%
Controls to manage agency use continue and authorisation for agency posts is held at
senior levels within CAGs. Assurance is required that controls are being fully implemented.
A recruitment drive for posts which require temporary cover commenced across Barts
Health in December. Augmenting the Bank pool and improving the “time to hire” period
are also core objectives to reduce agency spend.
15 Sickness absence rate % 3.24% 3.24% 3.20% 3.14% 3.10% 3.09% 3.09% 3.11% 3.45% 3.45% To follow
Current reporting is being improved and this will increase reported sickness levels.
Capacity issues in Occupational Health are being addressed and this will help augment
management action where appropriate.
16
Consultants which, at their last
appraisal, had fully completed their
previous years PDP
% - - - - - - - - 85% 85% To follow
Although there is an agreed process and policy for appraisals in place which includes
review of previous years PDP objectives and whether they have been achived, this is not
systematically monitored currently. We are putting in place a new computer system
across Barts Health (e-portfoliio) to record PDPs and we will develop a system for recording
an opinion by the appraiser on satisfactory completion of the PDP and a means of gaining
assuranceThis system has been mandatory from 1 April.
Audit taken from Staffing list on 13/02/2013. NHS Consultant, Locum NHS Consultant and
Academic Clinicans staffing groups selected to provide figures for this return:
Data Source : 2011-12 individual consultant appraisal documentation.

FINANCIAL RISK RATING
Barts Health NHS Trust
Risk Ratings
Insert the Score (1-5) Achieved for each
Criteria Per Month
Reported
Position
Normalised
Position*
Criteria Indicator Weight 5 4 3 2 1
Year to
Date
Forecast
Outturn
Year to
Date
Forecast
Outturn
Board Action
Underlying
performance
EBITDA margin % 25% 11 9 5 1

FINANCIAL RISK TRIGGERS
Barts Health NHS Trust
Insert "Yes" / "No" Assessment for the Month
Historic Data
Current Data
Criteria
Qtr to
Jun-12
Qtr to
Sep-12
Qtr to
Dec-12
Jan-13 Feb-13 Mar-13
Qtr to
Mar-13
Board Action
1
Unplanned decrease in EBITDA margin in two consecutive
quarters
No Yes No No No
2
Quarterly self-certification by trust that the normalised
financial risk rating (FRR) may be less than 3 in the next
12 months
Yes Yes Yes Yes Yes
Increased planned and actual I&E surpluses will improve the
FRR to 3 (currently an I&E deficit).
3
Working capital facility (WCF) agreement includes default
clause
N/a N/a N/a N/a N/a N/a N/a
4
Debtors > 90 days past due account for more than 5% of
total debtor balances
Yes Yes Yes Yes Yes
The Trust is continuing to pursue all debts vigorously and debt
write off is a last resort.
5
Creditors > 90 days past due account for more than 5% of
total creditor balances
Yes Yes Yes Yes Yes
Payments have been slower than plan as Trust-wide
compliance with purchase ordering remains an issue. An
executive led purchase to pay project has been launched.
6
Two or more changes in Finance Director in a twelve
month period
No No No No No
7
Interim Finance Director in place over more than one
quarter end
Yes No No No No
8 Quarter end cash balance

Quality
Patient Experience
Effectiveness
GOVERNANCE RISK RATINGS
Barts Health NHS Trust
Insert YES, NO or N/A (as appropriate)
See 'Notes' for further detail of each of the below indicators
Area Ref Indicator Sub Sections
Threshold
Weighting
Historic Data
Qtr to Jun- Qtr to
12 Sep-12
Qtr to
Dec-12
Current Data
Jan-13 Feb-13 Mar-13
Qtr to
Mar-13
Board Action
Referral to treatment information 50%
1a
Data completeness: Community services
comprising:
Referral information 50%
Treatment activity information 50%
1.0
No
No
Yes
Yes
Yes
This metric applies to those services
currently on an electronic system. While the
majority of the community services are now
on some form of electronic system, there are
some areas where implementation of the
EMIS Web system is still in progress or still
to happen. T. We are now getting a regular
CIDS data extract, which we have begun to
test and are on track to begin reporting for
April13
1b
Data completeness, community services:
(may be introduced later)
Patient identifier information 50% No No No No No See above
Patients dying at home / care
home
50% No No No No No
See above
1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a
1c
2a
Data completeness: outcomes for patients
on CPA
From point of referral to treatment in
aggregate (RTT) – admitted
50% 0.5 N/a N/a N/a N/a N/a
Maximum time of 18 weeks 90% 1.0 Yes Yes Yes No No
2b
From point of referral to treatment in
aggregate (RTT) – non-admitted
Maximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes Yes
2c
From point of referral to treatment in
aggregate (RTT) – patients on an
incomplete pathway
Maximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes Yes
2d
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
N/A 0.5 No No No No No
Working on policies and protocols across
Barts Health.
