1. Public board papers September 2010.pdf - Become an NHS ...

AGENDA FOR BOARD MEETING IN PUBLIC 28 SEPTEMBER 201010:00-12:00 MEETING ROOM 2MANDEVILLE WING, STOKE MANDEVILLE HOSPITAL1. Apologies for absence – Lynne Swiatczak 10:00- GE2. Meeting Protocol TBP 2 To note 10:15 GE3. Declaration of Interests - GE4. Minutes of the meeting held on 27 July 2010 TBP 4 To approve GE5. Action matrix review - To review GE6. Chief Executive’s report TBP 6 To noteAE7. Presentation by the Division of Community & Integrated Care - To note 10:15-10:30SECTION A – PATIENT SAFETY AND CLINICAL QUALITY8. Infection control:10:30- JO’D8.1 Report for August 2010TBP 8.1 To note 10:458.2 Infection Control StrategyTBP 8.2 To approve9. Clinical Outcomes Report at August 2010 TBP 9 To note GLSECTION B – RISK IDENTIFICATION AND CONTROL10. Board assurance framework TBP10 To approve 10:45- LH11. Corporate Risk Register TBP11 To approve11:00BP12. Progress Report on Trust Action Plan in response to AuditCommission ‘Taking it on Trust: a Review of How Boards ofNHS Trusts and Foundation Trusts Get Their Assurance’May 2009.13. 13.1 Governance Report for April to June 201013.2 Healthcare Governance Report 2008/0913.3 Audit Commission Review of governance Action PlanProgress ReportTBP12TBP13.1TBP13.2TBP13.3To noteTo noteTo noteCELHSECTION C – STRATEGY14. Strategic Update TBP14 To note 11:00- JB11:1515. Integration of Community Services – A new organisational TBP15 To note JBidentity16. Information Governance Strategy TBP16 To approve BPSECTION D – PERFORMANCE17. Finance report TBP17 To review 11:15- TT18. Performance and quality report TBP18 To review 11:40 BP19. Workforce report and update on the implementation ofBoorman and Health and WellbeingTBP19 To reviewSH

20. Patient Experience TBP20 To note CESECTION E – REGULATORY AND COMPLIANCE21. Use of Trust Seal TBP21 To note 11:40-11:45AESECTION F – OTHER22. Summary of committee meetings22.1 Healthcare Governance Committee 7/9/1022.2 Audit Committee 16/9/1022.3 Charitable Funds Committee 5/8/1022.4 Organ & Tissue Donation Committee11:45-12:00TBP22.1TBP22.2TBP22.3TBP22.4To noteTo noteTo noteTo noteKGLBLBBK23. Any other business (previously declared) - - GE24. Questions from the public - - GE25. Date of next meetingTo note that the next meeting to be held in public will takeplace at 10am on 23 November 2010 in the Lecture Theatre,Education Centre, Wycombe Hospital- -Confidential BusinessThe Board will then consider a motion: “That representatives of the press and other members of thepublic be excluded from the remainder of the meeting, having regard to the confidential nature of thebusiness to be transacted, publicity of which would be prejudicial to the public interest” Section 1 (2) of thePublic Bodies (Admission to Meetings) Act 1960)Papers for Board meetings in public are available on our websitewww.buckinghamshirehospitals.nhs.uk

AGENDA ITEM NO 2PUBLIC BOARD MEETING 28 SEPTEMBER 2010TRUST BOARD MEETINGSMEETING PROTOCOLThe Buckinghamshire Hospitals NHS Trust Board welcomes the attendance of members of thepublic at its Board meetings to observe the Trust’s decision-making process.Copies of the agenda and papers are available at the meetings, on our websitewww.buckinghamshirehospitals.nhs.uk, or may be obtained in advance from:Mrs Liz Greig, Head of the Executive Office,Amersham Hospital, Whielden Street,Amersham, Bucks, HP7 0JD.Direct Dial: 01494 734851e-mail: liz.greig@buckshosp.nhs.ukMembers of the public will be given an opportunity to comment on agenda items when themeeting finishes.If members of the public wish to raise matters not on the agenda, then arrangements will bemade for them to be discussed after the meeting with the appropriate director.Graham EllisChairman

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010and the Francis Inquiry to the next Board meeting.The Chief Nurse advised the Board that patient experience representatives would beinvited to present to the Board on a six monthly basis. The Chairman proposed thathe discuss these plans with the Chief Nurse.Action: The Chairman and Chief Nurse to discuss plans to invite patient experiencerepresentatives to present to the Board.128/2010 CHIEF EXECUTIVE’S REPORTThe Chief Executive outlined the key themes from the recently published White Paper“Equity and Excellence: Liberating the NHS”. The main thrust was to drive up qualitywith an emphasis on clinical outcomes, putting the NHS back into the hands of frontlinestaff and reducing bureaucracy. The Chief Executive advised the Board thatBuckinghamshire Hospitals was well placed to take on these challenges and to workmore closely with practice-based commissioners following the abolition of strategichealth authorities and primary care trusts in their present form.Further work was required to achieve financial stability to enable to the Trust to takeforward its application for foundation trust status. The Board was aware of the hugefinancial challenge required in order to reduce costs by 10% in the current year. Anadverse position at the end of the first quarter meant that the Trust was now workingwith the Strategic Health Authority to hasten progress. The Trust had beenrecommended to appoint an experienced Turnaround Director to help deliver thesavings plan and David Scanlon had taken on this role on 19 July.The Board was advised that 60% of costs were staff related and work had started toidentify areas for savings in the use of temporary and agency staff initially. Everyeffort would be made to keep redundancies to a minimum working closely with staff,staff representatives and trade unions.A GP led health centre at Wycombe Hospital had helped to take some pressure off theemergency services on that site and the Trust was working with Bucks Urgent Careand NHS Buckinghamshire to explore whether a similar model would be suitable forStoke Mandeville Hospital.To help deliver care closer to home, the Trust will be looking at better ways to use thecommunity hospitals. A series of public engagement meetings were being organisedto hear the views of the local population. The Chief Executive encouraged as manypeople as possible to attend. The Chairman emphasised the importance of engagingwith the public and recommended that all Board members talk to as many people aspossible to determine their views.The Chairman also recommended that Board members maintain contact with thePrimary Care Trust and the Strategic Health Authority during the transition period toGP commissioning.129/2010 PRESENTATION BY THE DIVISION OF MEDICINEThe Board received a presentation from John Quinn, Assistant Director of Operationsfor Medicine on performance and future plans. Also present were Dr Piers Clifford,Divisional Chair, and Mrs Alison Brandon, Divisional Lead Nurse. Mr Quinn, DrClifford and Mrs Brandon took questions from the Board on the areas coveredincluding infection control, cost improvement plans, quality assurance, staffPage 2 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010Mortality Review January 2010 Interim ReportThe Board received an interim report of the mortality review for January 2010 whichsummarised the findings and conclusions and actions to arise so far. The mortalityreview would form a pilot for a new process whereby deaths in hospital would bereviewed on a regular basis using a new mortality review template recommended bythe Strategic Health Authority’s Patient Safety Federation. The review had beenreassuring in identifying very few instances in which aspects of care could beimproved and no clear instances in which the death was avoidable. Mr Griffithspointed out that he would expect serious untoward incidents to rise as a consequenceand that this should be raised with the Patient Safety Federation.Action: The Medical Director to contact the SHA Patient Safety Federation regardingthe likely rise in serious untoward incidents as a result of the new mortality reviewtemplate.Mr Broude suggested that reports of mortality should include groupings of commonthemes and this was accepted. The Chief Executive recommended thatimplementation of any outcomes be audited and should inform divisional auditprogrammes.Action: The Board noted the interim report and approved the new process. TheMedical Director to ensure that reports of mortality include details of common themesand implementation of any outcomes be audited and inform the divisional auditprogrammes.133/2010 ASSURANCE FRAMEWORKThe Board Assurance Framework sets out the key threats to achieving the Trust’sobjectives for 2010/11. There were currently 32 threats to the principal objectives.The Assurance Framework had been reviewed by the Audit Committee on 15 July2010.Approved.134/2010 CORPORATE RISK REGISTERThe Corporate Risk Register sets out the highest current risks identified within theTrust. These risks had been reviewed by the relevant executive director and therewere seven risks currently included in the section scoring nine or above. There werealso currently two risks scoring 15 or above on the divisional risk registers. Theserelated to a decision to temporarily close the Midwifery Led Unit at Wycombe for threemonths and issues identified with generator support to Stoke Mandeville Hospital.The Chairman asked that projected completion dates be reviewed as some hadexpired. The Chairman also challenged the risk rating for achieving break even andwas advised that the score would be reviewed as the year progresses.Action: The Chief Operating Officer to review projected completion dates as well asthe responsible executive lead.135/2010 STRATEGIC UPDATEThe Director of Strategy presented a report to bring the Board up to date on a numberof strategic initiatives.Page 4 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010The Board was advised that the Trust continued to work with the NHS Co-Operationand Competition Panel (CCP) in order to complete their review of the merger withCommunity Health Bucks. It was hoped that the process could be completed withinone to two months to enable the necessary legal changes to take place. Mr Broudeasked if the delay was affecting savings plans and it was confirmed that it did not andthat the work still to be finalised related to technicalities and the CCP view was simplya recommendation and had no legal status.The Trust had formally restarted its Foundation Trust application process and it wasnoted that every trust should be a Foundation Trust or part of a Foundation Trust by2013.The ImPACT programme was a health economy-wide programme of work with anexternal chair. All work-streams would be programme managed. The Trust wasresponsible for some of the pathway redesign schemes which form part of theprogramme.The Board was advised of the need to temporarily close the Wycombe Birth Centre forthree months from 1 August due to extreme staff shortages. The service wouldtransfer to join the Aylesbury Birth Centre at Stoke Mandeville. The Trust was workingclosely with the six families affected and with the Overview & Scrutiny Committee forPublic Health.The Board was advised that the Trust was working with other local acute Trusts toexplore how specialist skills could be combined to continue to ensure local access tospecialist services in the future.Following public consultation in the spring, children’s speech and language therapyservices were being tendered jointly by Bucks County Council and NHS Bucks. TheTrust is required to bid within the competitive tendering process to provide theseservices in the future.136/2010 ANNUAL PLAN 2010/11The Annual Plan, produced along Monitor guidelines and, where appropriate, usingMonitor templates, comprising a review of the past year together with a more detailedanalysis of the Trust’s strategy and challenges for 2010/11 was approved.Approved137/2010 SINGLE EQUALITY SCHEMEThe Board received a presentation on the Trust’s Single Equality Scheme 2010/13which sets out publicly its commitment to embracing diversity and delivering equalityof opportunity for all employees and service users. The Board noted the action planwhich would be monitored by the Diversity Steering Committee which reports to theHR Workforce Committee and the Trust Management Committee by exception.It was agreed that performance would be incorporated into the assurance reports tothe Board. Leads would be identified for each of the actions. Mr Griffiths suggestedthat the Trust investigate any notices already issued to see if lessons could belearned.Action: The Board approved the Single Equality Scheme and requested thatPage 5 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010performance against the action plan into the assurance reports to the Board. TheDirector of Strategy to ensure that leads are identified for each of the actions andinvestigate any notices already issued to see if lessons could be learned.138/2010 PERFORMANCE AND QUALITYPerformance and Quality ReportThe Board received the performance and quality report for June 2010. The ChiefOperating Officer reported that since the Board last met some of the performancetargets had been revised relating to A&E and the 18 week pathway. The Trust hadagreed locally that it would continue to deliver the 98% target for patients to be seenwithin 4 hours of arrival at A&E and referral to treatment within 18 weeks.At 98%, the Trust was had been strong on the delivery of the emergency accesstarget during June. The 18 week target was being met in all specialities apart fromorthopaedics and there were plans to deliver this by the end of the calendar year.With regard to the call to needle target, treatment for such patients was in transitionand the Trust has started to deliver percutaneous coronary intervention (PCI),previously called angioplasty, and treated three new patients in this way in June with100% compliance of the target of treatment within 150 minutes of calling for help.The development of the monitoring and reporting of national and local indicatorsapplicable to community activity is being undertaken and is awaiting confirmation insome areas.Activity and IncomeThis was a new report and demonstrated that all areas were approximately on plan foractivity apart from A&E attendances. Income was below target due to the lower acuityof patients. The Board was asked for comments on how this report could be furtherenhanced.Action: Board members to comment on ways in which the new Activity & IncomeReport could be further enhanced.139/2010 FINANCE REPORTThe Director of Finance reported that cumulatively the Trust was overspent by £990kat the end of June which was £600k higher than expected. June had shown a fall inexpenditure but the main contributory factors were slippage on the delivery of savingsplans and operational pressures. Cost savings continue to be identified and costimprovement plan delivery arrangements had been strengthened in order to convertthese into savings. Mr Broude observed that the Trust still had a long way to go andthat the position was £3m behind plan and was a real challenge for the rest of theyear.The Community Services contract was currently being negotiated with NHS Bucks inorder to bring matters to a conclusion. The Strategic Health Authority had offered toarbitrate should agreement not be reached. Mr Gilchrist enquired whether it waspossible to monitor the impact of work moving from the acute to the community sector.Action: The Director of Finance to work with commissioners on mitigating the impactof work moving from acute cost per case to community block contract.The current spend on capital schemes is under the capital plan year to date figure andPage 6 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010work is taking place to recover this position. The Trust continues to maintain a healthycash position mainly due to the cash inflow from the PCT prior to year end. This islikely to become an emerging problem as we move through the year.Board members expressed concern at the amount of savings to be made during therest of the year and it was clear that as an organisation the Trust needed to movefaster to achieve the savings required. The Chief Executive acknowledged this andreported that the appointment of David Scanlon would help give the programme somereal focus. The Trust was meeting with the Strategic Health Authority on 8 September2010 to demonstrate the progress in making the necessary savings whilst maintainingsafe patient services.140/2010 WORKFORCE REPORTThe Director of Human Resources presented the workforce report as at June 2010.She reported that work continues to merge the hospital and community staff payrolls.Work was ongoing to reduce the pay bill with Mr Broude as the lead Non-ExecutiveDirector for this work. Future reports to the Board were being refreshed followingreceipt of members’ comments.141/2010 STAFF SURVEYThe Board had received reports in March and May in respect of the 2009 Staff Surveyresults for hospital and community based staff. An organisational action plan waspresented to the Board which identifies a number of actions to help supportinvolvement and engagement. Presentations had been delivered to divisional boardsand divisions were being asked to help deliver the Trust-wide plan and two or threelocal issues that they wish to improve. Progress was being monitored by the HRCommittee.Approved.142/2010 MEMBERSHIP AND INVOLVEMENT ANNUAL REPORT 2009/10The Board received a report providing assurance of the work undertaken in a numberof areas and which summarised the member/involvement events. The Board notedthat involvement work remained a key focus at local level, as it does nationally.143/2010 USE OF TRUST SEALThe use of the Trust seal on the following documents was noted.• Deed of Novation in relation to a change to Sodexo UK's trading entitybetween the Trust, Enterprise Healthcare Limited, Sodexo Limited, CarillionCapital Projects Limited, Balfour Beatty Engineering Services (HY) Limited,Sodexo SA and Sumitomo Mitsui Banking Corporation Europe Limited.• Deed of Guarantee in relation to a guarantee provided by Sodexo SA to theTrust, Enterprise Healthcare Limited and Sumitomo Mitsui Banking CorporationEurope Limited.• Third Supplemental Agreement in relation to the return to Trust managementof the retained estate maintenance service between the Trust and EnterpriseHealthcare Limited.The documents were signed by the Chief Executive and Director of Finance & IT on 9Page 7 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010July 2010.144/2010 BOARD COMMITTEESHealthcare Governance Committee Meting 6 July 2010The Board received a summary of the areas covered. Mr Gilchrist commented thatthe quality of information supplied to this meeting had greatly improved and greaterassurance was being achieved mainly thanks to the Assistant Director of Governanceand her team.Audit Committee Meeting 15 July 2010The Board received a summary of the meeting. The meeting had recommended thatthe audit fee for external audit work be approved but asked The Director of Finance towrite to the Audit Commission raising concerns on the level of fees and requestingdetails of what it is doing to reduce future costs.145/2010 ANY OTHER BUSINESSThere was no other business.146/2010 DATE OF NEXT MEETINGThe next meeting will take place at 10am on Tuesday 28 September 2010 in MeetingRoom 2, Mandeville Wing, Stoke Mandeville Hospital.147/2010 QUESTIONS FROM THE PUBLICMr John Wrigley from the League of Friends of Buckingham Hospital expressed aview that replicating a GP urgent care centre at Stoke Mandeville would not help thepeople in the north of the county and that it really needed to be at BuckinghamHospital. The Chief Executive invited Mr Wrigley to attend one of the publicengagement meetings on the future of the community hospitals.The meeting ended at 1.15pm.The Board considered and agreed a motion:“That representatives of the press and other members of the public be excluded from theremainder of the meeting, having regard to the confidential nature of the business to betransacted, publicity of which would be prejudicial to the public interest”Section 1 (2) of the Public Bodies (Admission to Meetings) Act 1960).………………………………………….. Chairman………………………. DatePage 8 of 9

AGENDA ITEM 4TRUST BOARD 28 SEPTEMBER 2010ACTION POINTSMinute Action By Status172/2009 Report progress on action plan for ExternalAudit’s review of Governance.9/2010 Ensure that the Patient Safety Strategy isreviewed by the Board on an annual basis.42/2010 Conduct a review of level of Board assuranceto run in parallel with the review of the Trustposition against the Francis Inquiryrecommendations.43/2010 Report on the results of the audit of hospitalstandardised mortality ratio for December2009/January 2010 to the HealthcareGovernance Committee50/2010 A progress report on the “Taking it on Trust”action plan to be presented to the Board in 6months’ time.127/2010 To present an assurance report based onnursing standards to a future Board meeting.127/2010 To discuss plans to invite patient experiencerepresentatives to present to the Board.130/2010 To report progress on the National InpatientSurvey Action Plan at the November meeting.132/2010 To contact the SHA Patient Safety Federationregarding the likely rise in serious untowardincidents as a result of the new mortality reviewtemplate.132/2010 To ensure that the reports of mortality includedetails of common themes and arecommendation that implementation of anyoutcomes be audited and inform divisionalaudit programmes.134/2010 To review projected completion dates on theCorporate Risk Register as well as theresponsible executive lead.137/2010 Incorporate performance against the SingleEquality Scheme action plan into assurancereports to the Board.Chief NurseAgenda itemChief Nurse January 2011Director ofHumanResourcesMedical DirectorChief NurseReview underwayInterim reportcomplete see132/2010Agenda itemChief Nurse November 2010Chairman and Agenda itemChief NurseChief Nurse November 2010Medical DirectorMedical DirectorChief OperatingOfficerAction completeBeingimplementedCompletedEnsure that leads are identified for each of theactions in the Single Equality Scheme andinvestigate any notices already issued to see iflessons could be learned.138/2010 Board Members to comment on ways in whichthe new Activity & Income report could beenhanced139/2010 Work with commissioners on mitigating impactof work moving from acute cost per case tocommunity block contract.Director ofStrategyBoard MembersDirector ofFinanceOngoingOngoingOngoingPage 9 of 9

AGENDA ITEM 6TRUST BOARD 28 SEPTEMBER 2010TRUST BOARD MEETING 28 SEPTEMBER 2010CHIEF EXECUTIVE’S REPORTAt this halfway point of the financial year, our plans for the future are starting to take shape.Our objectives are complex and multi-layered: a move to care offered in patients’ own homesand communities wherever possible whilst hospitals become more specialist in those things thatcannot be offered elsewhere; a step change in the productivity of the services we offer with arequirement to save nearly 10% of our budget in-year whilst at the same time maintaining thequality and safety of our services.Taking the Integration agenda first, a series of public engagement sessions have been heldacross our communities to establish what people want from their community health services andcommunity hospitals. Work continues with local GPs to establish their views.Access to the strategic change fund will help us to invest in our community teams and districtnurses and therapists. Extended beds in the Waterside Unit at Amersham opened on 6September 2010 allowing patients who do not need acute medical care to be treated in a moresuitable environment. As a consequence this has allowed us to refocus what is happening inthe acute wards at Wycombe Hospital, less beds needed etc.Turning to specialist services and the work of the clinical networks, our alliance withHeatherwood & Wexham Park Hospitals made a strong bid to become the second electivetreatment centre for vascular services and work is underway to develop a proposal for specialiststroke services.The Turnaround Plan is starting to grip. Financial outturn at month five demonstrates that thehard work is starting to pay off and the overspend is reducing. We are gaining control overtemporary and agency spend. Never complacent, there is a long way to go to achieve therequired £3m surplus. In conjunction with NHS Buckinghamshire, we are working to improvethe productivity of our services with work in progress in community teams, outpatients andtheatres. All this puts us in a good position to stay on track for our plans to achieve NHSFoundation Trust status by April 2012.Of prime importance is to ensure that the safety and quality of services is not compromised aswe strive to make the cost savings. The Board can take assurance from the fact that savingsschemes are clinically risk assessed and feature as part of the corporate risk register with plansto mitigate.Finally, I am delighted to advise the Board that the search is now on for those staff who havegone the extra mile for patients and colleagues in this year’s Staff Awards. There are sevencategories and the awards are open to anyone in any role working for or with Buckinghamshirehospitals, including all our community services staff. In addition, to ensure our patients continueto be involved, we’re inviting patients and visitors to tell us who their stars are.Anne EdenChief Executive

AGENDA ITEM 8.1TRUST BOARD 28 SEPTEMBER 2010Title: Infection Control Report for August 2010.To be presented by:Dr Jean O’DriscollDirector for Infection Prevention and ControlExecutive summary and key issues for the Board:9 cases of Trust-apportioned C.diff infections (3 cases above year-to-date limit).No MRSA BacteraemiasRisk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? Yes in that clusters of C.diffinfection may compromise our ability to stay within our limit by year-end.Does this paper provide assurance on the control of an identified risk? If so provide here the degree ofassurance given and reference the risk on the BAF or CRR that it controls. NoCommittee review and approval:Has the paper been reviewed and/or approved at a Board or executive committee? NoLegal Issues:Does the paper contain a legal issue or evidence compliance with legislation? NoAction required by the Board:For noting.

INFECTION CONTROL REPORT FOR TRUST BOARD: 28 TH SEPTEMBER 2010Month: August 2010C difficile:(cases reported on HPA database)SMH Wycombe Amersham CIC* TOTALBHT/CIC-acquiredcases 1 >65 yrs5 4 0 0 9BHT/CIC-acquired0 0 0 0 0cases 2-65 yrs* Community and Integrated Care (previously CHB)See Attached graph for trajectory information.Most recent published rates (April 09-March 10) - published 16 th July 2010:Cases > 2yrs/10,000 bed daysBHT: 2UK Average: 3.6MRSA Bacteraemias:SMH Wycombe Amersham CIC0 0 0 0See attached graph for trajectory information.Most recent published rates (April 09-March 10):No of cases/10,000 bed days:BHT: 0.49UK average: 0.50Norovirus Outbreaks: NoneDivisonal Hand Hygiene Compliance:CIC CSS Medicine Spinal Surgical W&C Access100% 99% 96% 96% 97% 96% 99%1 In-patient cases diagnosed >72 hours after admission to BHT.

BHT C DIFFICILE AND MRSA BACTERAEMIA TRAJECTORIES 2010/11August 2010BHT C difficile Trajectory 2010-2011BHT 2010/11Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar TOTLimit 5 5 5 5 5 5 6 6 6 6 6 5 65Actual 5 6 5 3 9BHT C difficile Trajectory 2010/11706050cumulative limitcumulative actual403020100Apr May June July Aug Sept Oct Nov Dec Jan Feb MarCIC C difficile Trajectory 2010-2011CIC 2010/11Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar TOTLimit 1 0 0 0 1 0 1 0 1 0 1 0 5Actual 0 2 1 0 0CIC C difficile Trajectory 2010/11654cumulative limitcumulative actual3210Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar1

MRSA Bacteraemia Trajectory 2010-2011BHT/CIC 2010-2011Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTLimit 1 0 0 0 1 0 1 0 1 0 1 0 5Actual 0 0 0 1 06MRSA Bacteraemia Cumulative Trajectory2010/11Limit: maximum of 5 cases at year end (Baseline: 03/04: 47 cases)54Cumulative limitActual3210Apr-10May-10Jun-10Jul-10Aug-10Sep-10Oct-10Nov-10Dec-10Jan-11Feb-11Mar-11Dr Jean O’DriscollDirector of Infection Prevention & ControlBuckinghamshire Hospitals NHS Trust 7 th September 20102

AGENDA ITEM NO 8.2TRUST BOARD 28 SEPTEMBER 2010Title: Infection Prevention and Control StrategyTo be presented by:Dr Jean O’DriscollDirector for Infection Prevention & ControlContact details: 01296 315330Executive summary and key issues for the Board:This Strategy summarises the Trust’s philosophy and implementation of actions to reduce healthcareassociatedinfections. It was recently updated to strengthen the section on information available to patientsand the public as requested by the NHSLA.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? NoDoes this paper provide assurance on the control of an identified risk? YesCommittee review and approval:Has the paper been reviewed and/or approved at a Board or executive committee? The previous version wasapproved at Board level.Legal Issues:Does the paper contain a legal issue or evidence compliance with legislation? It provides evidence ofcompliance with the Health and Social Care Act 2008.Action required by the Board:Approval.

Uncontrolled once printed – please check intranet for most up to date versionINFECTION PREVENTION &CONTROLSTRATEGYStrategy No. S022Version No. 2.2Approved by Governance Committee DateApproved by Trust Board DateIssued March 2006Revised September 2010Review Date September 2013AuthorInfection Prevention & Control TeamLead Director Director Infection Prevention & Control

Uncontrolled once printed – please check intranet for most up to date versionCONTENTSPage1 Introduction 32 Philosophy 33 Objectives34 Responsibilities 45 Implementation 56 Board Assurance 87 Dissemination of Strategy 88 Monitoring of Strategy 8Infection Prevention & Control StrategyV2.2Page 2 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date versionINFECTION PREVENTION & CONTROL STRATEGY1. INTRODUCTIONThe Health Act (2006) states that the prevention and control of Healthcare AssociatedInfections (HCAI) is a high priority for all parts of the NHS and other healthcare providers.Approximately 1 in 10 patients get an HCAI whilst they are in hospital. HCAI costs theNHS in excess of £1 billion per annum and causes 5,000 deaths per year. As well asincreased morbidity and mortality, HCAI also have a socio-economic burden for patients.30% of HCAIs are thought to be preventable through good practice; therefore the risk ofpoor infection prevention & control practice by staff presents a significant risk to bothpatient and the Trust.2. PHILOSOPHYReducing the risk of infection through good infection prevention & control practice is a highpriority for Buckinghamshire Hospitals NHS Trust and Community and Integrated Care(CIC). It is committed to promoting patient safety through keeping the risk of infection to aminimum. We aim to do this by developing a culture whereby patient, staff and visitorsafety is ensured through the promotion of excellence in all aspects of infection prevention& control practice and is embedded into every part of the organisation.3. OBJECTIVESa) The Trust Board will continue to take an active part in ensuring that Trust acquiredinfection are reduced to a minimum and that reduction of Trust acquired infections,(including IV line associated infections) are a priority for Divisions, wards and Departmentsb) Maintain compliance with all requirements of the Health Act (2006)c) Information is available to patients and the public about the organisation’s generalprocesses and arrangements for preventing and controlling HCAI (Health Act 2006 andrevised 2008) on the Trust’s website (Clean and Safe Hospitals Section). This includesweekly data on C.difficile and MRSA Bacteraemia numbers, and the Infection Preventionand Control Annual Report.• The Infection Prevention and Control Team responds to a wide variety of sourcessuch as lab reports, clinical rounds, local & national press and patientrepresentatives to identify the need for patient and public information. Informationleaflets are available about specific infections (also available in differentlanguages). All leaflets are approved by the Patient Experience Group (PEG).• It is a Trust objective that public awareness is raised through the hand hygienecampaigns. Posters and hand hygiene facilities are at the main entrances to theTrust premises.• Advertisements on the Trust website highlight infection control initiatives, forexample the annual WHO Global hand hygiene day and Infection control week.Clean your hands campaign posters and hand hygiene floor signs/boards arepresent throughout the wards and other clinical areas, and hand hygiene facilitiesare provided within wards and at entrances to inpatient areas. Wards displayinformation on their own C.difficile and MRSA numbers. Cleaning schedules arealso displayed.Infection Prevention & Control StrategyV2.2Page 3 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date versiond) Ensure decontamination across the Trust meets all the National mandatory requirementsand future standards are being worked towards.e) The Trust has appropriate policies and guidance in place in relation to prevention andcontrol of HCAI. These are available in the Infection Prevention & Control manual via theTrust Intranet or hard copies are available in all wards and departments and librariesf) Provision of education and training on prevention and control of infection in order for staffto understand their responsibilities and the action they must take.g) The inclusion of Infection Prevention & Control Knowledge as part of the performancereview system and the Knowledge & Skills Framework.h) Compliance with key policies is ensured through the implementation of HII and audit ofenvironmental risks and selected clinical practices. These will be agreed when setting theannual Infection Prevention & Control Programme and will be dictated by any particularincidents or risks identified at the time, policies/guidelines due for review, Department ofHealth directives, etc.i) Undertake surveillance of selected infections and conditions reflecting mandatory, nationaland local priorities.j) Continue to provide a proactive and reactive Clinical Service including the managementand investigation of outbreaks of infection and ensure the threat of new infections, e.g.Pandemic influenza, is prepared fork) Review relevant Infection Prevention & Control incidents, identify lessons learnt,implement improvements and link to audit prioritiesl) Achieve level 1 NHSLA Assessment new standards.m) Continue to provide an advisory service to non clinical Trust departments that may impacton infection prevention & control (e.g. Occupational Health, Estates)n) Development of a useful and effective infection prevention & control web page on the Trustintranet.o) Work with the local Health Protection Agency (HPA) and other agencies to ensure goodinfection prevention & control practices across the Local Health Economyp) Antibiotic resistance is minimised through appropriate and correct antibiotic prescribing.4. RESPONSIBILITIESThe Trust Board and ultimately the Chief Executive Officer, carries responsibility forinfection prevention & control throughout the Trust. From day to day this is delegatedthrough the DIPC to the ICT, Clinical Leads and Head Nurses/Heads of Department.All managers and clinicians must ensure that the management of infection prevention &control risks are one of their fundamental duties. This role also forms part of their JobDescription.Infection Prevention & Control StrategyV2.2Page 4 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date versionEvery clinical member of staff must demonstrate commitment to reducing the risk ofinfection through good infection prevention & control practice. This will be implemented,monitored and evaluated through staff Individual Performance Reviews and PersonalDevelopment Plans.4.1 Role of Director of Infection Prevention and Control (DIPC)The DIPC is responsible for the IPCT within the Trust and CIC and reports directly to theChief Executive Officer and the Board, providing a written infection prevention & controlreport to each Public Trust Board meeting. His/her role is as an integral member of theClinical Governance and Patient Safety teams. He/she overseas local infection prevention& control policies and their implementation and has the authority to challengeinappropriate clinical practice. He/she overseas the impact of existing and new policiesand plans on infection prevention & control and makes recommendation for changeswhere appropriate. He/ she is responsible for producing an annual infection prevention &control report for the Trust and for releasing it publicly.4.2 Role of Infection Prevention & Control Team (IPCT)The IPCT provides a clinical service for the prevention, surveillance, investigation andcontrol of infection within the acute Trust and CIC . All members of the team areresponsible for working with the bed management teams and other clinical staff to ensurethat through risk assessment patients are accommodated appropriately and the impact onthe capacity of the Trust is minimised in line with relevant policies. They are alsoresponsible for coordinating infection prevention & control audits, education and training,policy and strategy development and the production of relevant infection prevention &control reports and data for use within the Trust to monitor and promote improvements inpractice. The role is guided by the Department of Health document ‘Hospital infectionprevention & control – Guidance on Control of Infection in Hospitals’ (1995)The IPCT consists of all the Trust's Consultant Microbiologists and Infection Prevention &Control Nurses with secretarial support.4.3 Role of Antibiotic PharmacistThe Antibiotic Pharmacist is responsible for overseeing antibiotic prescribing practices,undertaking antibiotic audits and co-ordinating the review, writing and updating of antibioticpolicies Trust-wide.4.4 Role of Infection Prevention & Control Divisional Leads (Winning Ways/Saving LivesLeads)Each division has a nominated infection prevention & control lead who is responsible forensuring that infection prevention & Control issues (complaints, incidents, surveillancedata, RCAs etc.) are discussed at Divisional Clinical Governance meetings, forcoordinating infection prevention & control audits within their division with support of theICT and ensuring staff attend relevant infection prevention & control education and trainingas appropriate. They are also responsible for setting the Divisional infection prevention &control Programme based on identified priorities, for monitoring progress with this and forcompletion and submission of the monthly infection prevention & control performancemanagement tool.Infection Prevention & Control StrategyV2.2Page 5 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date version4.5 Link PractitionersLink Practitioners are responsible for promoting good infection prevention & controlpractice in their work area with their colleagues, patients, relatives and the environment.They are also responsible for undertaking infection prevention & control audits whenrequired within their work area and for disseminating new infection prevention & controlinformation to colleagues.4.6 Role of Pathology Business ManagerHe/she is responsible for overseeing the budget allocated to pathology which includesinfection prevention & control within it. He/she is invited to attend the monthly InfectionPrevention & Control Trustwide Meeting (TWIPC)4.7 Role of Divisional and Head Nurses (Matrons)The Head Nurses are responsible for the implementation of the infection prevention &control aspects of the Matrons' Charter including the continuing monitoring of their areas ofresponsibility in order to achieve an acceptable standard of cleanliness in the patientenvironment. They are also responsible for ensuring that infection prevention & controlaudits such as the Saving Lives High Impact Interventions (HII) are carried out in theirareas of responsibility. They will need to work closely with the Infection Prevention &Control Directorate Leads in order for this work to be co-ordinated effectively.4.8 Role of Facilities Management (FM) and Estates StaffEstates staff should ensure that the environment and equipment they are responsible for(e.g. washer disinfectors, autoclaves etc.) are maintained to required standards in order topromote good infection prevention & control practice and ensure easy cleaning of clinicalareas.FM staff should ensure cleaning is maintained to the standard required by the Trust in allclinical areas and that there are adequate supplies of consumables in order to facilitatethis.4.9 All StaffAll staff are responsible for ensuring that they follow good infection prevention & controlpractice at all times and that they are familiar with infection prevention & control policies,procedures and guidance relevant to their area of work. Staff have a duty to reportbreaches in good practice and take corrective action as appropriate. Failure to complywith Infection prevention & control practice may result in disciplinary action.5. IMPLEMENTATIONAn annual Infection Prevention & Control programme is set for each year containing keyobjectives and actions required. This programme is reviewed and approved by theInfection Prevention & Control Committee, Governance Committee and Trust Board.Progress with this programme is monitored throughout the year and reported through theInfection Prevention & Control Committee. The extent and success of this programmedepends on resourcing to an appropriate level. As foreseen and unforeseen demandsarise, the programme may need to be reprioritised. Any resultant inability to meet aspectsof the programme is reported through the Infection Prevention & Control Committee. Anannual Infection Prevention & Control Report is produced and progress on the InfectionInfection Prevention & Control StrategyV2.2Page 6 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date versionPrevention & Control Programme is included with reasons for inability to achieve the wholeprogramme given where necessary.5.1 Education & TrainingThe IPCT provide education and training for all Trust staff as set out in the Trust’s trainingneeds analysis matrix. This takes the form of annual mandatory Infection Prevention &Control updates which highlight relevant risk issues and priorities in the prevention andcontrol of infection. The IPCT will also input into other education and training programmesas required. The training department will provide information on the numbers ofattendance within divisions. Non compliance of attendance will be escalated to wardmanagers/matrons for action.All clinical staff will ensure they practise good hand hygiene, aseptic technique and wearPersonal Protection Equipment correctly. The IPCT support staff through audit,education/training and constructive feedback.All clinical staff involved in the prescribing of, or administration of antibiotics to ensureprudent practices are observed with regular review of prescriptions. The Consultantmicrobiologists, together with the antibiotic pharmacist, will provide advice and educationwhere necessary.The support of all Trust staff in implementing the strategy is essential.5.2 Surveillance & AuditThe IPCT provide surveillance data feedback to divisions/SDUs. This data is reviewed bythe divisions and actions identified and implemented to improve practice where necessary.Outbreaks of infection and other Infection Prevention & Control Serious Untoward Incident(SUI) are reported to the HPA and to the Trust via Clinical Incident forms and in themonthly Infection Prevention & Control reports to the Risk Monitoring Group meetings.The IPCT provides support for audits which are the basis of the Saving Lives High ImpactIntervention programme. The audits are primarily undertaken by wards/dept. staff andfeedback is to be used to influence and improve practice. The IPCT provide input torelevant training and education programmes to support this.5.3 Support Services:The IPCT is represented on the decontamination committee and provides specialist adviceas required.The IPCT work with Bed Management teams in order to organise the appropriate use ofisolation facilities. Effective communication between departments is promoted whentransferring patients for further investigation through the use of an Infection Prevention &Control transfer form.The IPCT work with Estates, FM staff, Head Nurses, etc. in order to develop anenvironment that is easy to clean and maintain and equipment can be decontaminatedcorrectly and stored appropriately. Head Nurses and FM staff will monitor the cleanlinessof clinical departments and ensure correct waste disposal.Infection Prevention & Control StrategyV2.2Page 7 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date versionInfection Prevention & Control responsibilities to be included in all job descriptions forclinical staff, contract staff, and form part of the IPR process (Agenda for Change CoreDimension Health & Safety and Quality) and become an integral part of staff PersonalDevelopment Plans.6. BOARD ASSURANCEThe Trust Board receives assurance on the Infection Prevention & Control position withinthe Trust through reports by the DIPC at every public board meeting. These includemonthly reports on numbers of Clostridium difficile, MRSA bacteraemia cases, and anyoutbreaks of infection. The infection prevention & control annual report, hand hygienestrategy and progress reports on other issues e.g. compliance with the Health Act are alsopresented formally to the Board by the DIPC.Monthly infection prevention & control reports are presented to the bimonthly HealthcareGovernance Committee which reports to the Trust Board and the Infection Prevention &Control Committee minutes are also reported to the Governance Committee. Thequarterly governance reports include infection prevention & control activities e.g. results ofhigh impact intervention audits. Infection prevention & control is also a standing agendaitem at the monthly Risk Monitoring Group meetings.The minutes of the Infection Prevention & Control Committee provide a progress report onthe objectives outlined in the infection prevention & control annual programme and includediscussion of confounding issues in achieving these objectives and proposed actions.Each objective in the Infection Prevention & Control programme is risk assessed andthese risks are monitored by the IPCC. Extreme risks are added to the corporate riskregister. The IPCC receives reports on uptake of Infection Prevention & Controlmandatory training and its evaluation. The IPCC minutes also include reports from theinfection prevention & control directorate leads meetings and other infection prevention &control related risks/issues and actions taken.Evidence of compliance with Standards for Better Health core standard C4a is collectedconcurrently throughout the year and provided as evidence to assure the Trust board ofcompliance with this and the Health Act.7. DISSEMINATION OF THE STRATEGYThe strategy will be available via the Trust intranet. Awareness of its existence will beraised through inclusion in induction and infection prevention & control mandatory trainingsessions.8. MONITORING OF THE STRATEGYThe DIPC is responsible for continually monitoring the appropriate implementation of theStrategy. This is achieved through meetings, review of minutes, audit, surveillance,outbreak and other relevant reports.Linked Documents• Minutes of Infection Prevention & Control meetings (IPCC, TWIPC)• Risk Management Strategy• Trust Infection Prevention & Control Manual• Trust Clinical GuidelinesInfection Prevention & Control StrategyV2.2Page 8 of 9 Issued March 2006Revised September 2010Review September 2013

Uncontrolled once printed – please check intranet for most up to date version• Hand Hygiene Strategy• Incident Reporting Policy• SUI Procedure• Medical Devices Policy• Infection Prevention & Control Annual Programme• Infection Prevention & Control Annual Report• Board Assurance Framework PolicyLinked Committees• Infection Prevention & Control Committee• Infection Prevention & Control Management Forum• Health and Safety at Work Committee• Buckinghamshire PCT Infection Prevention & Control Committee• Clinical Risk Review Panel• Medical Devices Committee• Nursing and Midwifery Board• Nursing IT link Group (W&A)• Patient Information Group• County Environmental Health Committee• Regional Professional Development Group (microbiologists)• Decontamination Committee• Governance Committee• Clinical Audit & Effectiveness Committee• Antibiotic Review Group• Thames Valley Healthcare Associated Infection Network Group (CHAIN)Infection Prevention & Control StrategyV2.2Page 9 of 9 Issued March 2006Revised September 2010Review September 2013

AGENDA ITEM 9TRUST BOARD 28 SEPTEMBER 2010Title: Clinical Outcomes Report, Produced in August 2010.To be presented by: Dr Graz Luzzi, MedicalDirectorContact Details: graz.luzzi@buckshosp.nhs.ukExecutive summary and key issues for the Board:This report provides a summary of key clinical outcomes up to May 2010.All available case notes associated with the rise in hospital standardised mortality ratio (HSMR) in January2010 have been reviewed by a clinician through a case note review using a tool recommended by the PatientSafety Federation. The final report is being prepared for submission to the Healthcare GovernanceCommittee in November 2010, and will be circulated to members of that committee in advance of theNovember meeting.The rate for readmission following ‘non elective’ discharge has had a number of months where it is statisticallysignificantly higher than the national average. This has been under review by the Division of Medicine. Initialfindings from the review suggest that there has been an issue with coding for one particular diagnosis whichhas now been addressed. This will be reflected in future reports.Risk and Assurance:This paper provides assurance to the Board regarding patient safety and clinical outcomes. Where theinformation indicates a risk this is further investigated.Committee review and approval:The Healthcare Governance Committee reviewed clinical outcomes data on the 7 th September 2010.Legal Issues:No legal issues identified.Action required by the Board:The Board is requested to note the information in this report.

In Hospital MortalityHow we compare nationally - Hospital Standardised Mortality RatiosElective Admissions - Trust - 56 diagnosesNon-elective admissions - Trust - 56 diagnosesMortality within 30 days of a specific procedureHow we compare nationallyFractured neck of femurEmergency Readmissions within 28 daysHow we compare nationallyFollowing Elective Discharge - Trust - 56 diagsFollowing Non-Elective Discharge - Trust - 56 diagsClinical Outcomes Report – Produced in August 2010 Page 2

In Hospital MortalityHow we compare nationally - Hospital Standardised Mortality RatiosNote: The Hospital Standardised Mortality Ratio (HSMR) – Taken from Dr Foster Intelligence who calculatethe numbers of deaths that would be expected in a particular hospital based on the national death rates foreach age group, sex, admission source (ER, physician etc), admission type (emergency, urgent, elective, etc),length of stay group, and ICD9 (for the ICD9 diagnoses that lead to 80% all deaths in the US Medicare 2000data). Binary logistic regression at the individual patent admission level is used to calculate the HSMRs. Thesum of the expected deaths gives the total expected deaths for that hospital. We then calculate the ‘hospitalstandardised mortality ratio’ (HSMR) for the hospital as the ratio of the total observed deaths to the totalexpected deaths (usually multiplied by 100 so that the national average for the year 2000 is 100 by definition,and a hospital with an HSMR of, say, 121 is 21% above the national value). The "bars" around each datapoint indicate the 95% confidence limits, that is, if this crosses the 100 line then the Trust is NOT statisticallysignificantly different from the country as a whole. This data due to the nature of the calculations is always afew months behind.Mortality within 30 days of a specific procedureComments: The numbers of deaths following fractured neck of femur procedures are comparable with thenational rates. The chart for shows the HSMR and no statistically significant variation from the national 100standard in the Trust.Emergency Readmissions within 28 daysHow we compare nationallyNote: The charts show the readmission rates for the 56 diagnostic groups that account for approximately 80%of discharges. These rates have been normalised so that the national average is 100 and is represented bythe horizontal (blue) line. These are taken from Dr. Foster Intelligence.Comment: Over the course of the last year since April 2008 the readmission rate following elective dischargeis similar to that for the country as a whole. The rate for readmission following non-elective discharge has hada number of months where it is statistically significantly higher than the national average, and has beeninvestigated by the division of Medicine.Clinical Outcomes Report – Produced in August 2010 Page 3

AGENDA ITEM 10TRUST BOARD 28 SEPTEMBER 2010Title: Board Assurance Framework (BAF).To be presented by:Liz Hollman, Associate Director of HealthcareGovernanceContact Details:elizabeth.hollman@buckshosp.nhs.ukExecutive summary and key issues for the Board:The Board Assurance Framework sets out the key threats to achieving the Trust’s objectives for 10/11. Theprincipal risks to achieving the objectives have been identified. They include risks associated with safety andquality, the integration of Community Health Buckinghamshire with BHT, risk around maximising productivity,efficiency and cost-effectiveness and the risks around strengthening our future through effective partnership.There are currently 33 threats to our principal objectives identified on the BAF. A risk appearing on the BAFmay be well controlled and mitigated to an acceptable level i.e. have a risk rating of < 9. Any risk that is notmitigated to a level of < 9 moves to the Corporate Risk Register for full evaluation and recording of the stepsbeing taken to improve control.Since the Trust Board in July, a new threat has been added to the BAF (BAF 33). This relates to the threat offailing to break even in 2010/11. The gap in control results in a risk score of 15. The risk has been added tothe Corporate Risk Register.No other scores have changed since the last Trust Board. Updates to the text are shown in pink font.Risk and Assurance:The BAF provides assurance relating to identified risks against Trust objectives and shows any gaps incontrol.Committee review and approval:The BAF was reviewed by the Audit Committee on the 16 th September 2010Action required by the Board:The Board are asked to discuss the BAF in relation to the following key issues:• Are the Board satisfied that the identified threats cover the full range of risks to achieving the Trust’sobjectives?• Note where gaps in control indicate a realised risk, the degree of risk and actions in place to improvecontrol.• Note the range of assurancesThe Board are asked to approve the BAF.