3a
All cancers: 31-day wait for second or
subsequent treatment, comprising :
Surgery 94%
Anti cancer drug treatments 98%
Radiotherapy 94%
1.0
Yes
Yes
Yes
Yes
Yes
3b
All cancers: 62-day wait for first treatment:
From urgent GP referral for
suspected cancer
From NHS Cancer Screening
Service referral
85%
90%
1.0
No
No
No
No
No
The IST have supported the organisation to
develop a comprehensive Action Plan to
remedy this indication during Q2. The Action
Plan has been shared with Commissioners
and is being monitored through our
Performance Reviews. Q2 compliance was
achieved for the 62 day target across Barts
Health as a whole (85.53%).
3c
All Cancers: 31-day wait from diagnosis to
first treatment
96% 0.5 Yes Yes Yes Yes Yes
The IST have supported the organisation to
develop a comprehensive Action Plan to
remedy this indication during Q2. The Action
Plan has been shared with Commissioners
and is being monitored through our
Performance Reviews. Q2 compliance was
achieved for the 62 day target across Barts
Health as a whole (85.53%).
3d
Cancer: 2 week wait from referral to date
first seen, comprising:
all urgent referrals 93%
for symptomatic breast patients
(cancer not initially suspected)
93%
0.5 Yes
Yes
Yes
Yes
Yes
3e
A&E: From arrival to
admission/transfer/discharge
Maximum waiting time of four
hours
95% 1.0 Yes Yes Yes No No
3f
Care Programme Approach (CPA) patients,
comprising:
Receiving follow-up contact within
7 days of discharge
Having formal review
within 12 months
95%
95%
1.0
N/a N/a N/a
N/a
N/a
3g
Minimising mental health delayed transfers
of care
≤7.5% 1.0 N/a N/a N/a N/a N/a
3h
Admissions to inpatients services had
access to Crisis Resolution/Home
Treatment teams
95% 1.0 N/a N/a N/a N/a N/a
3i
Meeting commitment to serve new
psychosis cases by early intervention
teams
95% 0.5 N/a N/a N/a N/a N/a
3j
Category A call – emergency response
within 8 minutes
Red 1 80% 0.5 N/a N/a N/a N/a N/a
Red 2 75% 0.5 N/a N/a N/a N/a N/a
3k
Category A call – ambulance vehicle
arrives within 19 minutes
95% 1.0 N/a N/a N/a N/a N/a

Effectiveness
Safety
GOVERNANCE RISK RATINGS
Barts Health NHS Trust
Insert YES, NO or N/A (as appropriate)
See 'Notes' for further detail of each of the below indicators
Area Ref Indicator Sub Sections
1a
Data completeness: Community services
comprising:
Threshold
Weighting
1.0
Historic Data
Qtr to Jun- Qtr to
12 Sep-12
No
No
Qtr to
Dec-12
Yes
Current Data
Jan-13 Feb-13 Mar-13
Is the Trust below the de minimus 12 No No No No No
4a Clostridium Difficile 1.0
Is the Trust below the YTD ceiling 99 Yes Yes Yes Yes Yes
Yes
Yes
Qtr to
Mar-13
Board Action
The Trust is below the YTD trajectory, but
with little margin for error. The Trust is above
the de minimis level of course. From a first
This metric applies to those services
cut analysis undertaken by the deputy DIPC
currently on an electronic system. While the
we were able to detect avoidable cases of
majority of the community services are now
cross infection. 2 patients were
on some form of electronic system, there are
inappropriately sampled. All patients were on
some areas where implementation of the
antibiotics – but these were within formulary
EMIS Web system is still in progress or still
and properly indicated. Future RCAs will
to happen. T. We are now getting a regular
focus on detailed pharmacist analysis and
CIDS data extract, which we have begun to
the chief pharmacist will consolidate
test and are on track to begin reporting for
oversight of antibiotic husbandry reporting
April13
across the full trust Additional measures to
improvse HCAI performance include more
intensive local peer review led by CAGs with
immediate actions, enhanced scrutiny of
RCAs for MRSA and CDiff, with targeted
actions to improve device management and
adopt BH approach to antibiotic surveillance.