BAF update September 2010ReferenceDescription of threat toachieving objectiveKey controls Assurance on controls Gaps in controlsRisk RatingRAGAssurance RAGLeadAction planreferenceObjective 1 Driving up Safety and QualityTo continue to ensure that our patient promises are central to all we do in providing high quality, safe and accessible careQuality - establish the learning from the Francis report(Health and Social Care Act Regulations 9, 14, 24, 11, 12, 13, 21, 22, 23, 10, 17, 21)BAF 1Threat of failure to implement learningfrom Francis reviewReview document showing assuranceagainst recommendations in FrancisreviewAction plan developed from gap analysisHealthcare Governance CommitteeminutesTrust Management Committee minutesTrust Board minutesAssigned executive and managerial leads NMAB minutesfor each recommendationEssence of care auditsCQC registration supporting evidence High Impact Interventions auditsunderpins compliance withInfection control auditsrecommendationsNutritional auditsProductive ward programme in place Healthcare governance action planPatient Safety StrategyProductive ward evidence showcased oneach participating wardEssence of Care audit reports are notcurrent. Process is being restarted.< 9 •CEO / Chief NurseService standards embedded in everyday practice(Health and Social Care Act Regulations 17, 9, 11)BAF 2Threat to achieving the embedding of Training programme in place includingservice standards in everyday practice corporate induction and e-learningNew appraisal form including servicestandards in placeRoll out to the Division of Community andIntegrated Care through champions -action plan being developedWorkforce report containing training Access to computers and software packagefigures to Trust Management Committee for some staffand Trust BoardInsufficient number of champions andStaff track monitoring softwarefacilitators in the Division of Community andAudit of a sample of completed appraisals Integrated CareThe Division of CIC is yet to agree its planfor roll-out and implementation and this willaffect delivery of target if not remedied.9 •Director of HumanResources andOrganisationalDevelopmentBAF ac 1BAF 3There is a threat to actively solicitingpatient feedbackImproving clinical outcomes(Health and Social Care Act Regulations 18, 9, 24, 10, 21)Seeking feedback from members via Survey resultssurveyHG quarterly reportComplaints trends (including service Recommender score results for Divisionstandards) reported in Healthcare of SurgeryGovernance quarterly reportFrancis review assurance documentDivisional ownership of Service StandardsPatient Experience Tracker reportse.g. Division of Surgery recommenderscoreAssurances through Francis reviewPatient Experience Tracker programme inNone< 9 •Chief NursePage 1

BAF update September 2010ReferenceDescription of threat toachieving objectiveKey controls Assurance on controls Gaps in controlsRisk RatingRAGAssurance RAGLeadAction planreferenceBAF 4Stroke peer reviewStroke ward in placeDaily capacity meetingsThreat of non achievement of target Actions agreed within stroke service withNational stroke auditproportion of time stroke patients spendlead stroke physicianStrategic Stroke Review Group minuteson a stroke wardOperational policy for stroke pathwayBoard performance reportsincluding direct admissions to stroke wardDivisional Board performance reportsNone < 9 •Medical DirectorBAF 5Threat of non achievement of targetaround risk assessment of patientswith TIARe-organisation of TIA service to ensureconsultant cover is available, includingweek-end workingStroke peer reviewDaily capacity meetingsNational stroke auditStrategic Stroke Review Group minutesBoard performance reportsDivisional Board performance reportsNone < 9 •Medical DirectorBAF 6Threat of not sustaining performanceregarding pre-operative length of stayfor fractured neck of femurTrauma service have implemented a plan Divisional Performance reportto prioritise this category of trauma.None< 9 •MedicalDirectorBAF 7Threat of not being able to demonstrateVTE committee in place chaired by VTE committee minutesVTE risk assessment performance Medical DirectorTrust Board performance reportVTE action plan based on NICE guidancedelivered through SDU'sReporting mechanism developedCurrently no mechanism in place forcapturing data on VTE risk assessment12 •Medical DirectorBAF ac 2BAF 8Threat to achieving target forthromboprophylaxisVTE committee in place chaired by Clinical audit on thromboprophylaxisMedical DirectorVTE committee minutesVTE action plan based on NICE guidancedelivered through SDU'sNone< 9 •MedicalDirectorStaff Development(Health and Social Care Act Regulations 21, 22, 23)Page 2

BAF update September 2010ReferenceBAF 9Description of threat toachieving objectiveThreat to achieving effective staffdevelopmentKey controls Assurance on controls Gaps in controlsBoorman action planStaff survey action plan for the wholeorganisation and each divisionDivisional performance meetingsStaff Survey Autumn 2010Action plan for dealing with sicknessabsenceTraining for managers on sicknessabsence handling, staff engagement,wellbeing, staff satisfaction, appreciation,motivationWorkforce ReviewHR committee minutesTMC minutesReleasing managers to attend trainingagainst a background of financialturnaround.Risk RatingRAGAssurance RAG< 9 •Objective 2 Integrating Community Health Bucks with Buckinghamshire Hospitals NHS TrustAchieve the successful integration of Community Health Bucks with BHT by delivering new patient pathways; robust governance and risk management processes; co-ordinated IT and information systems; a newstructure and workforce plans, supported by effective communications; a sound financial plan.(Health and Social Care Act Regulations 9, 24, 15, 16, 21, 22, 23, 10, 20)LeadDirector of Human Resourcesand OrganisationalDevelopmentAction planreferenceBAF ac 3Threat to achieving patient pathways Urgent care pathway reviewwhich reduce the need for admission toWorkforce plansBAF 10 hospitalWinter planningThreat to achieving effective integration Programme planbetween BHT and CHBProgramme leadBAF 11Daily capacity planning meetingsCapacity Governance reportWhole Systems Operational Action GroupNoneMinutes of Programme BoardFinancial value not agreedDue diligence reportInternal audit on disaggregation of budgets< 9 •9 •Chief NurseDirector ofStrategy andSystemReformn/aBAF ac 4Objective 3. Maximising Productivity, Efficiency and Cost-effectivenessFinance:(CQC regulation 13)BAF 12 Failure to achieve 3 year statutorybreak even dutyBAF 33 Failure to break even in 2010/11(Linked to Turnaround ProgrammeRisks PMO1 and PMO2)Cost improvement programme.SLA monitoring and management.Completion of ophthalmology land sale.BAF 13 Failure to achieve scores of 3 or above Self assessmentin ALE for 10/11Close working with auditors to confirmevidence required.Finance reporting to Board.Reports to Capital Monitoring Group andTMC.Turnaround Programme Management Programme Management Board led byOffice in place and working to support the Chief Executive Officer and Turnaroundorganisation in delivering costDirectorimprovements.Reporting to TMC.Reporting to Audit CommitteeFeedback from auditors during process.Meeting the conditions in the ophthalmologyland sale contract is not entirely in thecontrol of the Trust. 12 •Cost Improvements not yet fully realised.None15 •< 9 •Director ofFinanceDirector ofFinanceDirector ofFinanceBAF ac 5BAF ac 10Page 3

BAF update September 2010ReferenceDescription of threat toachieving objectiveKey controls Assurance on controls Gaps in controlsRisk RatingRAGAssurance RAGLeadAction planreferenceBAF 14 Buckinghamshire Primary Care Trustdoes not deliver its financial recoveryand shifts additional cost pressuresand financial risk to BHTBAF 15(Linked to Turnaround ProgrammeRisk PMO7)Threat to achieving enhanced ITbenefit through the implementation ofthe CRS programmeBusiness strategy based onFinance reporting to Board.accommodating the planned reductions in Performance report to Board.demand. Developed together with BPCT. Recovery meetings with BPCT (HealthyAug 09 Joint action 'Summit' plan with Bucks Leaders Meetings).BPCT to deliver system recovery. Minutes of Board to BoardBoard to Boards (x4 annually)Care Records Service BoardProject Plan in placePatient Management System foremergency careClick ViewNoneReliance on a centralised process12 •< 9 •Director of FinanceChiefOperatingOfficerBAF ac 5BAF 31Threat to achieving reduced reliance onDivisional Performance reviewslocum, agency and bank staff which Cost Improvement Programmeaffects financial performance and the Workforce controlsquality of careTransformation programmeDivisional dashboardsWorkforce reportMinutes of HR committeeCurrent expenditure on temporary staff9 •ChiefOperatingOfficerBAF ac 8Operational Best Practice:(Health and Social Care Act Regulation 10)BAF 16Threat that theatres are less efficientthan they can be making them moreexpensive to run and impacting onwaiting timesBoard performance reviewDivision of Surgery performance reviewWeekly review of users, bookers andtheatre teamsProductive Operating TheatresUse of Click View to monitor performance None < 9 •Chief OperatingOfficerBAF 32Threat to achieving efficient service inoutpatient / ambulatory careWorkstream in place to review this area oserviceNew initiatives being considered in theuse of community hospitalsWorkstream planTransformation ProgrammeExternal diagnostic on outpatientefficiency is being undertaken inSeptember 2010.New to follow up ratio worse than thenational upper quartileMonth 2 performance has improved onMonth 1 performanceMonth 4 new to follow up ratio is nowdelivering better than contracted level12 •Chief Operating OfficerBAF ac 9Page 4

BAF update September 2010ReferenceBAF 17Description of threat toachieving objectiveThreat of not achieving reduced lengthof stay resulting in patients not beingcared for in optimum locationKey controls Assurance on controls Gaps in controlsOngoing review of complex dischargesClinicians review of patients over 20 daysto Divisional ChairUrgent Care Work streamDaily bed meetingDaily discharge meetingHealthy leaders groupWhole systems Operational Action GroupDivisional performance reviewsTrust Board performance reportsDaily bed reportsHealthy Leaders minutesLength of stay currently high in the Divisionof MedicinePerformance improvieng (update June 2010)Risk RatingRAGAssurance RAG12 •LeadChief Operating Officer /Chief NurseAction planreferenceBAF ac 6Clinical Leadership and alignment of clinical workforce(Health and Social Care Act Regulations 21, 22, 23)BAF 18 Threat to the progression of leadership Programme for leadership development at Staff survey resultsdevelopment impacting on achievemenall levels of the organisationHR committee minutesof trust objectivesAction plan including training materialsand e-learningBAF 19There is a threat that volume of clinical Annual Appraisals with Personal Mandatory training figures are monitored Noneactivity may prevent nursing staff being Development Plansin Divisional performance reportsreleased from clinical areas for training Process for putting staff forward for Nursing and Midwifery Advisory Boardcourses includes manager consent minutes contain evidence of promotion ofTrust Training and Development strategy training and development for nursing staffDivisional Lead Nurse meeting (chaired byChief Nurse) minutesMatron review of a sample of PDPsReleasing Managers and Leaders to attendtraining whilst in financial turnaround.< 9 •< 9 •Director ofHumanResourcesandOrganisatioDirector of HumanResources andOrganisationalDevelopment / ChiefNurse / Medical DirectorImproving the Clinical Environment(Health and Social Care Act Regulations 15, 16)BAF 20Threat to achieving better use of theWycombe hospital estateBoard approval of investment planWorks to convert ground floor and firstfloor of PFI to commence to deliverEstates Strategy around inpatientaccommodation at Wycombe.Business caseTrust Board minutesCapital Management Group minutesTMC minutesProperty Services Management groupminutesERIC (Estates Return InformationCollection) to DoH annuallyInternal auditsProject management team yet to be fully putin place< 9 •Director of Property ServicesBAF ac 7Page 5

BAF update September 2010ReferenceDescription of threat toachieving objectiveKey controls Assurance on controls Gaps in controlsRisk RatingRAGAssurance RAGLeadAction planreferenceBAF 21Threat to achieving reconfiguration ofAccident and EmergencyBusiness case covering entirereconfigurationWorks on site during capital yearBusiness caseTrust Board minutesCapital Management Group minutesTMC minutesProperty Services Management groupminutesERIC (Estates Return InformationCollection) to DoH annuallyInternal auditsNone< 9 •Director of PropertyServicesBAF 22BAF 23Threat to achieving car park upgradeCapital investment programme fundingallocationBusiness case to Trust BoardTender documentsCar parking policyThreat to achieving relocation of CSSD Business case to Trust BoardservicesAllocation on capital programmeProject plan drawn upBusiness caseTrust Board minutesCapital Management Group minutesTMC minutesProperty Services Management groupminutesERIC (Estates Return InformationCollection) to DoH annuallyInternal auditsBusiness caseTrust Board minutesCapital Management Group minutesTMC minutesProperty Services Management groupminutesERIC (Estates Return InformationCollection) to DoH annuallyInternal audits4. Strengthening our Future through Effective PartnershipBuild a strong future for BHT by working in partnership to exploit new opportunities and develop innovative services for Bucks residents.NoneNone< 9 •< 9 •Director of PropertyServicesDirector of PropertyServicesPromote excellence in national and regional services(Health and Social Care Act Regulation 24)BAF 24 Threat to achieving the developmentand promotion of services of NSICBusiness planning processDivisional performance meetingsBusiness planMinutes of performance meetingsNone< 9 •ChiefOperatingOfficerBAF 25 Threat to establishing aBuckinghamshire-wide neurorehabilitationserviceNeuro-rehab project team deliveringintegrationDivisional performance monitoringProject planMinutes of performance meetingsNone< 9 •ChiefOperatingOfficerBuild a strong relationship with the people of Bucks(Health and Social Care Act Regulation 17)Page 6

AGENDA ITEM 11TRUST BOARD 28 SEPTEMBER 2010Title: Corporate Risk RegisterTo be presented by: Bob Peet, Chief Operating OfficerExecutive summary:The purpose of this paper is to keep the Board informed about the level of risk within the organisation.The Corporate Risk Register (CRR) sets out the highest current risks identified within the organisation.Section 1 of the Corporate Risk Register shows risks scored as 9 or above identified through gaps in controlin the Board Assurance Framework. These risks have been reviewed by the relevant Executive Director.There are 8 risks included in this section.Risks scored at 15 or above on the Divisional Risk Registers are recorded on Section 2 of the CRR. Thereis currently 1 risk in this section.Key issues for discussion:The CRR provides assurance to the Board that the organisation is both identifying and managing its risks.Risk and Assurance:‣ How does this item link to the Board Assurance Framework and the Trust’s PrincipalObjectives? There is a close relationship between the CRR and the Board Assurance Framework.‣‣ How does this item either mitigate or provide assurance on the control of any of the risksdetailed within the Board Assurance Framework? This item demonstrates that the organisationhas a process for identifying and managing risk.Legal Issues: noneAction required by the Trust Board: to note.e.g. to note, for approval etc

Corporate Risk Register for Trust Board September 2010Risk TrackingReferenceDate Added toRegisterService Delivery UnitDescription of riskSeverityLikelihoodRisk Score (LxS)Action plan to addressriskPredicted residualscoreLeadKey controlsGaps in controls andreference of plan toaddressProjected completiondateSection 1 - Risks identified through gaps in control on the Board Assurance Framework (scored 9 or above)BAF 33and 1409/09/2010 n/aThere is a risk to achieving financial breakeven duty for 2010/115 3 15Turnaround Programme Management Office in place andworking to support the organisation in delivering costimprovements5Director ofFinanceTurnaround ProgrammeCost Improvement PlansSome costimprovements yet tobe identified31.3.11BAF 12 05/05/2010 n/aThere is a risk to achieving 3 year financialbreak even duty4 3 12 Cost Improvement programme 0Director ofFinanceBusiness Planning processCost improvement programme.SLA monitoring and management.Completion of ophthalmology land sale.Meeting theconditions in theophthalmology landsale contract is notentirely in the controlof the trust31.3.11BAF 17 05/05/2010 n/aThere is a risk of not achieving a reducedlength of stay impacting on quality of patientcare4 3 12Ongoing review of complex dischargesClinicians review of patients over 20 days to DivisionalChairUrgent Care Work stream4Chief OperatingOfficer / ChiefNurseDaily bed meetingDaily discharge meetingHealthy leaders groupWhole systems Operational Action GroupLength of staycurrently high in theDivision of Medicine30.11.10BAF 7 05/05/2010 n/aThere is a risk around measuring compliancewith Venous Thrombo-embolism riskassessment4 3 12Reporting mechanism has been developedData collection has commenced.0 Medical DirectorData is not yet beingVTE committee in place chaired by Medical Directorconsistently capturedVTE action plan based on NICE guidance delivered throughacross all clinicalSDU'sareas.31.12.10BAF 32 05/05/2010 n/aThere is a risk around achieving efficiency ofoutpatient / ambulatory care service4 3 12Workstream in place to review this area of serviceNew initiatives being considered in the use of communityhospitalsTransformation ProgrammeExternal diagnostic on outpatient efficiency is beingundertaken in September 2010.0Chief OperatingOfficerWorkstream in place to review this area of serviceNew initiatives being considered in the use of communityhospitalsTransformation programmeNone 31.3.11BAF 2 05/05/2010 n/aThere is a risk around delivery of servicestandards training to all staff in the mergedorganisation3 3 9An action plan is being developed for roll out of servicestandards training to staff in the Division of Communityand Integrated Care0Director of HumanResourcesTraining programme in place including corporate inductionand e-learningNew appraisal form including service standards in placeRoll out to the Division of Community and Integrated Carethrough champions - action plan being developedThe Division of CIC isyet to agree its planfor roll-out andimplementation andthis will affect deliveryof target if notremedied.31.3.11BAF 31 05/05/2010 n/aThere is a financial risk around achieving areduction in dependence on temporarystaffing3 3 9Business planning in DivisionsPerformance reviews in divisionsRecruitment initiatives to fill vacancies0Chief OperatingOfficerDivisional Performance reviewsCost Improvement ProgrammeWorkforce controlsTransformation programme (update June 2010)Current expenditureon temporary staff30.11.10BAF 11 05/05/2010 n/aThere is a risk associated with the financialintegration between BHT and CHB3 3 9 Programme plan in place with significant controls. 0Director ofStrategy andSystem Reform /Director ofFinanceProgramme planProgramme lead30.11.10Under review aspart of BAF reviewBuckinghamshire Hospitals NHS Trust Confidential 23/09/2010 Page 1

Corporate Risk Register for Trust Board September 2010Risk TrackingReferenceDate Added toRegisterService Delivery UnitDescription of riskSeverityLikelihoodRisk Score (LxS)Action plan to addressriskPredicted residualscoreLeadKey controlsGaps in controls andreference of plan toaddressProjected completiondateSection 2 - Risks identified from Divisional Risk Registers, Property Services and Information TechnologyAM1 23/02/2010 Property ServicesIssues identified with generator support atSMH - site does not have full generator coverareas identified as at risk include theatres innew wing, burns, OPD, A&E etc5 3 15plan being developed to test all generators on full loadand establish which sockets are protecteded - thenchange these to RED fronts4 Anne MaguirePPM scheduled activity ensure the generators are fuelledand start and will run under load in accordance with theHTMThe generators havenot been tested in thePFI or in the REM fora live load test (takingthe hospitals live all areas tested andelectrical load onto sockets changed bystand by systems to end Dec 2010ensure that autoswitchs etc work -reports beingprepared nowBuckinghamshire Hospitals NHS Trust Confidential 23/09/2010 Page 2

Corporate Risk Register for Trust Board September 2010Trust ObjectiveObjective 3 MaximisingProductivity, Efficiencyand Cost-effectivenessObjective 3 MaximisingProductivity, Efficiencyand Cost-effectivenessObjective 3 MaximisingProductivity, Efficiencyand Cost-effectivenessObjective 1 Driving upSafety and QualityObjective 3 MaximisingProductivity, Efficiencyand Cost-effectivenessObjective 1 Driving upSafety and QualityObjective 3 MaximisingProductivity, Efficiencyand Cost-effectivenessObjective 2 IntegratingCommunity HealthBucks with BHTBuckinghamshire Hospitals NHS Trust Confidential 23/09/2010 Page 3

Corporate Risk Register for Trust Board September 2010Trust Objectivepatient safety and siteresilienceBuckinghamshire Hospitals NHS Trust Confidential 23/09/2010 Page 4

AGENDA ITEM 13.1TRUST BOARD MEETING 28 SEPTEMBER 2010Title: Summary of Healthcare Governance report Quarter 1, April to June 2010To be presented by: Contact Details: :Liz Hollman, Associate Director of Healthcare Elizabeth.@buckshosp.nhs.ukGovernanceExecutive summary and key issues for the Board:The report summarises healthcare governance information contained in the Quarter 1 HealthcareGovernance Report.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? NoThis report provides assurance around Objective 1, driving up safety and quality.Committee review and approval:The full report was considered in detail by the Healthcare Governance Committee on the 7 thSeptember 2010.Legal Issues:The report contains information about numbers of potential new claims in Q1 of the financial year.Action required by the Board:The Board is asked to note this paper.1

Healthcare Governance ReportQuarter 11 st April to 30 th June 20101.0 PurposeThe purpose of the paper is to: -• Summarise the key areas highlighted in Quarter (Q)1 Healthcare Governance report submitted tothe Healthcare Governance Committee in September 2010.2.0 Key areas from Q1 Healthcare Governance Report2.1 Patient SafetyIncidents including near misses1564 incidents were reported in the acute trust in Q1 compared with 1410 in the same quarter last year.This is an encouraging increase in reporting. During the quarter there was 1 patient where the incident wasreported as associated with a death and there were 21 patients where the incident was reported as causingsevere harm, 20 of which were patient safety incidents. 16 of these incidents were pressure ulcer related.Incident trends are reported to the Risk Monitoring Group and all incidents are investigated through theDivisional governance mechanisms.The Patient Clinical category accounts for 1251 (80%) of the incidents, which is consistent with previousreporting trends. The top 10 types of patient clinical incident are:Incidents by Detail - Top ( 15 )Slips, trips, falls and collisions 320Pressure sore / decubitus ulcer 173Administration or supply of a medicine from a clinical area 78Lack of/delayed availability of facilities/equipment/supplies 68Adverse events that affect staffing levels 56Accident caused by some other means 54Implementation of care or ongoing monitoring - other 52Other 51Medical device/equipment 45Laboratory investigations 40Patient's case notes or records 33Needlestick injury or other incident connected with Sharps 32Treatment, procedure - other 31Labour or delivery - other 30Abuse etc of Staff by patients 28Totals: 1091There are 147 incidents from Q1 awaiting sign off by managers across the divisions. 1417 incidents havebeen investigated and signed off.Incidents from the Division of Community and Integrated Care will be included in this report from Quarter 2.During Q1 the incidents from this division were reported and investigated through a separate mechanism.Central Alert System2

25 alerts from the Medicines and Healthcare products Regulatory Agency through the Central Alert Systemwere received in Q1. There are no outstanding alerts requiring action in this category.3 alerts were received from the National Patient Safety Agency. There are no NPSA alerts with an overduedeadline.New publications affecting healthcare governanceThe report contains a comprehensive list of guidance published in the quarter which could have an impacton the organisation. This guidance includes:• The Government’s Response to Lord Laming ‘One Year on’• The NHS Performance Framework 2010 Implementation Guidance• Delivering Enhanced Recovery (helping patients to get better sooner after surgery)• Revision to the Operating Framework for the NHS in England 2010/11Executive walkaboutsAn executive walkabout took place in June in the Medicine for Older People Service Delivery Unit attendedby the Chief Executive and a non executive director. Actions from this walkabout include promotional workto ensure that other Trust services know how and when patients would benefit from being cared for underMedicine for Older People, the use of Pressure Ulcer Prevention forms, action to reduce the risk of patientsfalling and a review of ‘hard to recruit’ areas.2.2 Patient ExperienceConcerns and Complaints315 PALS queries were dealt with in the quarter and 61 complaints not requiring full investigation and formalresponse. 141 formal complaints were received in Q1, compared with 142 formal complaints for the sameperiod in 2009.The report indicates that no new cases were received from the Ombudsman in the quarter and three caseswere closed.3 new clinical negligence claims were received in Q1 and 4 were closed in the same period. 1 closed caseinvolved payment before proceedings.3 new non clinical claims were received in Q1 and 1 was closed.There was notification of 2 new inquests from the Coroners office. No inquests were held in this quarter.The top 5 issues raised by patients, families and carers to the PALS and complaints teams shown on thegraph below.3

Top 5 SubjectsCommunicationNursing CareDischarge/Transfer/ReferralTreatment/Procedure/DiagnosisComplaintsPALSTotalsDelays/Cancellations/Waiting times0 20 40 60 80 100 120 140 160Delays/Cancellati Treatment/Proce Discharge/Transfons/Waiting times dure/Diagnosis er/ReferralNursing CareCommunicationComplaints 40 17 9 15 28PALS 97 28 20 17 26Totals 137 45 29 32 52The graph below provides an indication of the top trends in formal complaints by quarter from 1 st April 2009to 31 st March 2010.Complaint trends by quarter40353025201509/10 Q109/10 Q209/10 Q309/10 Q410/11 Q11050Communication with relative/friendEnvironmentCourtesy (Service Standards)MedicationDelays/Cancellation - SurgeryCommunication with patientCompassion (Service Standards)Nursing careMedical CareTreatment/ProcedureBehaviour and Attitude of staffDischarge/Transfer/ReferralDiagnosisCommunication - Verbal (Service Standards)Delays/CancellationsDuring the quarter PALS and Complaints teams dealt overall with a larger number of issues relating todelays, cancellations and length of waiting times for appointments, referrals and surgery dates than for anyother issue. There is an increase in the number of complaints and concerns relating to communication andalso to nursing care during the quarter.An evaluation of action plans completed over the past quarter demonstrates that the majority of actionstaken related directly to the patient’s care or were about the sharing of experience or information. However,there were some complaints that resulted in a review of current practices. Some of the issues related toverbal communication such as clinicians not ensuring that patients had understood the information they hadgiven to the patient in clinic and staff not communicating effectively with other staff or patients and their4

elatives. Other issues related to written communication and actions taken were to discuss the issues inteam meetings, to update signs about visiting on ward doors and to make a dermatological leaflet clearer.There were some complaints relating to way finding across the sites and this problem is being addressed bythe provision of maps and a review of signage in general.There was an issue raised about the provision of orthopaedic chairs in A and E waiting rooms and this willnow be addressed.The suitability of the waiting area at Wycombe reception was raised as an issue and this is being resolvedas part of the upgrading of that area.Clinical issues were also raised in complaints, including the decision to store ultrasound images in future inA and E for review and learning. There are plans to use a patient passport designed by the AlzheimersSociety on the wards for older people as a result of a complaint and a review is underway of the postnatalpathway.As previously mentioned the majority of complaints related to patient’s individual care but there were anumber that related to staff attitude and in these cases the action was to address this directly with the staffmember and deal with it in an appropriate manner.Compliments1037 compliments were received by wards and departments in Quarter 1.2.3 Patient ExperienceClinical auditChanges resulting from Trust-wide clinical audit projects are shown below:TitleNational Outpatient Survey 2009Recommendations/changesResults:Since 2004, >5% improvements in wait for appointment,information re clinic wait, cleanliness, length of appointment,introductions, explanations of treatment and how to takemedication, copies of letters received. Since 2004 >5%decline in always seeing same doctor, clinic waiting time,privacy, explanation of medication side effects.Our scores were in the bottom 20% of Trusts for the followingquestions.• From the time you were first told you needed anappointment, how long did you wait?• Do you see the same doctor or other member of staffwhenever you go to the Outpatients Department?• Did a member of staff explain the results of the tests in away you could understand?• Did you receive copies of letters sent between hospitaldoctors and your GP?• Did a member of staff tell you about any danger signalsyou should watch for?• Did hospital staff tell you who to contact if you wereworried about your condition or treatment after you lefthospital?Our scores were in the top 20% of Trusts for the followingquestion.• Was your appointment changed to a later date by thehospital?For all other questions our scores were in the middle 60% ofTrusts.Changes:Leaflet produced.Plans for redesign of seating area and refurbishment.Patient rebooked if cancelled.Piloting text message reminders.5

TitleVisual Infusion Phlebitis (VIP) Form Audit June 2009Re-audit of High Impact Intervention 2b PeripheralLines June 09Recommendations/changesCommunication to all doctors re importance of explainingresults of tests, danger signals.Patients given contact details.Medication information via different media forms.Choose and book making appointments easier.Car parking signs and maps available.Operational managers to consider sending copies of letters topatients.Patients with IV cannula device in situ should have VIP formproperly completed.Recommendations:The results of the audit are to be reviewed by Nurse DivisionalLeads and an action plan made to address issues identifiedand areas of non-participation.Educational sessions must be updated to include informationfrom the audit. Focus should be on areas on low compliance.All patients with an IV device in situ, including CVC lines andHickman lines, must have a VIP chart commenced oninsertion. All staff including medical and anaesthetists are tobe reminded of their responsibilities regarding this.Changes:This as been discussed and highlighted at the relevantmeeting. Also it is being monitored during Matrons' rounds.Also this will be re-audited as per the audit programme.Recommendations:Use of the VIP chart must continue to be promoted and itsinitiation on insertion and management of devices improved.All IV administration sets should be labelled using therecommended labels and changed in line with the IC policysection 2.2.Red emergency lines stickers should be used on all linesinserted in emergency situations and potentially non-asepticconditions and are then replaced as soon as possible.Changes:The daycase stickers have been highlighted througheducation sessions and to the relevant areas individually.Again IV sets labelling and the VIP chart is monitored duringMatrons' rounds. Also these will be re-audited as per theannual audit programme.National Institute for Health and Clinical ExcellenceThe report contained details of 28 sets of guidance from the National Institute for Health and ClinicalExcellenceResearchDuring quarter 1 the Trust Research Office had 148 projects registered. Of the 148 projects 65% areNational Portfolio studies through the National Institute for Health Research (NIHR).3.0 SummaryBoard members are requested to note the key areas of healthcare governance.6

AGENDA ITEM 13.2TRUST BOARD 28 SEPTEMBER 2010Title: Summary of Healthcare Governance Annual Report 2008/2009To be presented by:Liz Hollman, Associate Director of HealthcareGovernanceContact details:Elizabeth.hollman@buckshosp.nhs.ukExecutive summary:A detailed Healthcare Governance Annual Report for 2009/10 has been discussed at the HealthcareGovernance Committee in September 2010. The report demonstrates the Healthcare Governance activityin the Trust. A summary of the key sections is set out in Appendix 1. The full 52 page report is available onrequest.Key issues for discussion:This item is for information.Risk and Assurance:‣ How does this item link to the Board Assurance Framework and the Trust’s PrincipalObjectives? This report provides Assurance that the Trust is meeting its obligations in soundgovernance. This underpins the safety and quality objectives for the organisation.Legal Issues: noneAction required by the Trust Board: to note

Appendix 1 – Summary of Key sections of the Healthcare Governance Annual Report 2008/09Annual Health CheckThe Trust achieved a ‘Good’ quality rating for 2008/09. All core standards were declared compliant for 2009/10.Care Quality Commission RegistrationThe trust was registered by the Care Quality Commission for infection control in April 2009 and for the rest of itsservices in April 2010.NHSLA Risk Management AssessmentGeneral - the Trust achieved re-accreditation at Level 1 of the NHS Litigation Authority Risk Management Standardsin December 2009.Maternity - the Trust plans achieved re-accreditation at Level 1 of the NHS Litigation Authority’s Maternity ClinicalRisk Management Standards in December 2009.Infection control monitoring processesThe Care Quality Commission (CQC) made an unannounced visit to the Wycombe site in October to check theTrust’s compliance with The Health Act 2006, superseded in January 2009 by The Health and Social Care Act 2008.No breaches were found. Improvement was required in relation to one of the standards inspected (decontaminationof patient equipment). A gap analysis was produced and appropriate actions taken and the CQC were reassured thatwe were fully compliant in January 2010, without the need for a follow-up visit.BHT continued its sustained reduction in Trust-apportioned C. difficile cases, with a total of 49 cases against a limit of112 cases. We continue to be amongst the best-performing Trusts in the UK in regard to this infection.There was also a significant reduction in infections following orthopaedic surgery thanks to concerted multidisciplinaryefforts.Like most other Trusts in the UK, we experienced several Norovirus Outbreaks. We have had a debriefing meeting toreduce the impact in forthcoming years.Patient and Public InvolvementIn September 2009 the Trust achieved a representative membership of 12,000 public and staff members. The TrustBoard approved our new “Membership and Involvement Strategy” in January 2010.Members events have covered a range of topics. E.g. The views of our members have been sought on end of lifecare to inform the development of our local strategy. We have informed our patients about the range of cancerservices we provide and shared the improvements achieved for diet and nutrition in our hospitals. We have alsointroduced our service standards and updates on key corporate matters have been presented, by our Chief Executiveor Chair throughout. At least seven further involvement events are planned for 2010/11.Complaints / PALSIn 2009/10 the trust received 1491 concerns and complaints. The complaints team dealt with 805 complaints of which535 were deemed formal. These figures were less than for 2008-9 when 849 complaints (655 formal) were dealt withby the team. The PALS team dealt with 686 concerns in the same period of which 80% were resolved within oneworking day.AccoladesSince April 2009 wards and departments have been encouraged to forward a monthly total of the numbers ofcompliments they have received to the complaints department, where they are recorded along with those received bythe Chief Executive. This has resulted in a large increase in numbers on previous years. Over 4000 complimentswere received in 2009/10 compared with 643 in 2008/9.Identifying and Managing IncidentsThe Trust is committed to minimising risks and promoting a culture where improvements and lessons can be learnedthrough experience. This commitment includes identifying actual and potential areas of risk through the reporting ofadverse events and near misses.The Trust aims to develop a just and fair culture in which staff feel confident to report any adverse incident or nearmiss. Staff are supported and encouraged to be open and honest about issues, which have, or could have causedPage 2 of 4

harm and the objective is to learn from these events and to maintain or implement controls that will prevent arecurrence.The Trust has both electronic and paper incident report forms for staff to use to report incidents with the majority ofincidents reported using electronic forms. Electronic incident reporting facilitates timely communication of the incidentand assists with documentation of the incident investigation process.Divisional and Trust wide Reducing Harm Scorecards were introduced during 2009 / 2010 to assist Divisions withmonitoring and identifying patient safety issues from patient safety indicators so that appropriate and timely action canbe taken. The Divisional Reducing Harm Scorecards are updated each month and circulated to Divisional Chairs,Divisional Lead Nurses and Divisional Assistant Directors of Operations for discussion at Divisional Board Meetings.The scorecards are also included in the Quarterly Reducing Harm, Improving Quality Report which is discussed at theRisk Monitoring Group.Corporate and Divisional Risk RegistersDuring the year the organisation has continued to develop and improved the risk registers. Each Division owns itsown register. Risks with a score of 15 or more (extreme risks) are recorded on the Corporate Risk Register. TheHealthcare Governance and Audit Committees review all the risks, with a score of 12 or above, on a bi-monthly basis.Each risk now has a risk tracking reference to provide an audit trail.Claims, Litigation and InquestsThe Trust has received 23 new clinical claims in 2009/10 and 13 notifications for inquests.Clinical Audit and EffectivenessActivity in this department has included the monitoring of progress of the National Institute for Health and ClinicalExcellence (NICE) Technology Appraisal Guidance, Clinical Guidelines, Interventional Procedures Guidance andPublic Health Guidance; audit of New Clinical Procedures; a number of national and local audits; and themanagement of the process for developing and updating clinical guidelines.Medicines ManagementThe Medicines Management Annual report details the governance activity for medicines in2009/10.Essence of CareEssence of care audits in record keeping and health promotion have been completed.ResearchIn 2009/2010 the Research Office saw an increase in National Portfolio studies and the recruitment to these studieswere 766 compared to 430 in 2008/2009. We are faced with the problem that 2 large recruiting projects will in the firstquarter 2009/2010 which may hinder the target of increasing recruitment by 100% over the next 5 years. TheResearch Office is setting up a meeting with the Communications team and the Research PPI lead as to how we canpromote research among service users so they can be involved and see how the research that is currently beingundertaken within the Trust is working to improve patient care.The Research Office is working on improving approval times and an initial report sees there was a significantimprovement in 2009/2010 where the average approval time was 48 working days on receipt of a full application, thiscompares to 91 days in 2008/2009. This is mainly due to the improvement in Pharmacy support and streamlinedsystems within the Research Office.Information GovernanceThe Trust has self-assessed its performance on information governance using version seven of the informationgovernance toolkit managed by Connecting for Health. The Trust’s overall information governance submission for2009/10 achieved a score of 73 per cent, resulting in “green” rating. The main area of improvement was seen withinthe validity and accuracy of processes that support the Trust’s activities associated with the use of non direct clinicalbusiness information (Secondary Use Assurance).Page 3 of 4

Progress continued during 2009/10 on implementing risk controls associated with portable media with all knownapplicable portable devices being secured through encryption. Relevant information handling training andcommunication to staff continues to be a priority for the Trust and are supported by policies and guidance.In the period 1 st April 2009 to 31 st March 2010, the Trust received 231 Freedom of Information requests. Thisrepresented a small increase of 7.4% for the same period in the previous year. 221 requests were answered withinthe 20 working day target. The average time of response was 8.1 days.Annual National Staff Survey and the Stress SurveyThis year was the 7 th national survey. Capita administered the survey on behalf of the Trust and the PCT. Trusts canchoose to survey their whole workforce or just the basic number (or sample) of 850. BHT chose to sample 850 whilstthe PCT sampled the entire workforce, however the CQC only ever report on the sample of 850.The findings tell us that our issues are around communication, staff involvement and resources (staffing andworkload), which are not dissimilar to the national picture. If we are to influence any of the results in future surveyswe must ensure that there is greater levels of engagement across the organisation.DiversityThroughout 2009/10 Buckinghamshire Hospitals NHS Trust has continued to embed its equality and diversityschemes into the core functions of the Trust. The staff handbook, the Human Resources & Workforce Strategy, trustwebsite and the Equality & Diversity Policy statement reflect the commitment Buckinghamshire Hospitals has madeas an organisation in promoting equality of opportunity and access whilst encouraging its workforce to become morediverse.Mandatory TrainingA broad ranging review of all statutory and mandatory training delivery has been undertaken during 2009 and as aresult the move towards e-learning and an on-line system of ensuring staff are appropriately trained was launched inMay 2010 and is currently being transacted across the organisation.Board Assurance FrameworkThe Board Assurance Framework (BAF) provides the Trust with a tool for the identification and treatment of principalrisks to the achievement of the organisation’s objectives. It also provides a structure for the evidence to support theStatement on Internal Control (SIC) and the declaration of compliance with national healthcare standards.In 2009/10 it has been reviewed by the Trust’s internal auditors and the external auditors, in addition South CentralSHA has also carried out an interim and final year review. The SHA gave the BAF a category ‘A’ assessment.Child ProtectionThe last year has seen child protection in the spotlight after the tragic death of Baby Peter in Haringey in 2008.Following publication of the Serious Case Review and the report commissioned by the secretary of State by LordLaming published March 2009 “The Protection of Children in England: A Progress Report” all Trust Boards wererequired to publish a declaration locally on their websites that they had assured themselves that they were meetingtheir responsibilities for ‘Safeguarding Children and Young People who come into their care’ this declaration wasshared with the SHA and was part of the build up to registration with the Care Quality Commission in April 2010.The trust continues to ensure through a range of activities that child protection is a priority.Each year Internal Audit agrees an Audit Plan with the Audit Committee and the plan for 2008-2009 was agreed at theAudit Committee meeting in March 2009.Health and SafetyThe health and safety section of the report contains information about RIDDOR, Fire, and Security.Page 4 of 4

AGENDA ITEM 13.3TRUST BOARD 28 SEPTEMBER 2010Title: Audit Commission Review of Governance action plan update – September 2010.To be presented by:Liz Hollman, Associate Director of HealthcareGovernanceContact Details:Elizabeth.hollman@buckshosp.nhs.ukExecutive summary and key issues for the Board:In November 2009 the Audit Commission published its review of governance arrangements atBuckinghamshire Hospitals NHS Trust. In line with the recommendations in the report, an action plan wasdeveloped. This paper provides an update on outstanding actions below in Appendix 1.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? NoThis report provides assurance around Objective 2 relating to risk and safety.Committee review and approval:The full report was considered in detail by the Healthcare Governance Committee on the 4 th May 2010.Legal Issues:NoneAction required by the Board:The Board is asked to note this paper and delegate monitoring of the one outstanding action to theHealthcare Governance Committee.1

Appendix 1Actions still outstanding:Pageno.Recommendation9 R3 The Healthcare Governance teamshould produce detailed guidance fordivisions and service delivery units inthe form of the governance handbook.This should include information on thecorporate governance framework aswell as specific guidance on divisionalaccountability and reportingrequirements.Priority1=Low2=Med3=High2 Chief Nurse /Medical DirectorResponsibility Agreed Comments Date September 2010 updateLiz HollmanAgreedThe HealthcareGovernance team arepreparing agovernancehandbook which isexpected to becompleted by the endofDecember 2009.There will also be anassociated folder ontheTrust intranetcontaining additionalinformation to supportDivisions in theirgovernance activity.December2009December2009Information has been provided to Divisions inthe form of a Divisional Board GovernanceFramework. Information is available to supportgovernance on the Q drive and the Trustintranet. A member of the healthcaregovernance team attends each divisional boardto provide information / support in governanceactivity.Healthcare Governance handbook has beendrafted and will go to the Risk Monitoring Groupin October 2010 for approval.2

Actions completedPageno.Recommendation8 R1 The Board should evaluate the arrangementsfor ensuring the qualityof their data by assessing themselvesagainst the standards for better dataquality set out in Appendix 1 and bydeveloping systematic and formalisedreview programmes for their data,including checking accuracy back toprime records.8 R2 The Trust should develop policies andguidance on data quality and assuranceprocesses, includingdefining and allocating responsibilityfor data quality, to promote consistency andimprove awareness of board members.Priority1=Low2=Med3=High2 Bob Peet –leadExecutiveResponsibility Agreed Comments Date CompletedFaith Button2 Bob Peet –leadExecutiveFaith ButtonAgreedAgreedThe Trust has carried out a self assessmentagainst the standards for better dataquality.The majority of standards are met. Wheregaps are identified they will be picked up inthe data quality strategy plan, and by thenew data quality committee, setting realistictimescales to achieve each one during10/11.The Trust as part of its informationgovernance requirements is about toundertake an audit checking back theTrust’s PAS data against prime records(case notes). This is a regular auditscheduled, with current resourcing, to takeplace once a year.Polices and process are constantlyreviewed and scheduled for implementationas part of the either the Data Qualitycommittee orInformation Governance agenda. This is alonger term piece of work in some areas.Changes in priorities around process maytake place as the Trust moves to implementits upgrade of the PAS system.The Trust has a named senior managerresponsible for data quality and certain dataquality indicators are scrutinised through asystem of performance monitoring. TheTrust Management Committee receives aquarterly update, the board will receive thisProgrammeofachievementover 10/11Late October2009Qtr 1 10/11Programmeofdevelopmentthrough10/11YesYesYesYes3

Pageno.Recommendation10 R4 As part of embedding the risk managementframework, the Healthcare Governance teamshould continue their coaching and supportingrole with a view to capacity building in thedivisions around risk management, particularlythe risk identification process.Priority1=Low2=Med3=HighResponsibility Agreed Comments Date Completed2 Sarah Watson-Fisher/GrazLuzzi – leadExecutiveLiz HollmanAgreedinformation annually. Further data qualityreporting will be developed during 10/11.The Associate Director HealthcareGovernance meets regularly with key staffin each Division to increase awareness ofrisk management processes and to improveconsistency of risk assessment. Thisawareness raising around risk managementis a continuous part of the activity of theAssociate Director Healthcare Governance,and as such will not have an end date.No end date– seen ascontinuousimprovementwork11 R5 The Board should maintain a schedule ofthird party bodies with which the Trust has a dutyto cooperate. This should include the nature ofthe relationship and the reporting/communicationrequirements that apply. Appendix E of Monitor'sCompliance Framework gives a generic, nonexhaustivelist of such bodies.12 R6 Review the detailed governancerequirements set out in Monitor's FoundationTrust Code ofGovernance and periodically monitor progressagainst each provision.2 Anne Eden –lead executiveElizabethPalmer2 Anne Eden –lead executiveElizabethPalmerAgreedAgreedAchievement of this action is demonstratedthrough the monthly review of all risksscored12 or above at the Trust ManagementCommittee and Risk Monitoring Group; thebimonthly review of all risks scored 12 orabove at the Healthcare GovernanceCommittee; and the presentation ofDivisional Risk Registers in their entirety atHealthcare Governance Committee on arolling basis.A schedule of third party bodies with whichthe trust has a duty to co-operate will bepart of thePartnership StrategyAs part of the application for foundationtrust status the trust board has reviewedMonitor’s Code of Governance forFoundation Trusts.The Trust recognises that the Code ofJanuary2010CompleteYesYes(next Annual4

Pageno.RecommendationPriority1=Low2=Med3=HighResponsibility Agreed Comments Date CompletedGovernance sets out best practice incorporate governance and will continue tomonitor itself against the provisions that donot solely apply to an authorised foundationtrust. This review will take place annually.review will takeplace inNovember2010)5

AGENDA ITEM 14TRUST BOARD 28 SEPTEMBER 2010Title:Strategy updateTo be presented by:Juliet BrownDirector of Strategy and System Reform.Contact details:01494 734952Executive summary and key issues for the Board:This paper summarises current key strategic plans and issues for the Trust.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? noDoes this paper provide assurance on the control of an identified risk?noCommittee review and approval:None requiredLegal Issues:noneAction required by the Board:To note the content of the reportJuliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

Strategy Update1 Building a positive future for Wycombe HospitalIt is important to Buckinghamshire Hospitals that each of our acute sites has a strongfuture delivering effective health care to the population of Buckinghamshire. It isespecially important to develop the future of Wycombe Hospital given the healthneeds of the sizeable population of this area.Over the past years a number of exciting developments have been undertaken atWycombe hospital to ensure our patients are able to access the best possible carethese include:• Endoscopy unit, ranked as one of the top five in Britain by the national JointAdvisory Group, accredited as a national bowel cancer screening centre.• New angioplasty service – previously patients had to travel into London forthis service• Development of a one-stop breast clinic for all women with breast lumpsDespite these there continues to be public concern surrounding the future ofWycombe Hospital.In a recent Board seminar it was agreed that Wycombe Hospital should bedeveloped along three lines:• A cardiovascular unit – offering state of the art cardiac, elective vascular andstroke care.• An elective treatment centre – building on the excellent services alreadyprovided in this dedicated unit.• A local care hub – where local residents are able to access the outpatient,diagnostic, emergency and other non-specialist services they require from alocal hospital.We are now working with local commissioners to develop these plans into reality.These include working with Heatherwood and Wexham Park Hospitals to implementa partnership approach to vascular care. Under this arrangement we will undertakeall elective arterial operations for the residents of Buckinghamshire and BerkshireEast in Wycombe Hospital. The aim is to implement this by the end of 2010.In addition we are working with the commissioners in Berkshire East andBuckinghamshire to develop a hyperacute stroke unit at Wycombe, with the potentialfor a second hype acute unit at Stoke Mandeville to serve the population of NorthBuckinghamshire and Milton Keynes. Under this arrangement patients who havesuffered a stroke will receive the first 48 hours of their care at Wycombe Hospitalbefore being transferred to their local hospital, if that is not Wycombe. The first draftof these plans is being written for submission to the stroke network at the end ofSeptember 2010.Juliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