4b
MRSA
Is the Trust below the de minimus 6 Yes No No No No
1.0
Is the Trust below the YTD ceiling 8 Yes Yes No No No
Additional measures to improvse HCAI
performance include more intensive local
peer review led by CAGs with immediate
actions, enhanced scrutiny of RCAs for
MRSA and CDiff, with targeted actions to
improve device management and adopt BH
approach to antibiotic surveillance.
A
CQC Registration
Non-Compliance with CQC Essential
Standards resulting in a Major Impact on
Patients
0 2.0 No No No No No
B
Non-Compliance with CQC Essential
Standards resulting in Enforcement Action
0 4.0 No No No No No
C
NHS Litigation Authority – Failure to
maintain, or certify a minimum published
CNST level of 1.0 or have in place
appropriate alternative arrangements
0 2.0 No No No No No
TOTAL 3.5 4.5 3.5 5.5 5.5 0.0 0.0
RAG RATING : AR R AR R R G G
GREEN = Score less than 1
AMBER/GREEN = Score greater than or equal to 1, but less than 2
AMBER / RED = Score greater than or equal to 2, but less than 4
RED = Score greater than or equal to 4
Overriding Rules - Nature and Duration of Override at SHA's Discretion
Greater than six cases in the year to date, and breaches the
i) Meeting the MRSA Objective cumulative year-to-date trajectory for three successive
No No Yes Yes Yes
quarters
ii)
Meeting the C-Diff Objective
Greater than 12 cases in the year to date, and either:
Breaches the cumulative year-to-date trajectory for three
successive quarters
Reports important or signficant outbreaks of C.difficile, as
defined by the Health Protection Agency.
No No No
No
No
iii)
RTT Waiting Times
Breaches:
The admitted patients 18 weeks waiting time measure for a
third successive quarter
The non-admitted patients 18 weeks waiting time measure
for a third successive quarter
The incomplete pathway 18 weeks waiting time measure for
a third successive quarter
No
No
No
No
No
Fails to meet the A&E target twice in any two quarters over
iv) A&E Clinical Quality Indicator a 12-month period and fails the indicator in a quarter during No No No No No
the subsequent nine-month period or the full year.
Breaches either:
v) Cancer Wait Times
the 31-day cancer waiting time target for a third successive
quarter
No
No
Yes
Yes
Yes
the 62-day cancer waiting time target for a third successive
quarter
vi)
Ambulance Response Times
Breaches:
the category A 8-minute response time target for a third
successive quarter
the category A 19-minute response time target for a third
successive quarter
N/a
N/a
N/a
N/a
N/a
either Red 1 or Red 2 targets for a third successive quarter
Fails to maintain the threshold for data completeness for:
vii) Community Services data completeness
referral to treatment information for a third successive
quarter;
service referral information for a third successive quarter,
or;
No No No
treatment activity information for a third successive quarter
No
No
viii) Any other Indicator weighted 1.0 Breaches the indicator for three successive quarters.