We continue to work with surgeons to explore how the services provided by theTreatment Centre can be offered to more GPs and patients.Alongside this we are developing the estate at Wycombe Hospital with workunderway on the main entrance and a review of the location of all clinical services toensure that our patient care is provided from our best accommodation with a colocationof services that maximises clinical synergies.2 Developing community servicesThroughout August 2010 we held a series of community meetings to engage withlocal residents about the development of their community services. Thesediscussions were centred around our community hospital facilities in Amersham,Buckingham, Chalfont St Peter, Marlow and Thame.Community hospitals have a strong place in the future of care delivery inBuckinghamshire as we aim to deliver care as close to people’s homes as possible.These sessions explored the plans we have to develop our community services bothwithin out hospitals and those offered in people’s homes by our community teams.They went on to discuss residents’ ideas for how they would like services to befurther developed and how they would like to be involved in the ongoingdevelopment. Key points from these sessions included:• The need for integrated care with GPs and social care• Importance of “one stop” care• Desire for a wider range of local pre and post operative assessment• Development of services for the elderlyOver the next month we are meeting with local GPs to further develop these plansand will bring a full report to the board once the results from all these sessions havebeen collated.In the interim we have secured funding from NHS Buckinghamshire to significantlydevelop and increase the care our community teams are able to offer and we areworking with our clinical staff, GPs and users of the service to ensure we are able toprovide the service that is required.3 Becoming a Foundation TrustWe have now agreed a timetable with NHS South Central for our Foundation Trustapplication, with the aim of being authorised as a Foundation Trust in April 2012. Thefirst stage of this process is to refresh our original integrated business plan and longterm financial model as well agree plans for the new quality assessment. Work isunderway on all these aspects and the executive team have a meeting with NHSSouth Central at the end of November 2010 where the first draft of these plans will bepresented.Juliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

AGENDA ITEM 15TRUST BOARD 28 SEPTEMBER 2010Title: Integration of acute and community services – a new organisational identityTo be presented by:Juliet BrownContact details:01494 734952Director of Strategy and System Reform.Executive summary and key issues for the Board:From 1 October 2010 Buckinghamshire Hospitals NHS Trust will change its name to BuckinghamshireHealthcare NHS Trust to more accurately reflect our range of integrated acute and community services. Inaddition, our Patient Promises have been developed, in consultation with patients and staff, to reflect thisrange of services.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? noDoes this paper provide assurance on the control of an identified risk?integration of acute and community services.Highlights further progress on theCommittee review and approval:None requiredLegal Issues:noneAction required by the Board:To note the content of the report.Juliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

Integration of acute and community services – a new organisational identity1 Buckinghamshire Healthcare NHS TrustThe Board agreed in March 2010 to proceed with a legal name change to better reflect ournew integrated organisation.It was agreed at the time that neither Community Health Buckinghamshire norBuckinghamshire Hospitals suitably reflected the direction the organisation was going in and,following discussions with staff and GP colleagues, Buckinghamshire Healthcare NHS Trustwas decided on as a new name.The name of our organisation is a crucial part of our identity and therefore it should enablepatients and the public to clearly identify us. The NHS Identity Guidelines states that anorganisation’s name should:• be clear and descriptive – not conceptual or abstract• be written out in full – without the use of acronyms or abbreviations• contain a geographical reference where possible• make sense to service users.By changing our name to Buckinghamshire Healthcare NHS Trust, we believe that we willmeet the above requirements.We are preparing to go live with our new name on 1 October 2010 and will spend that monthembedding it into the organisation in time for when our establishment order is amended byParliament on 1 November 2010.2 Development of our Patient PromisesFor the last two years our five Patient Promises have been central to how we develop anddeliver care within our Trust. It is therefore imperative that we adapt and develop these toensure they remain relevant. In April 2010, we held three ‘vision and values’ sessions withstaff from acute and community services attending along with patient representatives. Thesesessions allowed us to discuss the patient promises in depth to ensure they reflected ourintegrated organisation and remained meaningful to staff and patients. The amendedpromises were then sent to members of our Patient Experience Group, who provided auseful sense-check.Juliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

As a result of this our Patient Promises have been developed to more accurately reflect therange of people we see within hospital and community settings. They are as follows:Buckinghamshire Healthcare … where your needs always come firstClean and safe practice, clinics and hospitals so you never need to worry undulyA caring, helpful and respectful attitude from approachable teams, who listen to you, involveyou in decisions about your care and ensure you’re clear about what to expectRespect for your time with care closer to home, offering choice and flexibility with a minimumof delays and cancellationsEasy access to comfortable and modern facilities, offering privacy and dignity, personalspace and good healthy foodThe best clinical care from teams of skilled healthcare professionals, who help you improveand maintain your health3 Implementing the ChangeOur current visual identity is centred on our three acute sites, it is therefore necessary toadapt this in conjunction with our organisational name. We have also spent some timeupdating our website to ensure our refreshed Patient Promises are prominent and that weprovide information about the range of community services available in Buckinghamshire.A detailed action plan is being implemented to ensure the new organisational name andidentity is introduced in a timely and cost effective manner.Juliet Brown/Sheryl PopeJoint Director Strategy and System ReformSeptember 2010

AGENDA ITEM NO 16TRUST BOARD 28 SEPTEMBER 2010Title:Information Governance Strategy Version 3.0 Ref: IG0041, Strategy No: S007To be presented by:Bob Peet, Chief Operating OfficerContact details:robert.peet@buckshosp.nhs.ukExecutive summary and key issues for the Board:The Information Governance Strategy has been has been reviewed and updated to support the recentlyapproved IG Policy ref: IG0005. The strategy documents the Trust’s Information Governance ManagementFramework in order to support it’s legal and statutory requirements as detailed within the Department ofHealth Information Governance toolkit (IGT).Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? NoDoes this paper provide assurance on the control of an identified risk? NoThis document outlines the controls to mitigate and reduce information riskCommittee review and approval:The strategy has been circulated and commented on by the Caldicott & Information Governance Committeeand Joint Management and Staff Committee.The strategy was approved by the Caldicott & Information Governance Committee through a Chairman’sAction in June 2010 and ratified by the Trust Management Committee in August 2010.Legal Issues:Does the paper contain a legal issue or evidence compliance with legislation?This document outlines the IG framework & controls in place to comply with legislation e.g. data protection,Freedom of InformationAction required by the Board:Ratification

Information Governance StrategyONCE PRINTED OFF, THIS IS AN UNCONTROLLED DOCUMENT. PLEASECHECK THE INTRANET FOR THE MOST UP TO DATE COPYTarget Audience: All staff employed or working on behalf of the TrustAuthor: Information Governance ManagerVersion: 3.0Status: ApprovedApproved by: Caldicott & Information Governance Committee June 2010Reference: IG0041Version date: June 2010Review date: June 2013Strategy no: S007EIA: August 2010Lead Director: Chief Operating Officer

IG0041 Information Governance StrategyApproval and AuthorisationCompletion of the following detail signifies the review and approval of this document,as minuted in the senior management group meeting shown.Version Authority Name of Approver Date1.0 ISG Anne Chilcott 30.06.052.0 Caldicott & InformationGovernance CommitteeAnne Chilcott Dec 073.0 Caldicott & IG Committee June 10Change HistoryVersion Status Reason for change date Author1.0 Approved Approved by ISG 30.06.05 30.06.05 Anne Chilcott1.1 Draft Formal Review Nov 06 A Chilcott1.2 Draft Comments from ISG Dec 06 A Chilcott1.2 Draft Circulated to JMSC Feb 07 A Chilcott2.0 Approved Reviewed 12.12.07 A. Chilcott2.1 Draft Formal Review April 2010 A Chilcott2.2 Draft Further Amendments April 2010 A Chilcott2.2 Draft Circulated to Caldicott & IG Committeefor commentMay 2010A Chilcott2.2 Draft Circulated to JMSC for comment May 2010 A Chilcott3.0 Approved Caldicott & IG Committee chairman’sactionJune 2010A Chilcott3.0 Ratified Trust Management Committee Aug 2010 A ChilcottDocument ReferencesRef # Document title Document LocationReference1 Information Governance Policy IG0005 Intranet2 Clinical Governance Strategy S002 Intranet3 Risk Management Strategy Pol045 Intranet4 Trust Assurance Framework and Corporate RiskIntranetRegister5 Policy on Production, Approval, Registration and Pol 075 IntranetImplementation of Trust-wide Strategies and Policies6 Department of Health Code of Conduct for Paymentby ResultsIG00041 Information Governance Strategy version 3.0 Page 2 of 16

IG0041 Information Governance StrategyTable of Contents1. Introduction.....................................................................................................................42. Aims and Objectives ......................................................................................................43. The Scope of the Strategy .............................................................................................44. Strategy Context.............................................................................................................55. Key Components of the strategy ..................................................................................56. Information Governance Deliverables..........................................................................57. Management Structure and Responsibilities..............................................................78. Strategy Implementation and Improvement Plans ......................................................79. Training ...........................................................................................................................810. Resources .......................................................................................................................811. Conclusion ......................................................................................................................812. Monitoring the Strategy .................................................................................................913. Review of this document ...............................................................................................9Appendix A - Information Governance Management & Accountability Framework…….10Appendix B - Terms of Reference………………………………………………………………..14IG00041 Information Governance Strategy version 3.0 Page 3 of 16

IG0041 Information Governance Strategy1. IntroductionThis strategy sets out the approach to be taken within the Buckinghamshire Hospitals NHSTrust to support the Information Governance Policy and provide a robust InformationGovernance (IG) framework for the management of information.Good quality information underpins sound decision making at every level in the NHS and mostimportantly contributes to the improvement of health care. With penalties for failure to complywith the laws and regulations on information handling on the increase, the Trust must makecertain that it has a plan to ensure that its business and person related information is beingproperly managed. This strategy provides a framework to bring together all of therequirements, standards and best practice that apply to the handling of personal information,allowing:• Implementation of Department of Health advice and guidance• Compliance with the law• Year on year improvement plans• Compliance with ISO/IEC 17799:2005, the international standard for InformationSystem SecurityInformation Governance is the mechanism by which the Trust handles information aboutpatients and employees, in particular personal and sensitive information.2. Aims and ObjectivesThe Trust aims to achieve a standard of excellence in information governance by ensuringinformation is dealt with legally, securely, efficiently and effectively in the course of Trustbusiness, in order to support high quality patient care.All information processing will be undertaken in accordance with relevant legislation and bestpractice. The Trust will set policies and procedures to ensure that appropriate standards aredefined, implemented and maintained.The Trust aims to minimise the risks arising from information handling processes, these are:• Legal action due to non-compliance with statutory and regulatory requirements• Loss of public confidence in the Trust• Contribution to clinical or corporate negligenceThe Trust aims to provide support to its staff to be consistent in the way they handle personalinformation and to avoid duplication of effort. This will lead to improvements in:• Information handling activities• Patient confidence in the NHS and the Trust• Staff training and development3. The Scope of the StrategyInformation Governance provides a consistent way for staff to deal with the many differentinformation-handling requirements and is a framework for the following processes and duties:• Information Governance Management (management, accountability and responsibility)IG00041 Information Governance Strategy version 3.0 Page 4 of 16

IG0041 Information Governance Strategy• Confidentiality & Data Protection Assurance (person related/identifiable information)• Information Security Assurance (manual and electronic information /records management)• Clinical Information Assurance (patient information/ records for direct clinical use))• Secondary Use Assurance (patient information/records e.g. data quality, non direct clinicaluse)• Corporate Information Assurance (records management e.g. Finance, Human Resources)4. Strategy ContextInformation plays a key part in governance, strategic risk, clinical governance, serviceplanning and performance management. The strategy links into all of these aspects and setsout the approach to be taken within the Trust to provide a robust information governanceframework for the management of information.Information Governance has been identified as a risk within the Information GovernanceAssurance Framework; therefore the implementation of this strategy will facilitate and maintaina reduction in the level of this current risk.Accurate, timely and relevant information is essential to deliver the highest quality health care.As such it is the responsibility of all staff to ensure that information is accurate and up to dateand that it is used proactively in the Trust’s decision-making process.The Trust will adopt the principles contained within the Department of Health, Code ofConduct for Payment by Results.5. Key Components of the strategy• The Trust Information Governance Policy outlines the objectives for informationgovernance.• An annual action plan arising from a base line assessment against the standards setout in the Connecting for Health Information Governance Toolkit and will be a keyvehicle for improving information governance within the Trust.• A management framework and robust infrastructure which will support theimplementation, monitoring and review of information governance within the Trust.6. Information Governance DeliverablesThe Trust will establish a robust information governance process conforming to theConnecting for Health standards and the objectives in the Trust’s InformationGovernance Policy. It is the responsibility of all organisations to comply with relevantlegislation.The Department of Health has developed the following five broad standards (called the “HORUS model”), that we should apply when information is processed:oooHeld securely and confidentiallyObtained fairly and efficientlyRecorded accurately and reliablyIG00041 Information Governance Strategy version 3.0 Page 5 of 16

IG0041 Information Governance StrategyooUsed effectively and ethicallyShared appropriately and lawfully6.1 All staff must understand and apply best practice and the principles of informationgovernance to manage all information to support the business activities of the Trust• All staff involved in the administration of information governance must receive SeniorManagement backing, training and encouragement to be aware of developments ininformation governance and any relevant information handling issues that will affectthem.• Delivery of mandated information governance induction and update training for all staff.• Regular communications to staff using Trust staff bulletin, intranet and managementteam briefs• All staff signing confidentiality clauses within all staff contracts6.2 The Trust will undertake regular reviews and audits of how information is usedthrough:• Mapping of data flows• Review of reported information incidents• Data quality checks6.3 The Trust will develop and maintain a robust management and responsibilityreporting structure to ensure that information governance and associated risks areappropriately managed to support the overall risk management function within theTrust.• Formation of a dedicated Information GovernanceCommittee• Appointment of the key roles and responsibilities• Informing staff of the key personnel and their responsibility• Provision of clear advice and guidance networks throughout the Trust• Implementation of defined information incident reporting and investigating procedureslinked to the risk management process.• Information Governance and Information Technology Policies and procedures will bedeveloped, regularly reviewed and maintained to reflect current standards6.4 Identifying where there are common areas of work will help all employees to workin a cohesive fashion towards a common goal, to the benefit of the patient.• Encouraging multi disciplinary teams to work more closely together will lead to areduction in repetitive practices by seamlessly sharing relevant information andstandardising practices and procedures6.5 The Trust will involve patients and staff in the development of information that isused to improve services.• Patients and staff will be involved in relevant surveys, forums and groups in order toseek the opinions of the service users and where appropriate will act on thoseopinions.IG00041 Information Governance Strategy version 3.0 Page 6 of 16

IG0041 Information Governance Strategy6.6 The Trust will ensure that clear advice and guidance are made available throughinformation leaflets and awareness posters to patients, families and carers about howtheir personal information is used.• Information will be made available in various formats explaining how information isrecorded and shared and how any concerns may be raised. Information will also beprovided on Subject Access requests (SAR) under the Data Protection Act 1998.• Patients will be made aware of the importance of providing accurate and up to dateinformation about themselves so that appropriate care is given to the correct patientand to manage the resources adequately.7. Management Structure and ResponsibilitiesThe Trust Management Committee (TMC) has the responsibility for overseeing theimplementation of this strategy, the Information Governance Policy and associated IG ToolkitAssessment action plan.The Chief Operating Officer/Senior Information Risk Officer (SIRO) is the named ExecutiveDirector on the Board with responsibility for information governance and information risk. ThisDirector is a member of the TMC.The Caldicott Guardian acts in a strategic, advisory and facilitative capacity in the use andsharing of patient information. The Trust’s Caldicott Guardian reports to the Trust Boardthrough the Medical Director.The Caldicott and Information Governance Committee (C&IGC), chaired by the CaldicottGuardian, is accountable to the Trust Board through the Trust Management Committee(TMC). Representation from designated Information Governance Toolkit/Caldicott FunctionLeads will ensure that information governance is embedded within the organisationalstructure.Information Governance Manager through the Associate Director of Information Managementwill assume day to day responsibility for driving forward the information governance agenda.The Information Governance Manager is responsible for the timely completion and submissionof the end of financial year Trust self assessment.Appendix A – Information Governance Management & AccountabilityFrameworkAppendix B- Caldicott and Information Governance Committee - Terms OfReference8. Strategy Implementation and Improvement PlansThe Caldicott and Information Governance Committee will monitor implementation of thisstrategy and its associated work programmes through regular quarterly meetings.All Trusts are mandated to complete a self assessment of their information governanceperformance using the IG Toolkit. This is an on-line self assessment tool based on 62Information Governance Standards (IG) and is used as one of the sources of information byIG00041 Information Governance Strategy version 3.0 Page 7 of 16

IG0041 Information Governance Strategythe Care Quality Commission for assessing compliance with Standards for Better Health, selfimprovement reviews etc. The IG standards are based on generally accepted definitions ofgood practice in relation to information governance and inter-link with other recommendationsand standards such as those in Standards for Better Health, NHSLA, and the Data ProtectionAct 1998 etc.Note: New versions of the IG Toolkit are released annually and the requirements can bechanged to reflect current standards and may be more rigorous. This means that the Trust willhave to provide additional evidence to support the changes and to maintain the scoreachieved in the previous year.The Caldicott and Information Governance Committee will:• Undertake a baseline assessment of the current position in relation to the IG standards• Agree an annual work programme to ensure a year on year improvement inperformance• Ensure the development and implementation of information governance strategies,policies, procedures.• Identify resources for implementation• Ensure that the IG agenda is supported by appropriately skilled InformationGovernance Toolkit/Caldicott Function Leads• Monitor progress against action plans• Report on progress, incidents and issues to the Trust Management Committee• Complete the self assessment toolkit on an annual basisThe Caldicott and Information Governance Committee will formally review this strategy everythree years however the content will be reviewed annually to include any significant changesto mandatory requirements, national guidance or as a result of significant informationgovernance breaches or incidents in order to ensure that all types of information are moreeffectively managed within the Buckinghamshire Hospitals NHS Trust.9. TrainingFundamental to the success of delivering the Information Governance Strategy is developingan information governance culture within the Trust, providing training and promotingawareness for all staff that have access to Trust information.10. ResourcesResource implications incurred by the implementation of the Information Governance Strategyand action plan, will be identified by the Caldicott & Information Governance Committee.Business cases will be then developed and submitted to the Trust Management Committee forapproval.11. ConclusionThe implementation of the Information Governance strategy, policy and implementation planwill ensure that information is more effectively managed at Buckinghamshire Hospitals NHSTrust. Each year the strategy will be reviewed and an action plan developed against theConnecting for Health Toolkit to identify key areas for continuous improvement. This strategyshould be classified as a working document for the period of 2010-2013 and will be reviewedannually.IG00041 Information Governance Strategy version 3.0 Page 8 of 16

IG0041 Information Governance Strategy12. Monitoring the StrategyThe Caldicott and Information Governance Committee will monitor the implementation of thisstrategy in terms of its supporting Policy, Procedures, Plans and subsequent revisionsthrough:• regular reports from Information Governance Toolkit/Caldicott Function Leads onimprovements, risks and issues• overseeing the content and review of patient information13. Review of this documentThis document will be formally reviewed every three years.This document will be subject to revision when any of the following occur:• The adoption of the standards highlights errors and omissions in its content.• Where other standards/guidance issued by the Trust conflict with the informationcontained.• Where good practice evolves to the extent that revision would bring aboutimprovement.IG00041 Information Governance Strategy version 3.0 Page 9 of 16

IG0041 Information Governance StrategyAppendix A - Information Governance Management &Accountability FrameworkINFORMATION GOVERNANCE MANAGEMENT & ACCOUNTABILITY STRUCTURETRUST BOARDCLINICAL RECORDSCOMMITTEETRUST MANAGEMENTCOMMITTEEHEALTHCAREGOVERNANCECOMMITTEECALDICOTT & INFORMATIONGOVERNANCE COMMITTEEIG Management & Accountabilitystructure July 09 V 11IG00041 Information Governance Strategy version 3.0 Page 10 of 16

IG0041 Information Governance StrategyINFORMATION GOVERNANCE ROLES & ACCOUNTABILITY CHAINChief ExecutiveAccountable OfficerMedical Director(Lead responsibility for clinicalgovernance with theDirector of Nursing& Patient Care Standards)( overall responsibility for ensuring that organisation risksare assessed and mitigated to an acceptable level)Chief Operating Officer/Deputy CEO/SIRO(board level position with lead responsibility forthe organisation’s information risk and owningthe Information risk policy & risk assessmentprocedure)Information Asset Owner (IAO)(assigned owners responsible for aparticular information asset/s andresponsible for providing assurancesto the SIRO on information risks)Caldicott Guardian(Provide focal point to patientconfidentiality and informationsharing issues. Is concerned withmanagement of Patient information.Is the advisory and conscienceof the organisation.)Assoc Director Of InformationManagement(Overall responsibility for informationmanagementdevelopment withinthe Trust)Information Governance Manager(Management of IG across the wholeorganisation, ensuring it complies withstatutory requirements in relation toInformation security, confidentiality,data Protection, caldicott)IG Management & Accountabilitystructure July 09 V 1Information AssetAdministrators (IAA)(supports IAOs in undertakingassets specific risk management.Raising IG awareness andbest practices.)2IG00041 Information Governance Strategy version 3.0 Page 11 of 16

IG0041 Information Governance StrategyINFORMATION GOVERNANCE DEPARTMENT STRUCTUREChief Operating Officer/Deputy CEO/SIROAssociate Director ofInformation ManagementFreedom ofInformation LeadInformation GovernanceManagerData QualityManagerInformation GovernanceofficerCl Coding Teams@SMH & WHIG Management & Accountabilitystructure July 09 V 1IG00041 Information Governance Strategy version 3.0 Page 12 of 16

IG0041 Information Governance StrategyCALDICOTT & INFORMATION GOVERNANCE ASSURANCE PROCESSTrust ManagementCommitteeSIROCaldicott & InfoGovernance CommitteeInformation AssetOwnerIG Toolkit/CaldicottFunction Leads *Caldicott GuardianInformationGovernance Manager*Freedom of Information LeadData Quality ManagerRegistration Authority ManagerIT Service ManagerInformation Service ManagerMedical Records Service ManagerIG Management & Accountabilitystructure July 09 V 1InformationGovernance Officer4IG00041 Information Governance Strategy version 3.0 Page 13 of 16

IG0041 Information Governance Strategy14. Appendix B - Terms of ReferenceJune 2009Name of Committee: Caldicott and Information Governance CommitteePurpose of CommitteeThe committee will be responsible to the Trust Board through the Trust Management Committee (TMC)for ensuring that the Trust has effective policies and management arrangements covering all aspects ofInformation Governance in line with the Trust’s overarching Information Governance Policy i.e.• Openness• Legal Compliance• Information Security and Confidentiality• Information Quality AssuranceObjectives and Key TasksTo ensure that the Trust undertakes or commissions annual assessments and audits of its InformationGovernance policies and arrangementsTo establish an annual Caldicott and Information Governance work programme leading on from yearlysubmission of the IG Toolkit. Monitor the implementation of the programme and identify to the TrustManagement Committee, the requirement for necessary resources to support its implementation.To ensure that all existing and proposed databases and data flows involving patient-identifiableinformation are tested against Caldicott and Data Protection principles and basic principles of goodinformation management practice.To review and monitor IG risks identified though issues registers and incident reports and ensuing whereappropriate they are entered onto the relevant risk register.To receive updates from IG initiative leads on IG toolkit progress, action plans and areas of risk.To develop, monitor and review internal protocols governing the protection and use of patient identifiableinformation by Trust staff and ensure delivery of adequate training and awareness.To oversee the development and review of protocols governing the sharing and disclosure of patientinformation across organisational boundaries, between both NHS and non- NHS bodies.To develop and monitor information governance policy, raising confidentiality requirements and potentialareas of risk at Board level.To co-ordinate the activities of staff given data protection, confidentiality, information security,information quality, records management and Freedom of Information responsibilities.To ensure that Information Governance training is made available by the Trust and is taken up by staffas necessary to support their role.IG00041 Information Governance Strategy version 3.0 Page 14 of 16