N/a N/a N/a No No
Adjusted Governance Risk Rating 3.5 4.5 4.0 5.5 5.5 0.0 0.0
AR R R R R G G

CONTRACTUAL DATA
Barts Health NHS Trust
Information to inform discussion meeting
Insert "Yes" / "No" Assessment for the Month
Historic Data
Current Data
Criteria
Qtr to
Jun-12
Qtr to
Sep-12
Qtr to
Dec-12 Jan-13 Feb-13 Mar-13 Qtr to
Mar-13
Board Action
1 Are the prior year contracts* closed? Yes Yes Yes Yes Yes
2
3
Are all current year contracts* agreed and
signed?
Has the Trust received income support outside
of the NHS standard contract e.g.
transformational support?
Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes
Main contracts signed on 14th September
2012
The Trust has received additional funding
to support the transition as detailed the
merger FBC and agreed by all relevant
stakeholders.
4
5
6
Are both the NHS Trust and commissioner
fulfilling the terms of the contract?
Are there any disputes over the terms of the
contract?
Might the dispute require third party intervention
or arbitration?
Yes Yes Yes Yes Yes
No No No No No
N/a N/a N/a N/a No
7 Are the parties already in arbitration? No No No No No
8 Have any performance notices been issued? No No No No No
9 Have any penalties been applied? No No No No No
*All contracts which represent more than 25% of the Trust's operating revenue.

TFA Progress
Barts Health NHS Trust
Apr-13
Select the Performance from the drop-down list
TFA Milestone (All including those delivered)
Milestone
Date
Performance
Board Action
1
TFA - Board approval of BELH Merger OBC and support to moving to FBC
stage
Jul-11
Fully achieved in time
2 TFA - NHS L CIC consideration of OBC Aug-11 Fully achieved in time
3
TFA - Liquidity - complete assessment of cash/liquidity issues and scale of
merger funding requirement together with identification of potential solutions
Sep-11
Fully achieved but late
Confirmation of near-term transaction-related financing and longer-term
transition costing required finalisation, including agreement from all
stakeholders; status of business case funding (as specified in OBC);
continuing challenge on aspects of financial/ performance position of
merger partners.
4 TFA - CCP response expected Nov-11 Fully achieved but late
5 TFA - FBC to be finalised and taken to Trust board Nov-11 Fully achieved in time
6 TFA - Trust Board approval of FBC Dec-11 Fully achieved in time
7 TFA - NHS L Main Board approval of FBC Dec-11 Fully achieved in time
8 TFA - Initial DH Transaction Board consideration of FBC Jan-12 Fully achieved in time
9 TFA - Final DH Transaction Board consideration of FBC Feb-12 Fully achieved in time
10 TFA - NHS Co-operation and Competition Panel (CCP) recommendation Feb-12 Fully achieved in time
CCP Stage 2 review was extended (announced 14 November)
FBC finalised on 25th November and taken to Trust Boards in early
December .
FBC, including transaction financing, approved by the Boards of BLT,
Newham, Whipps Cross INEL and ONEL.
FBC, including transaction financing, approved by NHS London Board on
13 December.
Informal consideration and feedback received 'no substantive concerns'
DH Transaction Board considered merger on 9 February and submitted
to the Secretary of State for Ministerial approval.
CCP announced w/c 6 February that they would recommend to the
Secretary of State for Health that the proposed merger goes ahead
11 TFA - Complete commissioning of phase 1 of Royal London Hospital Mar-12 Fully achieved in time
All services intended to move into the new Royal London Hospital
transferred and the hospital opened on 1 March.
12 TFA - Secretary of State approval Mar-12 Fully achieved in time
13 TFA - Trust dissolved, Barts Health established Apr-12 Fully achieved in time
14 TFA - 18 months trading (April 2012 - September 2013) Sep-13 On track to deliver
15 TFA - Develop IBP / LTFM (April 2012 - September 2013) Sep-13 On track to deliver
Barts Health NHS Trust successfully established on the 1st April 2012.
Quarter 1 and Quarter 2 trading arrangements based on post merger
implementation plan. The eight Clinical Academic Groups (CAGs) went
live in Quarter 3 2012/13
Strategic and annual planning processes with CAGs commenced in
Quarter 3 2012/13
16 TFA - Public Consultation (July - September 2013) Jul-13
17 TFA - HDD1 Jul-13
18 TFA - HDD1 Actions *(August - September 2013) Aug-13
19 TFA - HDD2 (October - November 2013) Oct-13
20 TFA - HDD2 Actions (November - December 2013) Nov-13
21 TFA - FT Application submission to DH Dec-13
22 TFA - Secretary of State Approval Apr-14
23 TFA - Submission to Monitor May-14
24 TFA - Monitor Assessment Process (June - September 2014) Jun-14
25 TFA - Working Capital Review Oct-14
26 TFA - Target Authorisation Date Dec-14
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
A Barts Health TFA including a revised trajectory for FT authorisation was
submitted to NHS London at the end of November and is currently being
agreed. This will change the future milestones.
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Notes
Ref Indicator Details
Thresholds
1a
1b
1c
The SHA will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing to
achieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or no
tolerance against the target, e.g. those set between 99-100%.
Data
Completeness:
Community
Services
Data
Completeness
Community
Services (further
data):
Mental Health
MDS
Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, to
consist of:
- Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;
- Community treatment activity – referrals; and
- Community treatment activity – care contact activity.
While failure against any threshold will score 1.0, the overall impact will be capped at 1.0. Failure of the same measure for three quarters will
result in a red-rating.
Numerator:
all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).
Denominator:
all activity data required by CIDS.
The inclusion of this data collection in addition to Monitor's indicators (until the Compliance Framework is changed) is in order for the SHA to
track the Trust's action plan to produce such data.
This data excludes a weighting, and therefore does not currently impact on the Trust's governance risk rating.
Patient identity data completeness metrics (from MHMDS) to consist of:
- NHS number;
- Date of birth;
- Postcode (normal residence);
- Current gender;
- Registered General Medical Practice organisation code; and
- Commissioner organisation code.
1d
Mental Health:
CPA
Numerator:
count of valid entries for each data item above.
(For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’s
website: www.ic.nhs.uk/services/mhmds/dq)
Denominator:
total number of entries.
Outcomes for patients on Care Programme Approach:
• Employment status:
Numerator:
the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or other
multi-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during the
reference period. The reference period is the last 12 months working back from the end of the reported month.
Denominator:
the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the
reported month.
• Accommodation status:
Numerator:
the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is known at the time of their
most recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews were
carried out during the reference period. The reference period is the last 12 months working back from the end of the reported month.
Denominator:
the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the
reported month.
• Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:
Numerator:
The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.
Denominator:
The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.
2a-c
2d
3a
3b
3c
3d
RTT
Learning
Disabilities:
Access to
healthcare
Cancer:
31 day wait
Cancer:
62 day wait
Cancer
Cancer
Performance is measured on an aggregate (rather than specialty) basis and trusts are required to meet the threshold on a monthly basis.
Consequently, any failure in one month is considered to be a quarterly failure. Failure in any month of a quarter following two quarters’ failure of
the same measure represents a third successive quarter failure and should be reported via the exception reporting process.
Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any threshold will score 1.0, the
overall impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where a trust with existing
acute facilities acquires a community hospital, performance will be assessed on a combined basis.
The SHA will take account of breaches of the referral to treatment target in 2011/12 when considering consecutive failures of the referral to
treatment target in 2012/13. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patients
target in quarters 1 and 2, it will be considered to have breached for three quarters in a row.
Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH,
2008):
a) Does the trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of
care are reasonably adjusted to meet the health needs of these patients?
b) Does the trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:
- treatment options;
- complaints procedures; and
- appointments?
c) Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities?
d) Does the trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?
e) Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers?
f) Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in
routine public reports?