IG0041 Information Governance StrategyTo oversee the provision of appropriate information to patients regarding the purpose for which data iscollected and the people and bodies who may have access to it.To report quarterly on an exception basis to the Trust Management Committee on InformationGovernance issues.To liaise with other Trust committees, working groups and programme boards in order to promoteInformation Governance issues and to provide a focal point for the resolution and/or discussion ofinformation governance issues.Completion and submission of the Information Governance toolkit baseline assessments in July andOctober and final assessment by 31 st March each year.To monitor committee attendance and review the Terms of Reference yearlyMembershipCaldicott Guardian (Chair) , Reports to the Trust Management CommitteeSenior Information Risk OwnerMedical DirectorAssoc Director Of InformationHead of Information Governance (vacant)Information Governance Manager(Information Security Officer/ IG toolkit lead)Governance RepresentativeHead of Access or Operational ManagerAssociate Director of ITFreedom of Information Lead (toolkit lead)Health Records Manager (toolkit lead)IT Services Manager/ IT Security Officer (toolkit lead)Information Governance OfficerNursing representativeHuman Resource representativeOther IG Toolkit initiative leads (exception reports):• Data Quality Manager• RA Manager• Information Services ManagerSenior Information Asset Owners (exception reports):Co-Opted members where required. This may include a patient representative.Frequency: At least quarterlyQuorum4 members plus the Caldicott Guardian or a member of the committee with their designatedresponsibility.IG00041 Information Governance Strategy version 3.0 Page 15 of 16

IG0041 Information Governance StrategyAccountability:Reports to the Trust Management (TMC) formally on a quarterly basis or more frequently as requiredLinks with other committees and groups (e.g. PCT links)Clinical Records Committee, Healthcare Governance CommitteeIG00041 Information Governance Strategy version 3.0 Page 16 of 16

Financial Overview as at August 2010Income & ExpenditureExecutive Summary- Overall SummaryThe Trust’s deficit has reduced in month 5 by £198k to currently stand at £789k, reflecting an improvement in the underlying run rate. This is £602k worse than the planned deficit of £187k. The Trust is currentlyforecasting a best case scenario of achieving a £3,615k surplus, with the most likely outturn being a £2,750k surplus. The worst case scenario is currently a deficit of £11,940k which includes the Trust not achievingthe profit on the Stoke Mandeville land sale.Mitigation: Turnaround Team introduced to continuing to provide increased focus on savings plans in support of performance management and reinforcing the controls environment.- Cost Improvement PlansThere has been slippage across the recurrent divisional CIPs plans. This is reflected in the division variance analysis section, and will be offset by non recurrent savings within the divisions and additional overarching Trust wide schemes.Mitigation: Increased focus on new recurrent and non recurrent items are being identified to ensure achievement of financial targets.- Temporary StaffingMonthly costs from use of temporary medical staff within a number of specialties to cover vacancies and to meet targets is currently not decreasing in year, although has improved compared to last year. Pressure isarising from the use of agency nursing in Theatres and the use of escalation beds.Mitigation: Maximise the use of the Trust’s total bed base, including community based beds to maintain closure of escalation beds and increased internal control on agency usage.- Activity / Demand ManagementActivity information shows a slowdown in elective activity throughout August, whilst non-elective activity has maintained its previous level. Overall, activity volumes for the year to date remain above the contractedlevel of the Buckinghamshire PCT SLA. Where demand has reduced, this has led to a pressure on expenditure budgets as capacity has not matched reductions.Mitigation: Capacity planning being refined by Divisions supported by the Turnaround Team.- Community ServicesAgreement has now been reached between the Trust and Buckinghamshire PCT on the value of the contract for CHB services.Cash Position- The Trust ended the month with a cash balance of £6.3m. However it will need to make PDC Dividend payments of £2.5m and loan repayments and interest of £2m during September. The respective Trust andPCT teams are working to close the net cash position in respect of Community Services by the end of October. It will become increasingly important throughout the remainder of the year that cash releasing savingsare made if the Trust is going to meet its forecast.Mitigation: The project management office is keeping focus on cash releasing CIPs and driving out cash savings.Capital Expenditure- Spend in month 5 overtook plan and further information is included later in the report. The Trust is on target to meet its current CRL of £11m at year end. When the land sale is achieved, the CRL will need to bereduced accordingly and the Trust is in discussion with the SHA on how best to achieve this.Mitigation: The forecast continues to be refined to ensure that the anticipated month of spend is accurately identified. The forecast remains achievement of the Capital Resource Limit (CRL) of £11m.Year to Date Financial Position (£000)Draft Year to Date Surplus/(Deficit) - Pre ImpairmentsBudget Actual Var2010/11 2010/11 2010/11Income 137,667 140,870 3,203Pay -82,985 -88,054 -5,069Non pay -54,869 -53,605 1,264Total -187 -789 -6024,0002,000£0000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar-2,000MonthPlan Actual Forecast

Divisions & DirectoratesAnn BudIncome (£000's)Pay (£000's)Non Pay (£000's)Total (£000's)(£000's) YTD Budget YTD actual YTD Variance YTD Budget YTD actual YTD Variance YTD Budget YTD actual YTD Variance YTD Budget YTD Actual YTD VarianceClinical Services Division -42,733 1,260 1,390 130 -13,272 -13,073 199 -5,852 -6,017 -165 -17,864 -17,699 165Medicine Division -44,602 1,595 1,704 109 -15,737 -17,301 -1,564 -5,087 -5,170 -83 -19,229 -20,767 -1,538Spinal & Private Patients 8,770 8,256 8,264 8 -3,908 -3,905 3 -588 -620 -32 3,760 3,739 -21Surgery Division -55,281 2,207 2,075 -132 -18,772 -21,387 -2,615 -6,836 -7,735 -899 -23,401 -27,047 -3,646Women & Children Division -32,744 1,276 1,271 -5 -13,506 -14,314 -808 -1,341 -1,293 48 -13,570 -14,335 -765Comm & Integrated Care -21,193 525 795 270 -7,749 -7,901 -152 -1,607 -1,598 9 -8,830 -8,704 126Corporate -82,913 8,632 8,866 234 -10,042 -10,173 -131 -33,558 -31,174 2,384 -34,968 -32,481 2,487Contract Income 273,446 113,915 116,505 2,590 0 0 0 0 0 0 113,915 116,505 2,5902,750 137,666 140,870 3,204 -82,986 -88,054 -5,068 -54,869 -53,607 1,262 -187 -789 -602Variance Against BudgetMedical DivisionThe division is overspent by £1,538k, an increase since month 4 of £298k. The increase in the overspend is due to:-(b) Use of locum and agency staff medical staff in A&E, £34k increase in the overspend to a year to date figure of £251k.(c) The devolvement of the Demand Management savings target, £250k movement in the month to £1,136k, although some of this will be offset by additional contract income due to activity remaining above plan, specifically for non-elective work.The division has a risk assessed savings forecast of £2.9m (excluding Demand Management) against a target of £2.9m.Surgical DivisionThe division is overspent by £3,646k, an increase since month 4 of £611k. The increase in the overspend is due to:-(a) Use of locum and agency medical staff in Anaesthetics to cover vacancies and sickness, movement in the month £163k to £780k.(b) Use of agency nursing staff in Theatres/ICU, £92k movement in the month to £322k.(c) The devolvement of the Demand Management savings target, £180k movement in the month to £825k. The reduction in elective activity means that this is unlikely to be offset by additional income.(d) Clinical supplies in Theatres, £221k movement in the month to £464k.The division has a risk assessed savings forecast of £3.4m (excluding Demand Management) against a target of £5.6m.Spinal DivisionThe division is overspent £21k, a deterioration since month 4 of £41k. The change in the position is due to:-(a) Drug costs where the overspend has increased by £15k in August to £45k, this is currently being investigated.The division has a risk assessed savings forecast of £942k (excluding Demand Management) against a target of £1m.Women’s & Children’s DivisionThe division is overspent by £765k, an increase since month 4 of £74k. The increase in the overspend is due to:-(a) Use of locum and agency medical staff to cover vacancies and maternity leave, £65k movement in the month to £213k.(b) Shortfalls in inherit CHB pay budgets which are currently being fully quantified.(c) The devolvement of the Demand Management savings target, £31k movement in the month to £141k.The division has a risk assessed savings forecast of £1.6m (excluding Demand Management) against a target of £2.4m.Clinical Support DivisionThe division is underspent by £165k, a decrease since month 4 of £101k. The main overspends are due to:-(a) Pathology non pay, with a swing in the month of £143k against clinical supplies.The division has a risk assessed savings forecast of £2.4m (excluding Demand Management) against a target of £2.6m.Corporate Directorates (including Access)Property Services is overspent by £808k, an increase since month 4 of £186k. The increase in the overspend is due to:-(a) High level of works undertaken, £278k movement in the month to £665k, this includes asbestos clearance and road improvements at Wycombe.In respect of savings, the directorate has a risk assessed savings forecast of £1.7m, including savings from the corporate restructure.The Access division is overspent by £254k, an increase since month 4 of £44k. The overspend is due to:-(a) An under recovery against delayed discharges income of £8k in month 5 to a year to date £87k.(b) The devolvement of the Demand Management savings target, £30k movement in the month to £136k.The division is currently forecasting achievement of £611k of risk assessed savings for the year.Within the Corporate Directorates full integration of BHT and CHB corporate structures continues, with savings expected in the second half of the year.Community & Integrated Care DivisionThe division is underspent by £126k, an improvement since month 4 of £153k.A savings target of £1,170k has set for this division, and £1,012k of risk assessed savings are currently being forecast against this target.

Month 5 Income PositionThe Trust total income position as at the end of August is £3.203m over-recovered.Income from ActivitiesOf the £3.203m income over-recovery, £2.935m relates to ‘Income from Activiites’. Of the £2.935m, £1.6m is associated with Bucks PCT and £0.7m to non Bucks PCT’s. Othersignificant variances are over recoveries against RTA’s and private patients of £317k & £227k respectively.Non Bucks PCT’sBased on activity trends to date the Non Bucks PCT activity is expected to continue on a fairly even basis through to the end of the year forecasting an £800k overperformanceby the year end. The main areas of over/underperformance are Milton Keynes PCT £409k overperformance to M5, Herts PCT £213k underperformance to Month 5 and BurnsIncome is £237k under-recovered to date.Bucks PCTIf activity trends do not change the current £1.6m overperformance will become an end of year position on Bucks PCT of £4million above contract. The activity plan assumes areduction in activity month on month based on demand management schemes. Activity levels were lower in August due to the theatre shut-down.All Income and Activity assumptions have been based on the weekly demand management plans which show the following trends in activity;Bucks PCT Activity Compared toTarget for August 2010ActivityVarianceOver /(Under)TargetNEL Admissions (131)Elective Inpatients (219)New Outpatients 119Follow Up Outpatients 935A&E Attendances 831Change fromJuly 2010Contract ChallengesThe income position includes a provision for M1-5 contract challenges for all PCT’s; this is predominantly misallocated patients and outpatients charged during an inpatient stay.Bucks PCT have raised circa £3million of contract challenges in Quarter 1 alone, the majority of these queries have been rejected as there is no basis for credit, they do notrelate to non adherence to PbR guidance, Data Dictionary definitions or to any measures agreed in the contract documentation for financial penalties so this is viewed as low risk.A request for payment of outstanding overperformance invoices has been sent to Bucks PCT and processes are now in place to ensure overperformance invoices are not heldup on the basis of outstanding queries.

INCOME & EXPENDITURE POSITION AS AT MONTH 5 2010/11Current Position (£000s)Forecast ScenariosAnnual Budget YTD Budget YTD Actual YTD Variance Best Case Most Likely Worst CaseIncomeIncome From Activities 265,203 110,433 113,368 2,935 272,501 272,501 270,551CHB Income Only 44,369 18,487 18,603 116 43,449 43,449 43,449Other Operating Income 16,345 6,968 7,127 158 17,132 17,132 17,132325,916 135,889 139,097 3,209 333,083 333,083 331,133PayNursing (79,964) (33,198) (35,324) (2,126) (82,604) (82,823) (85,146)Medical Staff (49,326) (21,131) (23,513) (2,382) (56,830) (56,996) (58,579)Admin & Clerical (20,756) (8,829) (9,218) (389) (22,330) (22,395) (23,017)Professional & Tech (33,623) (13,899) (14,005) (107) (33,067) (33,163) (34,084)Senior Manager (8,955) (3,712) (3,392) 320 (7,908) (7,931) (8,152)Other Staff (4,105) (1,783) (2,195) (412) (5,881) (5,898) (6,062)Exec & Non Exec Dirs (1,040) (433) (407) 26 (946) (949) (975)(197,770) (82,985) (88,054) (5,069) (209,566) (210,155) (216,016)Non PayDrugs (18,276) (8,176) (7,062) 1,114 (16,005) (16,051) (16,497)Clinical Supp Servs (25,949) (10,949) (11,607) (658) (26,930) (27,008) (27,758)Gen Supp & Servs (21,424) (9,024) (9,007) 17 (20,792) (20,852) (21,432)Establishment Exps (4,746) (1,987) (1,959) 28 (5,280) (5,295) (5,442)Premises & F Plant (14,409) (5,963) (6,052) (89) (13,807) (13,847) (14,232)Non Nhs Healthcare (27) (10) (16) (5) (16) (16) (16)Consultancy Services (351) (211) (340) (129) (789) (791) (813)Miscellaneous (13,121) (5,478) (4,774) 704 (10,643) (10,674) (10,971)(98,302) (41,799) (40,817) 982 (94,261) (94,535) (97,162)TOTAL EBITDA 29,845 11,105 10,226 (879) 29,256 28,393 17,955OtherDepreciation (15,474) (6,448) (6,346) 102 (14,512) (14,512) (14,512)Interest Paid And Pdc Div (15,888) (6,623) (6,442) 181 (15,421) (15,421) (15,421)Interest Receivable 67 28 23 (5) 42 40 38Profit/Loss Disposal of Assets 4,200 1,750 1,750 (0) 4,250 4,250 0(27,095) (11,292) (11,015) 277 (25,641) (25,643) (29,895)TOTAL 2,750 (187) (789) (602) 3,615 2,750 (11,940)Notes:This report does not include any estimated impairment charges for 2010/11.

STATEMENT OF FINANCIAL POSITION FOR YEAR 2010/2011Balance at 31July 2010Balance at 31August 2010MovementExplanation for significant movementsForecast Scenarios at 31st March 2011£'000s £'000s £'000s Best Case Most Likely Worst CasePROPERTY, PLANT AND EQUIPMENTNet Book Value Tangible and Intangible assetsOwnedDonatedPFI Deferred Asset235,98315,3252,887235,51515,2322,887(468)(93)-236,54115,7592,754236,54115,2592,754238,34115,2592,754Total Non-Current Assets 254,195 253,634 (561)255,054 254,554 256,354CURRENT ASSETSInventories and work in progress 3,268 3,268 - 3,200 3,200 3,200Increase due to additional months accrual for CHB SLA incomedue from Bucks PCT (£3m), outstanding monies due from BucksTrade Receivables (net of provision for impairments) 23,202 27,288 4,086 PCT for TAX,NI and Pensions Costs (£2.6m), partially offset by an 26,000 26,000 23,945invoice raised in month 4 for CIP Support settled by the PCT inmonth 5 (£2.1m).Other Receivables 881 1,023 142 1,000 1,000 1,000Accrued income 6,058 6,554 496 2,000 2,000 2,000Prepayments (other current assets) 2,616 2,408 (208)Decrease in cash balance due to Creditors payment run timing1,000 1,000 1,000Cash at bank and in hand 9,084 6,278 (2,806)(£2.0m), payment of CHB payroll costs (£2.7m) and CHB Tax, NIand pensions (£0.7m), partially offset by the receipt of £2.1m CIPsupport. 1,747 540 90PFI Deferred Asset (current element)Total Current assets9845,2078646,905(12)1,69814735,09414733,88714731,382CURRENT LIABILITIES (amounts due in less than one year)Increase due to Trust raising an invoice to Bucks PCT recoupingTrade and other payables(18,029) (20,688) (2,659)Income tax, National insurance and Pensions Costs for the periodApril-July (£1,900k) and the same costs for August payable to(22,961) (22,619) (25,004)HMRC and the NHSPA (£0.7m).Capital Payables (1,485) (1,367) 118(1,400) (1,400) (1,400)Payments on Account (110) (26)84 - - -Increase due to expenditure accruals made in relation to CHBAccruals and deferred income (23,605) (22,328) 1,277being made within the Trust's ledger for the first time in Augustpartially offset by a reduction in the need to defer income received(5,000) (5,000) (5,000)in advance (£1.08m).Provisions: Current (412) (372) 40(500) (500) (500)Finance leases (1,297) (1,189) 108(1,500) (1,500) (1,500)Current borrowings (3,900) (3,900) -(3,900) (3,900) (5,660)Total Current Liabilities(48,838) (49,870) (1,032) (35,261) (34,919) (39,064)NET CURRENT ASSETS (LIABILITIES)(3,631) (2,965) 666 (167) (1,032) (7,682)TOTAL ASSETS LESS CURRENT LIABILITIES 250,564 250,669 105 254,887 253,522 248,672Non-current liabilities:Finance leases (69,939) (69,939) -(68,388) (68,388) (68,388)Other Creditors (2,186) (2,186) -(2,025) (2,025) (2,025)Provisions for liabilities and charges (1,635) (1,635) -(1,534) (1,534) (1,534)TOTAL ASSETS EMPLOYED 176,804 176,909 105 182,940 181,575 176,725LOANSTotal Loans 13,500 13,500 - 14,600 14,600 24,440TOTAL LOANS 13,500 13,500 - 14,600 14,600 24,440TAXPAYERS' EQUITYPublic dividend capital 154,724 154,724 - 154,724 154,724 154,724Income and expenditure reserve (37,941) (37,743)198In month movement in Trust's I+E position moving from deficit of(32,918) (33,783) (48,473)£0.99m to £0.79m.Revaluation reserve 31,196 31,196 - 30,775 30,775 30,775Donated asset reserveOther Reserves (Government grant reserve etc)15,325-15,232 (93)-15,759 15,259 15,259TOTAL TAXPAYERS EQUITY 163,304 163,409 105 168,340 166,975 152,285TOTAL FUNDS EMPLOYED 176,804 176,909 105 182,940 181,575 176,725Note: CHB accrued expenditure and accrued income previously shown separately on the Statement of Financial Position have now been consolidated within the Trust's own accrued expenditure and accrued income balances formonth 5 and for consistency the month 4 values have also been consolidated. The respective teams are working on settlement of the net cash position with the PCT in order to remove the accruals for income and expenditure.

Statement of Financial Position Information - August 2010Analysis of Receivables£'000s25,00020,00015,00010,000In order to maximise its cash position the Trust needs to ensure that as high proportion as possible of itsreceivables has been invoiced and that accrued income is also converted into invoices. The graph shows sharplyincreasing accruals which relate to the income for CHB that is due from the PCT. Work is being carried out by therespective teams to settle the net position between accrued income and accrued expenditure.5,0000Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10MonthINVOICED RECEIVABLES ACCRUED RECEIVABLES ACCRUED INCOMEBetter Payment Practice CodePercentage100.00%90.00%80.00%70.00%60.00%50.00%40.00%BPPC is affected by two factors - the availability of cash to pay creditors and the timing of receipt of authorisedinvoices within Finance. BPPC until March 2010 was affected by the former as the Trust needed a workingcapital loan. The Trust has a target of 95% of invoice payments within 30 days, and an action plan is in place toimprove performance.30.00%20.00%10.00%0.00%Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10Month% of trade invoices paid with target by number % of trade invoices paid with target by valueWorking Capital - Net Current Assets£000's-(1,000)(2,000)(3,000)(4,000)(5,000)Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Net current assets less liabilitiesHaving negative net current assets/liabilities is a cause for concern, although historically the Trust has operatedfrom this position. Improving this position both in the short term, maintaining this in the longer term andmonitoring the underlying net cash position has become a key function within the Finance department. TheTrust’s improving short term position is due to the strategy adopted for its capital programme for 2010/11. Itscash income is expected to cover forecast depreciation of £14.5m and its capital programme is £11m, leading toan improved working capital balance. There has been a greater benefit in the earlier months due to the profile ofcapital expenditure.(6,000)Capital Programme£'00014,00012,00010,0008,0006,000PlanCRLBudgeted spend (incl charitable)Forecast as at M05During August 2010 the Trust accounted for £603k of capital expenditure, the Trusts capital expenditure year todate is currently £2.175m which, with the revised phasing for the remaining part of the year the Trust will achievethe Capital resource limit of £11m. Key areas of spend in the current period were through 3 projects, Mobile X raymachines (£80k), Core supervisor cards (£210k), and ITU/HDU NSIC Mixed sex accomodation (£132k) all ofwhich were new projects in the year.4,0002,00001 2 3 4 5 6 7 8 9 10 11 12Month

BHT Capital Programme 2010/11SUMMARY CAPITAL PROGRAMME MONTH 52010/11YEAR TO DATE FULL YEAR 2010/11PLANACTUALMONTH 5VAR PLAN F'CAST VAR£'000 £'000 £'000 £'000 £'000 £'000A CAPITAL MANAGEMENT GROUP - PROJECTS 230 174 56 2,632 2,632 -B MEDICAL EQUIPMENT PANEL - PROJECTS 144 171 (27) 1,238 1,238 -C IT CAPITAL GROUP - PROJECTS 67 240 (173) 990 990 -DESTATES PROJECTS GROUP - PROJECTSWycombe Hospital SchemesStoke Mandeville Hospital SchemesAmersham Hospital Schemes241269-263527-(22)(258)-1,5003,740-1,5003,740----BHT Trust-Wide Schemes - - - - - -P.F.I S Bucks. Rationalisation 790 799 (9) 900 900 -SUB-TOTAL BHT Funded Schemes 1,741 2,174 (433) 11,000 11,000 -Donated/ (charitable) - 59 (59) 500 1,000 (500)Grand Total 1,741 2,233 (492) 11,500 12,000 (500)Notes:The variance as at month 5 has been caused by spend that was profiled to take place later in the year occurring earlier thanplanned. In particular within IT the spend on core supervisor cards of £210k had been profiled to occur in month 7 and £100k ofspend on Mixed Sex Accommodation at SMH had been profiled in period 6.Currently each line of the forecast still equals plan but this will change as more information on project spend becomesavailable. We still anticipate that full year spend will be £11m due to the fact when the plan was drawn up spend wasoriginally budgeted in equal 12ths we have amended the budget phasing to more accurately reflect anticipated timings.Donated assets have not been profiled due to the uncertainty around timing. It is expected that donated assets will exceed thatoriginally planned.

Foundation Trust MetricsForecast Forecast Month 1 Month 1 Month 2 Month 2 Month 3 Month 3 Month 4 Month 4 Month 5 Month 5Financial Risk Rating (FRR) 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11 2010/11Rating Rating Rating Rating Rating RatingMetricEBITDA margin 8.5% 3 6.4% 3 6.9% 3 7.1% 3 7.1% 3 7.4% 3EBITDA, % achieved 95.1% 4 128.6% 5 83.4% 4 92.9% 4 91.5% 4 92.1% 4ROA 4.5% 3 -0.2% 2 0.1% 2 0.2% 2 0.4% 2 0.8% 2I&E surplus margin 0.8% 2 -2.8% 1 -1.5% 2 -1.2% 2 -0.9% 2 -0.6% 2Liquid ratio 16.9 3 20.4 3 16.6 3 13.6 2 11.7 2 27.8 3Weighted Average 2.9 2.6 2.5 2.5 2.5 2.7Financial CriteriaUnderlying Performance 3 3 3 3 3 3Achievement of Plan 4 5 4 4 4 4Financial Efficiency 3 2 2 2 2 2Liquidity 2 3 3 2 2 3Overriding RulesLowest ranked metric a '1'? No No No No No NoOne financial criteria '1' or '2'? Yes 2 Yes 2 Yes 2 No No Yes 2Two financial criteria '1' or '2'? No No No Yes 2 Yes 2 NoTwo financial criteria '1'? No No No No No NoLess than 1 year as a Foundation Trust No No No No No NoOverriding Rules Rating 2.0 2.0 2.0 2.0 2.0 2.0Overall Rating 2.0 2.0 2.0 2.0 2.0 2.0Definitions• EBITDA : Earnings before Depreciation, Interest, Tax and Amortisation.• I&E Surplus Margin : Surplus Deficit as Percentage of Turnover• ROA : Return on Assets Employed• Liquidity Ratio : Level of immediate resources available in comparison to immediate liabilities.