Note: trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each month. Failure to
do so will result in the application of the service performance score for this indicator.
31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold represents a failure against
the overall target. The target will not apply to trusts having five cases or less in a quarter. The SHA will not score trusts failing individual cancer
thresholds but only reporting a single patient breach over the quarter.. Will apply to any community providers providing the specific cancer
treatment pathways
62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants.
Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or less in a
quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to
any community providers providing the specific cancer treatment pathways.
National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a
50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided the SHA receive evidence of written
agreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the trust makes its monthly declaration
to the SHA.
In the absence of any locally-agreed contractual arrangements, the SHA encourages trusts to work with other providers to reach a local systemwide
agreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of this
nature has been reached, the SHA will consider applying the terms of the agreement to trusts party to the arrangement.
Measured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. The SHA
will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any community
providers providing the specific cancer treatment pathways.
Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary care
professional).Failure against either threshold represents a failure against the overall target. The target will not apply to trusts having five cases or
fewer in a quarter. The SHA will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter.
Will apply to any community providers providing the specific cancer treatment pathways.
Specific guidance and documentation concerning cancer waiting targets can be found at:
http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

Notes
Ref Indicator Details
3e
A&E
Waiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator will
apply to minor injury units/walk in centres.
3f Mental 7-day follow up:
Numerator:
the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion)
within seven days of discharge from psychiatric inpatient care.
Denominator:
the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.
All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within
seven days of discharge. Where a patient has been transferred to prison, contact should be made via the prison in-reach team.
Exemptions from both the numerator and the denominator of the indicator include:
- patients who die within seven days of discharge;
- where legal precedence has forced the removal of a patient from the country; or
- patients discharged to another NHS psychiatric inpatient ward.
For 12 month review (from Mental Health Minimum Data Set):
Numerator:
the number of adults in the denominator who have had at least one formal review in the last 12 months.
Denominator:
the total number of adults who have received secondary mental health services during the reporting period (month) who had spent at least 12
months on CPA (by the end of the reporting period OR when their time on CPA ended).
3g
Mental Health:
DTOC
For full details of the changes to the CPA process, please see the implementation guidance Refocusing the Care Programme Approach on the
Department of Health’s website.
Numerator:
the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care
was delayed during the month. For example, one patient delayed for five days counts as five.
Denominator:
the total number of occupied bed days (consultant-led and non-consultant-led) during the month.
3h
Mental Health: I/P
and CRHT
Delayed transfers of care attributable to social care services are included.
This indicator applies only to admissions to the foundation trust’s mental health psychiatric inpatient care. The following cases can be excluded:
- planned admissions for psychiatric care from specialist units;
- internal transfers of service users between wards in a trust and transfers from other trusts;
- patients recalled on Community Treatment Orders; or
- patients on leave under Section 17 of the Mental Health Act 1983.
3i
3j-k
Mental Health
Ambulance
Cat A
The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolution
team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in
admission.
For full details of the features of gate-keeping, please see Guidance Statement on Fidelity and Best Practice for Crisis Services on the
Department of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:
a) provide a mobile 24 hour, seven days a week response to requests for assessments;
b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires face-to-face contact unless it can be
demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, a
declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;
c) be notified of all pending Mental Health Act assessments;
d) be assessing all these cases before admission happens; and
e) be central to the decision making process in conjunction with the rest of the multidisciplinary team.
Monthly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance,
rounded down.
For patients with immediately life-threatening conditions.
The Operating Framework for 2012-13 requires all Ambulance Trusts to reach 75 per cent of urgent cases, Category A patients, within 8 minutes.
From 1 June 2012, Category A cases will be split into Red 1 and Red 2 calls:
• Red 1 calls are patients who are suffering cardiac arrest, are unconscious or who have stopped breathing.
• Red 2 calls are serious cases, but are not ones where up to 60 additional seconds will affect a patient’s outcome, for example diabetic
episodes and fits.
Ambulance Trusts will be required to improve their performance to show they can reach 80 per cent of Red 1 calls within 8 minutes by April 2013.
4a
4b
C.Diff
MRSA
Will apply to any inpatient facility with a centrally set C. difficile objective. Where a trust with existing acute facilities acquires a community
hospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C.
difficile will be taken into account for regulatory purposes.
Where there is no objective (i.e. if a mental health trust without a C. difficile objective acquires a community provider without an allocated C.
difficile objective) we will not apply a C. difficile score to the trust’s governance risk rating.
Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring cases of

Report
to the Trust Board: 10 Aprill 2013
TB 35/13
Title
Sponsoring Director
Author( (s)
Purpose
Previously considered by
Single Operating Model (SOM) – April A Self Certification
Submissionn
Director of Informatics
and Chief Information Officer
Director of Informatics
and Chief Information Officer
To seek Trust Board approval of the t April 2013 self‐certification
return of the Single Operating Model, reporting February 2013
data (to bee submitted to the NHSS Trust Development Authority
on 15 April 2013).
Trust Executive, 2 April 2013
Executive summary
The ratings for this
month’s self‐certification return are:
Key area for rating
Governance Risk Rating (GRR)
Score
5.5
RAG rating
Red
Financial Risk Rating (FRR)
2
Red
Related
Trust objectives
10. Agree a foundation trust authorisatio
on trajectory
and achieve all milestones.
Risk and
Assurance
Related
Assurance
Framework entries
Legal implications/
regulatory requirements
The report provides assurance in relation to Trust objective 10.
n/a
As an aspirant NHS foundation trust, Barts Health is required to
submit a monthly SOM
return.
Action required:
The Trust Board is asked to
review and approve
the April
(reporting February
2013 data).
2013 self‐certification
return

TB 35/13
BARTS HEALTH NHS TRUST
TRUST BOARD MEETING: 10 APRIL 2013
SINGLE OPERATING MODEL (SOM) –
APRIL 2013 SELF CERTIFICATION SUBMISSION
SUMMARY OF KEY POINTS
1. The purpose of this report is to inform the Trust Board of the content of the April
2013 self‐certification return of the Single Operating Model, reporting February 2013
data, and present the templates which will be submitted to the NHS Trust
Development Authority on 15 April 2013. The ratings for this month’s selfcertification
return are:
Key area for rating Score RAG rating
Governance Risk Rating (GRR) 5.5 Red
Financial Risk Rating (FRR) 2 Red
INTRODUCTION
2. On 3 August 2012 the Department of Health (DH) launched part 2 of the Single
Operating Model (SOM), focusing on SHA oversight of NHS Trusts. Oversight includes
clinical quality, finance, service performance, governance and the delivery of the
Tripartite Formal Agreement (TFA). The SOM aims to ensure a consistent approach to
FT development across the country and to prepare for the establishment of the NHS
Trust Development Authority (NTDA).
PRINCIPLES UNDERPINNING THE SINGLE OPERATING MODEL
3. The model is designed around Monitor’s criteria and assessment methodology and
the eight domains of assurance against which the DH considers FT applications for
Secretary of State. As such, the oversight approach aims to develop the skills which
will be tested in detail as part of the assessment for FT status and will be required
once authorised. The model aims to remove duplication of activity across all stages of
the applications process and promote integrated performance management of
actions and milestones in Tripartite Formal Agreements (TFA).
2

TB 35/13
4. Monthly self‐certification returns are expected to be submitted on time and in full.
Late, incomplete or inaccurate submissions will automatically be overridden to a red
governance risk rating. The SOM framework comprises:
NHS Trust Governance Declarations
Board Statements
Quality Return
Financial Risk Rating
Governance Risk Rating
Contract status
TFA Progress
SUMMARY OF APRIL 2013 SELF‐CERTIFICATION RETURN (FEBRUARY 2013 POSITION)
a. Board Statements
5. The latest position is that 7 of the 15 Board Statements can be confirmed and 8
cannot. The 8 exceptions are:
The board is satisfied that processes and procedures are in place to ensure all
medical practitioners providing care on behalf of the trust have met the relevant
registration and revalidation requirements.