Cash Items (£000's) Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Actual/forecast opening balance 716 10,444 12,044 11,660 9,055 6,278 9,737 4,295 5,744 3,499 3,142 1,420NHS cash receipts 26,150 23,407 23,097 25,182 24,678 32,946 35,040 25,198 25,198 25,562 25,193 23,093Non-NHS cash receipts 1,302 1,399 488 2,236 1,566 1,683 3,563 2,423 2,823 2,423 2,438 2,43828,168 35,250 35,629 39,078 35,299 40,907 48,340 31,916 33,765 31,484 30,773 26,951Payroll costs (including N.I. & pension contributions) (note 2) (7,981) (13,813) (15,211) (14,384) (16,535) (18,844) (24,536) (16,615) (16,445) (16,275) (16,105) (14,175)Non Pay spend (including capital)(9,743) (9,393) (8,758) (15,639) (12,486) (7,674) (19,509) (9,557) (13,821) (12,067) (13,248) (19,096)Non trading cash movements2010/2011 Cashflow ForecastAnalysis of actual/forecast cashflow as at 31 August 201010,444 12,044 11,660 9,055 6,278 14,389 4,295 5,744 3,499 3,142 1,420Loan drawdowns from DH 5,000Loan principal & interest repayments to DH(2,190) (2,157)PDC DividendsCapital receipts (land sale proceeds)(2,462) (2,605)6,050Actual/forecast closing cash balance 10,444 12,044 11,660 9,055 6,278 9,737 4,295 5,744 3,499 3,142 1,420Note:1. Both pay and non pay costs appear to rise substantially in October as it is anticipated that the Trust will be billed by Bucks PCT for April to July CHB payrolls and payments to suppliers. This is offset by anticipatedincome (in September & October) from Bucks PCT relating to CHB. From August onwards, the Trust is paying out cash direct for CHB payrolls and payments to suppliers funded by a monthly service level agreementwith Bucks PCT.2. Non-pay spend fluctuates month on month due to the fact that BACs payments are made on the same day each week and July, October, December and March have 5 BACs payments rather than 4.3. The drop in cash during October is due to the fact that the 5 week month includes 5 BACs runs at £1.6m and two payments to the Stoke PFI provider of £1.6m. This results in an additional £3.2m outflow in October.4. The graph below is based on the most likely cashflow forecast scenario.5. The 'Best Case, Most Likely, Worst Case' scenario will be included within the month 6 Board Report.(6,320)(32)Cashflow forecast as at 31 August 2010Original budgeted cash balance (excludes CHB)14,000Actual/ forecast cash balance12,00010,000£'0008,0006,000`4,0002,000Note 4-Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Note:The forecast cash balance is well in excess of the budget due to the fact that the budget anticipated the trust making a loss in the last financial year and did not take into account late invoices to, and payments from, thePCT.

AGENDA ITEM 18BOARD MEETING 28 SEPTEMBER 2010Trust Performance and Quality reportAugust 2010The Trust Board’s performance report covers the following sections:1. Care Quality Commission indicators for 2010/112. Clinical quality indicators covering Outcomes, CQUIN, Advancing Quality andCare.3. Efficiencies, Activity levels, Workforce and Health and Safety KPIs4. Community Health covering national indicators for 2010/11 and Quality &Safety.Some of the indicators included within this report are new for this financial year andwhile every effort has been made to measure all indicators, monitoring and recordingprocesses are now being developed for a number of the new indicators. Thoseindicators where it is currently not possible to measure have been marked with an *.Points to note• No of specialties under the 18 week target for admitted patients: 1specialty – The one specialty breaching 18 weeks is T&O but a plan toachieve this by December is on target.• 62 day referral to treatment from Consultant upgrade: 71.4% YTD – Smallnumbers of patients are counted towards this indicator giving a large swing inpercentages. April reported 0.5 patients with no breaches, June reported 1patient who breached and August reported 2 patients with no breaches.• 62 days urgent referral to treatment of all cancers: 82.9% YTD – Reasonsfor patients breaching in August were: patient choice (6), tertiary breach (1),thinking time (2), complex cases (3) and not originally thought to be cancer(1).• Pressure Sores (Grade 4 hospital acquired): 5 YTD – The Trust is over itstrajectory for acute pressure ulcers in quarter 2.• Headcount, WTE actuals: The rise in WTEs in July was due to the move ofcommunity staff to ESR.Page 1

Care Quality Commission Indicators 2010/112010/11 National Priority IndicatorsRAG Actual Proxy YTD ActualStatus Target TargetApr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Access to genito-urinary medicine clinics apt offered within 48 hrs G >=98% 99.95% 100.0% 100.0% 100.0% 100.0% 99.8%Data quality on ethnic group - % FCEs with ethnic coding G >=85% 87.2% 87.5% 87.2% 86.8% 86.4% 87.5%Patients receiving primary PCI within 150 mins of calling for help G 75.0% 82% 100% 75% 100% 67% N/ADelayed transfers of care to reduce to a minimal level G 3.5% 2.97% 4.20% 3.46% 2.60% 1.79% 2.47%Maintain 4-hour maximum wait in A&E G 98.0% 98.4% 98.6% 98.6% 98.1% 98.5% 97.96%Waiting time for rapid access chest pain clinic within 2 weeks G >98% 99.4% 99.0% 100.0% 100.0% 100.0% 98.0%Cancelled operations: % of elective patients cancelled on the day of surgery G

Clinical IndicatorsClinical Quality - CQUINRAGStatusVenous Thromboembolism (VTE) mandatory July onwards 90% 30% 35.1% * * 30.0% 35.1% TBCPressure Sores (Grade 4 hospital acquired) A =85% 74% 86% 94% 84%EnvironmentSingle sex breaches reported (events) 214 24 43 45 59 43Single sex breaches reported (patients affected) 1009 115 177 207 290 220* Recording being established

Efficiencies, Activity & Other MeasuresClinical EfficiencyTheatresRAGStatusActualTargetProxyTargetYTD ActualApr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Theatre Utilisation (against planned schedule) A 85.0% 80.0% 78.7% 79.4% 79.8% 80.5% 81.6%Theatre Utilisation (including late starts) A 90.0% 87.5% 85.6% 86.4% 87.2% 88.8% 89.6%Day of Surgery Admission Rate G 95.0% 98.6% 98.5% 98.2% 98.7% 99.0% 98.7%Daycase RatesTrust Daycase Rate A 85.0% 83.5% 84.7% 83.6% 82.6% 83.5% 82.9%Trust Daycase Rate for the HCC Basket of 25 Procedures A 90.0% 86.7% 87.8% 86.8% 87.2% 88.6% 81.9%Length of StayLOS - Non elective General Medicine - Stoke A 5.4 8.1 5.6 6.0 5.9 6.0LOS - Non elective General Medicine - Wycombe A 5.4 6.3 6.2 5.5 5.5 7.8Long LOS patients (> 14 days, month end snapshot, target - 5% reduction of 09/10 avg) A 159 151 177 165 182 201OutpatientsDNAsA

Community Health2010/11 National Priority Indicators% Patients seen within 18 weeks (admitted & non admitted pathways)RAG StatusActual TargetProxyTargetYTD ActualApr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11DOH Shadow Reporting for 2010/11 - Dietetics A 95% 75% 68% 43% 98% 88%DOH Shadow Reporting for 2010/11- OT Paeds R 95% 28% 21% 21% 20% 21%DOH Shadow Reporting for 2010/11 - Podiatry A 95% 82% 86% 88% 91% 90%DOH Shadow Reporting for 2010/11 - Physiotherapy - Paediatrics On trajectory 95% 100% 91% 87% 93% 91%DOH Shadow Reporting for 2010/11 - Physiotherapy - Adults A 95% 75% 78% 74% 93% 89%DOH Shadow Reporting for 2010/11 - SALT - Paediatrics A 95% 31% 47% 48% 45% 47%DOH Shadow Reporting for 2010/11 comm paeds G 95% 28% 21% 69% 67% 98%Children, Young People and Womens' ServicesYear 8 % who have completed immunisation for human papilloma virus 3rd uptake A90%(year end)63% 61.0% 63.0%Diptheria, Tetanus & Polio booster by 5th birthdayOn trajectory95%(year end)93.00% 93% 93% 93.0% 93.0% 92.5%Infants breastfed at 6-8 weeksOn trajectory68.7%(year end)57.0% 57.0% 57.0% 56.0% 58.0%Newborn bloodspot screening - untested babies identified by 17 days of age On trajectory 100.0% 93% 100.0% 84.0% 84.0% 84.0%% children (NCMP) measured - reception A 90.0% 93% 87.0% 87.0% 87.0% 93.1%% children (NCMP) measured - year 6 G 80% 90% 90.0% 90.0% 90.0% 90.3%Chlamydia screening - 15-24yrs TBC TBC 64.0% 63.0% 88.0% 51.0%Other National PrioritiesSmoking cessation - 4 week quitters TBC 72.0% 61.0% 74.0% 92.0%MRSA bacteraemis G 0 0 0 0 0 0C-diff acquisition G 5 3 0 2 1 0 0Grade 4 pressure ulcers (patients in contact with community services) A Min 15 3 3 0 6 3Delayed transfers of care (total beddays) TBC 315 265 188 269 284Single sex breaches reported (events) G min 0 0 0 0 0Single sex breaches reported (patients affected) G min 0 0 0 0 0Clinical Quality & SafetyRAG Status Actual Target Proxy YTD ActualTargetApr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Outpatient DNA rates G

Activity & Income - MonthlyElective Non Elective A&E4500ActivityActualPlan3500ActivityActual Plan Activity10000ActualPlan40003300900031008000Activity3500Activity2900Activity700060003000270050002500Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth2500Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth4000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonthApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual 3478 3486 3870 3764 3470 Actual 3287 3198 3239 3240 3192 Actual 9044 9397 9118 9382 8355Plan 3485 3312 3835 3835 3660 3835 3660 3835 3660 3486 3486 4009 Plan 3252 3364 3242 3344 3344 3217 3320 3193 3286 3244 2894 3231 Plan 7651 7848.42 7518.3 7683.04 7583.95 7143.78 7076.89 6813.04 6526.05 5864.57 4880.3 5534SpecialtyPlan Actual VarianceSpecialtyPlan Actual VarianceClinical Haematology 1199 1465 266 General Medicine 4512 4680 168Oral Surgey 276 480 204 Urology 236 279 43Gynaecology 1253 1120 -133 Plastic Surgery 907 744 -163General Surgery 1486 1340 -146 General Surgery 1675 1510 -165£5,000IncomeActual (£k)Plan£7,000IncomeActual (£k)Plan£1,000IncomeActual (£k)Plan£4,500£6,500£800Income (£k)£4,000Income (£k)£6,000Income (£k)£600£400£3,500£5,500£200£3,000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth£5,000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth£0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarQuarterApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual (£k) 3,912 4,175 4,681 4,613 4,206 Actual (£k) 6,166 5,883 6,293 6,106 6,132 Actual (£k) 925 956 933 957 850Plan (£k) 4,197 3,987 4,617 4,617 4,407 4,617 4,407 4,617 4,407 4,197 4,197 4,827 Plan (£k) 6,129 6,332 6,101 6,292 6,292 6,051 6,244 6,004 6,177 6,093 5,431 6,066 Plan (£k) 831 853 817 834 823 775 767 739 706 633 525 596SpecialtyUrologyClinical HaematologyGynaecologyObstetricsPlan Actual Variance SpecialtyPlan Actual Variance1,752,344 1,934,389182,045General Medicine10,175,00110,664,476489,475616,971788,756171,785Obstetrics6,224,3186,394,392170,0741,580,6481,452,523-128,125 General Surgery3,344,8283,026,470-318,358261,117 70,325-190,792 Cardiology1,460,3911,111,288-349,103

Activity & Income - MonthlyNew Outpatients Follow Up Outpatients Referrals13500ActivityActualPlan25000ActivityActual Plan GP Referrals - Activity10,0002010/112009/1013000240009,000Activity12500120001150011000Activity230002200021000Referrals8,0007,00010500200006,00010000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth19000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth5,000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonthApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual 11484 11873 13009 12832 11710 Actual 23552 22491 24219 24237 22505 2010/11 6672 6714 7566 7375 6690Plan 11004.5 10454.8 12111.1 12114.8 11561.5 12111.1 11561.5 12111.1 11561.5 11008.2 10997 12668 Plan 20920.3 19871 23019 23019 21970 23019 21970 23019 21970 20920 20920 24068 2009/10 7834 7580 8652 8456 7105 7256 7026 6502 5684 5719 6784 7787Specialty PlanActualVarianceSpecialty PlanActualVarianceSpecialtyGeriatric Medicine 458 1002 544 Obstetrics 13168 15605 2437 OphthalmologyAudiological Medicine 2850 3318 468 Geriatric Medicine 1533 2954 1421 GynaecologyDermatology 3896 3432 -464 General Surgery 5231 4668 -563 Pain ManagementGynaecology 3626 3137 -489 General Medicine 1525 288 -1237 Clinical Haematology2010/112009/103,8255,2262,4743,540454 387412343Variance-1,401-1,0666769£3,000IncomeActual (£k)Plan£3,000IncomeActual (£k)Plan2500Other Referrals - Activity2010/112009/10£2,500£2,5002000Income (£k)£2,000£1,500£1,000Income (£k)£2,000£1,500£1,000Referrals15001000£500£500500£0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth£0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonth0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarMonthApr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual (£k) 2,111 2,164 2,389 2,352 2,134 Actual (£k) 2,162 2,088 2,257 2,253 2,104 2010/11 1,714 1,599 1,769 1,872 1,667Plan (£k) 2,008 1,909 2,206 2,207 2,108 2,206 2,108 2,206 2,108 2,008 2,006 2,306 Plan (£k) 1,942 1,845 2,137 2,137 2,040 2,137 2,040 2,137 2,040 1,942 1,942 2,234 2009/10 1,668 1,809 2,074 1,973 1,864 1,986 1,998 1,780 1,672 1,706 1,569 1,768Specialty PlanActualVarianceSpecialty PlanActualVarianceSpecialtyGeriatric Medicine 134,099293,483159,384Geriatric Medicine 214,521411,827197,306Plastic SurgeryCardiology 763,098837,33974,241Obstetrics 977,9581,158,897180,939General SurgeryDermatology 540,957503,577-37,380General Surgery 567,798506,639-61,159Respiratory MedicineGynaecology 569,518502,988-66,530General Medicine 181,20034,221-146,979 Clinical Haematology2010/112009/10Variance689 895-206310 509-199186 11571304 193 111

Demand ManagementBuckinghamshire PCT ActivityGP ReferralsActual Target Median UL LLNumber of GP referrals received1900170015001300110090070050005/04/200926/04/200917/05/200907/06/200928/06/200919/07/200909/08/200930/08/200920/09/200911/10/200901/11/200922/11/200913/12/200903/01/201024/01/201014/02/201007/03/201028/03/201018/04/201009/05/2010Week ending30/05/201020/06/201011/07/201001/08/201022/08/201012/09/2010Non Elective Admissions (SLA Activity)Actual Target Median UL LL850800Number of Non Elective Admissions75070065060055050045005/04/200926/04/200917/05/200907/06/200928/06/200919/07/200909/08/200930/08/200920/09/200911/10/200901/11/200922/11/200913/12/200903/01/201024/01/201014/02/201007/03/201028/03/201018/04/201009/05/201030/05/201020/06/201011/07/201001/08/201022/08/201012/09/2010Week endingElective AdmissionsActual Target Median UL LL1300Number of Elective Admissions110090070050030005/04/200926/04/200917/05/200907/06/200928/06/200919/07/200909/08/200930/08/200920/09/200911/10/200901/11/200922/11/200913/12/200903/01/201024/01/201014/02/201007/03/201028/03/201018/04/201009/05/201030/05/201020/06/201011/07/201001/08/201022/08/201012/09/2010Week endingTrust ActivityA&E AttendancesActual Target Median UL LL2400Number of A&E Attendances22002000180016001400120005/04/200926/04/200917/05/200907/06/200928/06/200919/07/200909/08/200930/08/200920/09/200911/10/200901/11/200922/11/200913/12/200903/01/201024/01/201014/02/201007/03/201028/03/201018/04/201009/05/201030/05/201020/06/201011/07/201001/08/201022/08/201012/09/2010Week ending

CQUIN TargetsVenous Thromboembolism (VTE)Pressure Ulcers(Grade 4 hospital acquired)Enhanced Recovery Hips(discharge within 4 days)Stop before the op(Smoking cessation offered to elective & antenatal patients)100%VTEActualTrajectory12Pressure UlcersActualTrajectory100%Enhanced Recovery HipsActualTrajectory200Smoking CessationActualTrajectory% achieved80%60%40%20%No. of ulcers108642% achieved80%60%40%20%number achieved150100500%Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0%Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0Qtr 1 Qtr 2 Qtr 3 Qtr 4QuarterQtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4Actual 30% 35% Actual (cum) 1 5 Actual 36% 45% ActualTrajectory 10% 30% 55% 90% Trajectory 2 4 7 10 Trajectory Establishing baseline50% Trajectory Est baseline 98 195 To be reviewed50.00% 98 195TB to Babies(High risk babies given BCG within 1 month)TIA(High risk seen within 24 hours)TIA(Low risk seen within 7 days)TIA(Percentage treated as outpatients)100%TB to BabiesActualTrajectory100%High Risk TIAActualTrajectory100%Low Risk TIAActualTrajectory100%% Treated as OutpatientsActual80%80%80%80%% achieved60%40%% achieved60%40%% achieved60%40%% achieved60%40%20%20%20%20%0%Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0%Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0%Qtr 1 Qtr 2 Qtr 3 Qtr 4Quarter0%Qtr 1 Qtr 2 Qtr 3 Qtr 4QuarterQtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4Actual 96% Actual 61% 67% Actual 70% 71% Actual 79% 68%Trajectory 50% 70% 80% 90% Trajectory 45% 57% 63% 63% Trajectory 50% 55% 60% 65% Trajectory No trajectory

AGENDA ITEM 19TRUST BOARD 28 SEPTEMBER 2010Title: Workforce Performance Report.To be presented by: Sandra Hatton, Directorof Human Resources & OrganisationDevelopmentContact Details: Trust Headquarters,Amersham Ext 4674Executive summary and key issues for the Board:This report updates the Board on progress against key Workforce KPIs as well as developments in respectof Health and Well being. Also, the report brings to the Board’s attention the launch of next national NHSStaff Survey which is being conducted in autumn 2010.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives?This paper updates the Board with an update on the total workforce and costs of temporarystaffing and identifies variance from plan.Does this paper provide assurance on the control of an identified risk? If so provide here thedegree of assurance given and reference the risk on the BAF or CRR that it controls.This paper provides assurance that workforce controls and monitoring are in place to mitigate riskarising from deviation from plan.Committee review and approval:Has the paper been reviewed and/or approved at a Board or executive committee?NoLegal Issues:Does the paper contain a legal issue or evidence compliance with legislation? NoAction required by the Board:This should clearly describe why this paper has come to the Board and what the Board is beingasked to do; this will appear against the item on the agenda. Please indicate the time youconsider is needed for discussion - taking the paper as read.The Board is asked to note this report as it provides an update on our Workforce Plans andhighlights the progress to be made to year-end to support the Organisation Transformation &Turnaround Programme

WORKFORCE MONTHLY REPORT – AUGUST 2010Introduction and Trust OverviewThis report provides an update on key workforce KPIs, key risks to the delivery of the Trust’s objectives and an update on workforce and organisation changeprogrammes as at 31 August unless indicated otherwise.AreaMarch 2010 OutturnAugustActualMarch 2011Plan4783.6YTD RatingStaff in Post (exc. Temp4973.2Staff)4890.7 FTEAmberStaff in Post (inc. Temp5333.24918.05185.3 FTEStaff)AmberTurnover 13.82 13.22% GreenSickness Absence 4.56% 3.69% 3% Amber• The workforce plan has been re-set to align with the organisation transformation and turnaround updated plans.Key Workforce Performance Indicators – Paybill spend in Month 5August 2010 July 2010Paybill (Substantive Staff)£16,390,710 £16,204,547Bank Spend £504,911 £550,273Agency Spend (inc. MedStaff)£596,641 (3.36% of the paybill) £731,317 (4.14% of the paybill)Locum£238,199 £156,773Total£17,730,461£17,642,911

Trust-wide Organisation & Financial Turnaround – Workforce Change ProgrammesThe progress with the key corporate workforce change programmes is outlined below.Sickness Absence Management- over 100 staff attended briefings- sessions for HR & Workplace Health teams held- Bradford Score – plans in place for all with score > 1000, plans being worked up for all with a score > 300- Training (½ day) for managers set up for September 2010- Communication to Leadership & Management Community (circa 300) on Boorman and Health and Wellbeing, sickness absence- Communications to staff through Newsletter and Team BriefingPlanned RetirementsFollowing discussion with our staff side, we have reviewed our planned retirement process and to date have issued 55 notices to staff in accordance with theextant age discrimination legislation.Annual Leave ManagementThe consultation with our Staff Sides is complete and the annual leave policy changes now agreed.Mutually Agreed Resignation (MAR) SchemeThe Department of Health has issued guidance to all NHS Employers on this new initiative. Our own final draft Scheme which has been the subject ofconsultation with our local staff sides is now submitted to the SHA for approval of the Scheme and its contents.Workforce Redesign and RestructuringThis programme of change continues as part of the Organisation Transformation & Financial Turnaround Programme. This has led to a number ofredundancies mainly in the corporate service areas.Other Key Workforce DevelopmentsHealthcare 100 Survey resultsFor the first time the Trust participated in the Healthcare 100 survey. The survey was conducted by Ipsos Mori, and was sponsored by DOH, NHS Employers,HSJ and the Nursing Times. The survey was sent to 1040 randomly selected staff and took place in January / February 2010 with the results published in July2010. Our response rate was 32% with 329 questionnaires returned.The results provide us with information on the overall level of employee engagement, as well as highlighting where there is scope for improvement. The resultscombined with those of the staff survey indicate the key areas on which we need to focus our efforts are on management and leadership, Promoting Diversityand Communication.

Health & Wellbeing (Boorman Recommendations)Employee health and wellbeing has been raised in profile following the recent Boorman recommendations as well as in the NHS constitution requiring the NHSto ‘provide support and opportunities for staff to maintain their health, wellbeing and safety. In 2010/11 the Health and wellbeing of our staff is incorporated intoour Trust objectives.As part of our action plan a dedicated Project Implementation Group has been established with representation from across all areas of the organisation. ThisGroup has looked into the health and wellbeing needs of staff by undertaking a survey. The results are now being compiled into an overarching report. Thework on health and wellbeing is completed by the implementation of a new Sickness Absence Policy, which incorporates the Bradford score. Open sessionbriefings have been held with manager training sessions taking place during September and onwards.Mandatory TrainingThe Associate Director of Human Resources leading on Learning and Development presented the revised mandatory training framework and methods ofdelivery to the September 2010 meeting of the Healthcare Governance Committee. Significant improvements have been made, including the online e-learningmodules which can be accessed on desktops.2010 National Staff SurveyThis is being launched in October. Work continues on our current plans.2010 Staff AwardsStaff Award nominations are now underway, and it has been covered in the local press to encourage patients to take part. The nominations close on 8 th Octoberand the ceremony is booked for November.Recruitment & Retention HotspotsHotspot pressures continue in Women & Children’s, theatres, critical care and anaesthetics. Recruitment activity is ongoing, with new starters in these areasjoining in September / October.