The board anticipates that the trust will continue to maintain a financial risk
rating of at least 3 over the next 12 months.
All current key risks have been identified (raised either internally or by external
audit and assessment bodies) and addressed – or there are appropriate action
plans in place to address the issues – in a timely manner.
The board has considered all likely future risks and has reviewed appropriate
evidence regarding the level of severity, likelihood of it occurring and the plans
for mitigation of these risks.
The necessary planning, performance management and corporate and clinical
risk management processes and mitigation plans are in place to deliver the
annual plan, including that all audit committee recommendations accepted by
the board are implemented satisfactorily.
An Annual Governance Statement is in place, and the trust is compliant with the
risk management and assurance framework requirements that support the
Statement pursuant to the most up to date guidance from HM Treasury
(www.hm‐treasury.gov.uk).
The board is satisfied that plans in place are sufficient to ensure ongoing
compliance with all existing targets (after the application of thresholds) as set out
in the Governance Risk Rating; and a commitment to comply with all
commissioned targets going forwards.
The trust has achieved a minimum of Level 2 performance against the
requirements of the Information Governance Toolkit.
3

TB 35/13
6. The full return and the Board Statement Exception Report includes a brief summary
of the issues and actions relating to each of these statements.
b. Quality Return
7. This section is not risk rated but the indicators are used to inform clinical quality
discussions between the Trust and the SHA. Key areas to highlight are:
HMSR – 2011 data (the latest published) indicates a positive position for the
Trust (0.8 against a national average of 1) as a whole and for each of the three
legacy Trusts.
VTE Screening ‐ performance has improved from prior month (90.25 compared
to 88.58 in January 2013).
MRSA screening ‐ data is still being collated.
Open Serious Incidents Requiring Investigation – incidents have increased to 33
from 21 in January 2013. A recovery plan is in place to address the high number
of legacy and current Sis.
Single Sex Accommodation Breaches – Remedial action is in place to address the
causal factors
Formal Complaints Received – there has been a decrease in the number of
complaints from previous months.
Sickness absence rate ‐ data is still being collated.
Consultant PDPs – data is still being collated.
Agency spend – decreased from 5.58 to 4.99% due to implementation of controls
around spend.
c. Financial Risk Rating (FRR)
8. Financial Risk Ratings remain at 2 (red) due to the current in year deficit position.
d. Governance Risk Rating (GRR)
9. The GRR is based on Monitor’s latest compliance framework. For April 2013 the Trust
is RAG rated red with a score of 5.5. The following indicators contributed to this
position:
Certification against compliance with requirements regarding access to
healthcare for people with a learning disability (weighting 0.5)
18 week Referral to Treatment (RTT) waits – admitted (weighting 1.0)
All cancers – 62 day wait for first treatment (weighting 1.0)
A&E – 4 hour waits (weighting 1.0)
Clostridium Difficile ‐ above the de minimis threshold (weighting 1.0)
MRSA ‐ above the de minimis threshold and above the year to date ceiling
(weighting 1.0)
4

TB 35/13
10. Additionally, the overriding rules around cancer wait times and meeting the MRSA
objective have been triggered. The position remains static from the March position
(red, with a score of 5.5).
e. Contract Status
11. All main contracts were signed on 14 September 2012 and there are no issues or
disputes.
f. TFA Progress
12. This section outlines progress with the milestones and actions in the tripartite formal
agreement. For November, an amber/red rating was agreed for TFA progress, with
the comment “A Barts Health TFA including a revised trajectory for FT authorisation
was submitted to NHS London at the end of November 2012 and is currently being
agreed. This will change the future milestones”.
RECOMMENDATION
13. The Trust Board is asked to review and approve the April 2013 self‐certification return
(reporting February 2013 data).
5