DIVISIONAL BREAKDOWN – AUGUST 2010MEDICAL LOCUM BREAKDOWNAgency Cost by ReasonAgency Spend by Month140,000120,000120,000100,000100,00080,00080,000Cost £60,00060,00040,00040,00020,00020,0000April May June July August0April May June July AugustA greed Trust-Funded V Extra Cov er acancy SicknessChange Over/Induction Week Study Leave MaternityDeanery-Funded Vacancy Compassionate/Carers Leave PaternityA&EAnaestheticsE.N.T. Ophthalmology Oral Surgery & OrthodonticsGeneral Surgery Trauma & Orthopaedics Plastic surgery & BurnsMedicineObs & GynaeSpinal InjuriesMedical Locum/Agency- Clinician input to monitoring locum use being implemented at SDU level (SDU director sign-off)- All locum requests are monitored and fed back to Divisions/SDUs weekly- Internal locum use reported back to SDUs/COO to encourage switch from external locum- Foundation Year 1 doctor no locums as are in essence supernumerary- Internal bank being “cleansed” and induction programmes encourage new doctors to join bank

DIVISIONAL BREAKDOWNDivisionStaff inPostSicknessAbsenceTurnover Bank Expenditure Agency Expenditure Locum Expenditure OvertimeActualfigure (Jul2010)AnnualActualfigureVariancefrom Trustbenchmark(15%)Actual figurein £s (Aug2010)Variance from SHAbenchmark(3% of FTE)Expenditure insame month lastF/Y (2009/2010)Actualfigure in £s(Aug 2010)As apercentage ofdivisionalpaybill(SHAbenchmark is1% of paybillcosts)Expenditure insamemonth lastF/Y(2009/2010)Actualfigure in £s(Aug 2010)Expenditurein samemonth lastF/Y(2009/2010)Actualfigure in£s (Aug2010)Expenditure insamemonthlast F/Y(2009/2010)ClinicalSupportServices721.09 2.31% 11.88% -3.12% £32,527 1.35% £88,177 £11,722 0.46% £39,979 £7,653 £11,247 £5,187 £4,265Corporate 623.65 3.72% 14.10% -0.90% £9,011 0.43% £8,590 £101,215 4.58% £94,402 £0 £0 £10,000 £4,480MedicineDivision860.59 4.17% 12.36% -2.64% £172,638 6.02% £188,268 £104,141 3.00% £78,134 £52,305 £78,134 £1,698 £2,027SpinalInjuries246.62 3.35% 7.62% -7.38% £53,167 6.47% £59,948 £1,311 0.16% -£198 £11,530 £6,113 £478 -£294SurgeryDivisionWomen &Children964.44 3.85% 8.98% -6.02% £126,481 3.93% £155,384 £326,987 7.60% £341,793 £162,484 £47,152 £14,597 £14,846493.95 5.06% 13.93% -1.07% £49,853 3.03% £42,635 £57,312 2.03% £121,745 £4,227 £20,357 £4,111 £16,061Community&Integrated980.31 3.52% 19.81% 4.81% £61,234 1.87% N/A -£6,047 -0.40% N/A £0 £0 £4,904 N/AServicesTOTAL 4890.65 £504,911 £596,641 £238,199 £40,975

WORKFORCE DATA – AUGUST 2010Staff in Post (FTE)6000500040003000200010000Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarSiP ActualSiP Plan12010080Starters & Leavers (Headcount)302520Qualified Nurses - Starters & Leavers (Headcount)6040200Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar151050Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarStartersLeaversStartersLeaversSickness Absence Rate %Trust Annual Rolling Turnover5%16%4%3%12%2%8%1%0%Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarAcutal SHA Benchmark4%0%Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

AGENDA ITEM NO 20TRUST BOARD 28 SEPTEMBER 2010Title:Patient ExperienceTo be presented by:Celina EvesDeputy Director of Nursing (Interim)Contact details:(110) 6141Executive summary and key issues for the Board:This paper outlines a new strategy for collecting data and actual patient experience within the Trust. It willallow Board members to monitor patient experience on a quarterly basis through the Patient Journey Matrixand actively listen to the real experiences of patients and relatives. This will also allow the learning aroundcare provision and how it affects and impacts on patients and their families and allow us to maintain a focuson continually improving patient safety and experience.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives?NoDoes this paper provide assurance on the control of an identified risk?NoCommittee review and approval:Has the paper been reviewed and/or approved at a Board or executive committee?NoLegal Issues:Does the paper contain a legal issue or evidence compliance with legislation?NoneAction required by the Board:The Board is asked to note this paper.

Patient ExperienceCurrently we monitor patient experience throughout the Trust using many varied and differentmethods. Our National Patient Survey gave us some cause for concern whilst 70% of our patientssurveyed rated our services as ‘very good’ or ‘good’, it is an unknown quantity as to what the other30% are experiencing.• We have 10 patient PET trackers within the system. There have been problems gettingthese established in some areas, ensuring that the questions are the right ones and alsomaking sure that there are staff available to ensure that the questionnaire is completed.• The Productive Ward undertakes quarterly patient satisfaction surveys in those areaswhere Productive Ward has been established. They currently have the same questions asthe PET tracker.• The patient responder score is currently being piloted on Ward 6.• Discharge questionnaires go out to patients within the Spinal Unit and to every mother whogives birth within our Maternity Service.• Our Head of Membership and Engagement within the Trust has commenced a number ofactivities which involve patients seeking their views and experiences.• Services within the Trust have engaged with the Clinical Audit Department to monitor andevaluate their services and undertake Patient Satisfaction Surveys.• National surveys have been undertaken on an annual basis, ie: the National Patient Surveyand most recently the Maternity Services.• Complaints and trends are monitored Trust wide and within Divisions.It is evident that we are collecting vast amounts of data around our patient experience, however,this needs to be more systematic with a view to gaining more frequent, consistent and usefulinformation. The proposal would be:• PET TrackersOur Complaints Manager is now in discussions with Dr Foster to increase the PET trackerswithin the Trust to 30. These would be PET Tracker Plus and would be a much moreflexible reporting tool where we would be able to gear the questions to the area. This hasbeen enabled by a successful bid to Charitable Funds and we hope to have this in by theend of this year.• Voluntary InvolvementNegotiations with our Voluntary Services Manager have taken place and we would hopethat Voluntary Services would assist with the PET Trackers in areas to ensure thatconsistent reporting is undertaken throughout the Trust. This would be supported by anadministration post to support the PET Tracker Plus scheme. This post is currently beingrecruited to.• Productive Ward Patient SurveyProductive Ward is on the fourth wave to ensure that all areas throughout the Trust wouldnow have productive work ongoing. This includes theatres and commencement within thecommunity hospitals and teams. Part of the Productive series is a quarterly survey ofpatients. The results of these surveys will be available to the Chief Nurse, Divisional LeadNurses and Matrons and would be given to all suitable patients on the ward to increase thesample size, rather than 10 patients which had previously been undertaken.• Patient Responder ScoreAfter a successful pilot on Ward 6, this would be used in areas identified where patientsatisfaction was causing concern. This would take the form of a card with 5 questions on fora quick response so that the Matron could get to the root of the problem very quickly andaddress issues on the Ward.

• Spinal Discharge and Reflections of Childbirth questionnairesSpinal Discharge Questionnaire and “Reflections of Childbirth” questionnaire wouldcontinued to be given to spinal and maternity patients on discharge and results collated fortheir Governance meetings.• Matrons RoundsNew template has been designed and discussion with the Matrons that they would alsocomplete a Matron’s round in each others area for a fresh eyes approach. It is felt that theresults of these, plus the work ongoing on the High Impact Actions and the Essence of Careaudits being undertaken on the Wards would feed into a Patient Journey Matrix which theChief Nurse will be able to report quarterly to the Board. Work is on going to have thisavailable by the end of the year.• Member and Involvement EventsThroughout the summer we have held a Member and Involvement Event each month.ooApril – Are we delivering our patient promises?.May – Service Standards – Our service, your care, your views matter.o June – An online service poll of 500 members and also the new complaints processhelped shape the development of our policies.oooJuly – Young at Heart open to the public. Patient feedback - how we might improvethe discharge process.August – Carer’s voice, open to the public.We have planned for November the Patient safety event.The Head of Membership and Engagement will continue a full programme of engagement,member and involvement events for the remainder of the year and into 2011. Patientexperience is fed back to all areas following these events.• Patient StoriesEveryone has experienced the power of narrative and story telling at some time or anotherin their professional or personal lives. True stories engage the listener in a way thathypothetical scenarios cannot and at times trigger significant emotional responses.Patient stories can help forge and maintain a connection between an organisation’s leadersand their primary purpose; providing high quality safe care.Our executive walkarounds which are well established, do bring contact with patients andtheir stories and experiences but in these situations the function of the walkaround is widerand time limited. Using a patient story with a Board is more focused on one event orepisode and really understanding what happened and taking forward the lessons learned.There are a number of ways of collecting and presenting stories but choosing and takingpatient stories will be an executive led process. Where the stories are collected frompatients or relatives this will be led by the Chief Nurse and all stories will be fullyanonymised.The methods of taking and sharing the stories can be in the form of written notes, audiorecording, presenting in person. It is hoped that we would be able to have twice a year apatient or relative come to Board and tell their story in person with the Matron from thatarea.Other Trusts around the country have seen great impact from using stories at Board and itallows more detailed discussion around safety and related mortality measures.The Chief Nurse will commence this process at the next Board Seminar.

By putting this new strategy together it is hoped that we will be able to maintain a focus oncontinually improving patient safety and experience and this will allow us to create a moresystematic approach to collecting the data and actual patient experience.Celina EvesDeputy Director of Nursing (Interim)Useful Links1000 Lives CampaignSee the document Wales produced on using patient storieshttp://www.wales.nhs.uk/sites3/page.cfm?orgid=781&pid=41303Institute for Healthcare ImprovementCopy of the notes produced by Delnor-Community Hospital, Geneva, Illinois, USA on usingpatient stories with Boards.http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/Tools/GuidelinesforUsingPatientStorieswithBoardsofDirectors.htmPatient Safety FirstInformation regarding the Leadership for safety intervention and a copy of its related How toGuide.http://patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Leadership/walkrounds/Patient Safety FirstShort films on safety walkarounds and a copy of the related How to Guide supplement.http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Leadership/walkrounds/Patient Safety FirstDownload a copy of the How to Guide on Human Factors in Healthcare.http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Interventionsupport/Human%20Factors%20How-to%20v1.2.pdf

AGENDA ITEM 21PUBLIC BOARD MEETING 28 SEPTEMBER 2010TRUST BOARD MEETING 28 SEPTEMBER 2010USE OF TRUST SEALThe Board is asked to note the use of the Trust seal on the following documents underdelegated powers in accordance with Standing Orders (Sealing of Documentsparagraph 8.2).No 57Sealing of a Unilateral Undertaking between Buckinghamshire Hospitals NHSTrust and Morbaine Limited relating to the disposal of retail site land at StokeMandeville Hospital.The documents were signed by the Chief Operating Officer and Director of Strategy &System Reform on 14 September 2010.Anne EdenChief Executive

AGENDA ITEM 22.1TRUST BOARD 28 SEPTEMBER 2010Title: Healthcare Governance Committee Minutes Summary covering 7 th September 2010.To be presented by: Keith Gilchrist, Non-Executive DirectorExecutive summary:Areas covered by Healthcare Governance Committee:Risk registers – Review of corporate risks rated at 12 and above at each meeting. Monitoring of infectioncontrol performance through the infection control report.Received the following reports and minutes –• Risk Register for the Division of Women and Children• Control of Infection: July 2010 report and discussion re August HW Ward 6B• Clinical Outcomes August 2010 report• Medical Readmissions Audit• Patient Discharge audit• Clinical Coding briefing• Stroke Services Peer Review Visit• Healthcare Governance Report 2010/11 Q1• Progress with implementing the new mandatory training framework and new style corporateinduction• Audit of Pharmacy Aseptic unit at Wycombe Hospital• Healthcare Governance Annual Report 2009/10• Drug and Therapeutics Committee 12 th May 2010• Risk Monitoring Group 24 th June, 13 th July and 18 th August 2010The following policies were ratified:Point of Care Testing PolicyRisk and Assurance:This paper provides assurance that the Board sub-committee for Healthcare Governance is reviewing a widerange of risk and assurance related information.Committee review and approval:Healthcare Governance CommitteeLegal Issues: N/AAction required by the Board:The Board is asked to note.

AGENDA ITEM 22.2TRUST BOARD 28 SEPTEMBER 2010Title:Audit Committee Summary Report for 16 th September 2010To be presented by:Les Broude, Chair of Audit CommitteeExecutive summary:The Annual Report of the Audit Committee is attached. This was discussed and agreed at the AuditCommittee of 15 th July.The Committee considered Progress reports from the Local Counter Fraud Service and from Internal Audit.The revised Information Governance Toolkit Audit required by the Department of Health, was discussed andadditional Internal Audit time will be allocated to this work.The Committee considered the final Opinion Audit Memorandum from external audit. External Auditconfirmed that responses to recommendations raised in that document satisfied their requirements andwould be followed up as appropriate. It also considered the Annual Audit Letter from external audit and theCommittee recommends it to the Board for approval. It received an update from the Audit Commission onthe recent announcements concerning the Audit Commission’s future.The Committee considered the Board Assurance Framework and the Corporate Risk Register. The differentscores for two apparently connected risks were discussed and the Committee were satisfied with theresponse concerning mitigating actions.A potential internal audit of the clinical audit process was discussed. It was agreed that the scope of thisaudit would be discussed outside Committee and once agreed would be carried out at the optimal timeduring the current financial year.Key issues for discussion:Consideration of the Annual Report of the Audit Committee and the Annual Audit Letter. Consideration ofincreased high risk items on the BAF and their mitigation. .Risk and Assurance:‣ How does this item link to the Board Assurance Framework and the Trust’s PrincipalObjectives? Audit Committee is the Board committee responsible for monitoring the AssuranceFramework.‣ How does this item either mitigate or provide assurance on the control of any of the risksdetailed within the Board Assurance Framework? The Audit Committee scrutinises assurancescovering a wide range of controls in the assurance framework.Legal Issues:NoneAction required by the Trust Board: For information

Annual Report of the Audit Committee2009/101. Introduction1.1 The purpose of the Audit Committee is to consider the full range of the Trust’sinternal controls mechanisms, as demonstrated through a range of assurances andto in turn provide assurance to the Trust Board that effective internal controlarrangements are in place.1.2 This report outlines how the Committee has complied with the duties delegated bythe Trust Board through its terms of reference, and identifies key actions to addressdevelopments in the Committee’s role.2. Constitution2.1 The Board Committee structure has been put in place to ensure an integratedgovernance approach. The Board has delegated scrutiny of assurance processesand information to the both the Audit and the Healthcare Governance Committees.The committees work together to deliver this integrated approach to governance.2.2 The Audit Committee is responsible for reviewing the establishment andmaintenance of an effective system of integrated governance, risk management andinternal control that supports the achievement of the organisation’s objectives. TheCommittee’s work on the system of internal control covers the whole of theorganisation’s activities both clinical and non-clinical. The Audit Committee isresponsible for gathering assurance on internal controls as a whole and seeksassurance on the processes used, including those used by the HealthcareGovernance Committee for gathering assurance regarding clinical matters.2.3 The Audit Committee has a membership of four non-executive directors and ischaired by a non-executive with relevant financial experience. It is required to meetsix times in 2009/10 as required by the Committee’s terms of reference. During2009/10 there were six ordinary meetings, three extraordinary meetings to considerthe Annual Accounts and one workshop which satisfied this requirement.2.4 The Director of Finance and an Assistant Director of Finance is invited to attend andthe Committee may request the attendance of the Chief Executive and any otherexecutive director of the Trust to discuss areas of risk or operation that are theirresponsibility.The Chief Executive may request attendance at any Committee meeting and theCommittee will extend an invitation at least once a year. In addition, the Internal andExternal auditors are invited along with the Local Counter Fraud Specialist. Aschedule of attendance at the meetings is provided in Appendix A whichdemonstrates that each committee was fully quorate and there was regularattendance of members of the Committee. It should also be noted that the Chairmanhas attended a meeting as part of the Trust’s self assessment process ongovernance.Page 1 of 5

2.5 The Committee has an annual work plan with meetings timed to consider and act onspecific issues within that plan. The Committee Chair reports to the Trust Boardfollowing each meeting.3. Meeting the Committee’s Terms of Reference3.1 The terms of reference of the Committee were reviewed and approved at the March2010 meeting. As there were no major changes to the Terms of Reference they werenot resubmitted to the Board for approval, but the Board was advised of their reviewin the Audit Committee Update.3.2 As described in the terms of reference, the Committee is charged with reviewing howthe Trust applies internal controls, financial reporting and risk management principlesacross the full range of its business.Governance, Risk Management and Internal Control3.3 The Audit Committee has reviewed the Assurance Framework in full at least at everyalternate meeting in 2009/10. At the intermediate meetings an update on any majorchanges to the Assurance Framework has been provided. The Committee issatisfied that it covers the full range of risks to achieving the objectives of the Trust.Assurances used to populate the framework have also been reviewed through theattendance of senior managers at Audit Committee and through the Internal Auditwork plan.3.4 Review of the highest risks on the corporate risk register has allowed the Committeeto assured itself the system of risk management is adequately identifying risks andallowing the Board to understand the appropriate management of these risks. TheCommittee has also reviewed the risk register for consistency with risks identified toTrust objectives through the Assurance Framework.3.5 The Audit Committee monitors the work of the Healthcare Governance Committeethrough shared membership and reports from the Chair of the HealthcareGovernance Committee. The Audit Committee concludes overall that there are noareas of significant duplication or omission in the Trust’s governance systems thathave come to its attention and are not adequately resolved.3.6 The Audit Committee has reviewed the draft SIC (2009/10), and the significantissues described within it, and has concluded that it is consistent with the view of theCommittee on the organisation’s system of internal control and accordingly supportsthe Board’s approval of the SIC. The Committee’s view is further supported by theHead of Internal Audit Opinion for 2009/10, received in April 2010 and the ExternalAudit Opinion received on 10 June 2010.3.7 The Committee has also reviewed, through Internal Audit, the process used by theTrust to carry out the self assessment against the Core Healthcare Standards, thisprovides assurance of compliance to the Board prior to the end of year declaration.The Committee is satisfied that the process is robust.3.8 The Committee has reviewed the process of the approval of policies and protocolscovering financial matters to obtain assurance that the process provides for financialcontrols to meet all relevant regulatory, legal and code of conduct requirements.Page 2 of 5

Internal Audit and Counter Fraud3.9 Internal audit and counter fraud services are provided by CEAC, an NHS consortiumof which the Trust is a member.3.10 The internal audit work plan is developed using a risk based approach. CEACreviewed the Assurance Framework and Risk Register and focussed on areas of theTrust’s operations which were either high risk or had not been recently reviewed aspart of the regular audit cycle. Prior to agreeing the plan the Committee reviewed itand contributed to its development.3.11 The Head of Internal Audit Opinion (HIAO) summarises the work undertaken during2009/10 and provides 3 rd party assurance about the effectiveness of the Trust’ssystem of internal control. The HIAO indicated that an Assurance Framework hadbeen operating to meet the requirements of the 2009/10 SIC and provided significantassurance that there was an effective system of internal control to manage theprincipal risks identified by the Trust. The opinion provides a satisfactory level ofassurance for all areas reviewed in 2009/10.3.12 The Committee invites the Counter Fraud Specialist to attend to present reports onprogress with this programme of work and has received the annual report on counterfraud services. The report highlighted work undertaken to embed an anti-fraudculture through deterrence, prevention, detection and counter-fraud management.3.13 During 2009/10 the Committee has put in place meetings between internal audit andthe Committee members, these meetings have taken place three times a year after ameeting of the Audit Committee.External Audit3.14 External audit services in 2009/10 have been provided by the Audit Commission.3.16 The Committee approved the External Audit Plan at the start of the financial year andreceived regular updates on the progress of work. In addition, reports and briefingswere received from the External Auditors.3.17 An Extraordinary meeting of the Audit Committee was held on 1st June to enable theCommittee to consider issues in the 2009/10 accounts raised by the external auditor.3.18 The 2009/10 report to those charged with governance was considered by the AuditCommittee at its meeting on 15 July 2010. The main item of consideration was thematerial error that had been discovered during the audit.3.19 During 2009/10 the Audit Commission have carried out an assessment of the Trustagainst the standards in the Auditors Local Evaluation. This assessment reviewshow the Trust is operating against a number of standards and forms a view inrespect of five distinct areas covering financial reporting, financial management,financial standing, internal control and value for money.3.20 The Trust’s performance against the financial reporting and financial standing areashas been adversely affected by material error made in the 2009/10 Accounts and thedeficit reported by the Trust in 2008/09. The Trust is likely to achieve an overall scoreof 2 (adequate performance). Scores of 3 (good) for financial management, internalcontrol have been indicated in the interim report. The final report will be available inAugust 2010 and will contribute to the Annual Health Check score for Use ofResources.Page 3 of 5

3.21 During 2009/10 the Committee has put in place meetings between external audit andthe Committee members, these meetings have taken place 3 times a year after ameeting of the Audit Committee.Self Review and Development3.22 Committee members have carried out a self-assessment in November 2009 againstthe criteria set out in the NHS Audit Handbook 2005 and have used this to identifyareas where the Committee can be further developedPage 4 of 5

AppendixMeeting Date14 th May20093/8/10 June2009(Extraord)2 nd July200917 th Sept200912 th Nov200910th Dec2009(Workshop)14 th Jan200918 thMarch2010Les Broude (Chair) X X X X X X X XBrenda Kersting X X X X X X X AMalcolm Griffiths X X X X X X X XKeith Gilchrist X X X X X X X XTom Travers X X X X X X A XHead ofX X X X X X X XFinance/Assistant DoFGraham Ellis XAnne Eden XPage 5 of 5

AGENDA ITEM 22.3BOARD MEETING 28 SEPTEMBER 2010Title:Charitable Funds Committee Summary Report for 5 th August 2010To be presented by:Les Broude, Chair of Charitable Funds CommitteeExecutive summary:The Committee considered a large number of bids. The Charity reserved approval on some of these bidsuntil it had received additional information and ensured requests aligned with the Trusts vision and planswhere appropriate.The Committee also considered a bid to provide funding for additional work required to refurbish theLaparoscopic Theatre of £260,000. The Committee agreed to fund half this shortfall as long as the Trustmade up the remainder. This has now been agreed by the Trust.The Committee referred two other bids for approval to the Chief Executive and Director of Finance asapproval was within their delegated limits (both bids have subsequently been approved).The Committee considered the draft Annual Accounts and Annual Report for the Charity for 2009/10. Theseare due to be audited in October, for submission before the end of January 2011.The Committee reviewed the updated Charitable Funds Investment Policy. The format of this had beensignificantly revised in order to clarify roles, responsibilities and other requirements of Trust Policies.However the underlying investment policy has not been changed. The Committee approved this Policy,which is attached for ratification by the Board.The Committee requested that fund holders be reminded of what is and what is not justifiable CharitableFunds Expenditure.Key issues for discussion:Approval of the funding of £130,000 towards the shortfall on the Laparoscopic Theatre Project. Approval ofCharitable Funds Investment Policy.Risk and Assurance:‣ How does this item link to the Board Assurance Framework and the Trust’s PrincipalObjectives? Assists the Trust in Patient and Staff Welfare‣ How does this item either mitigate or provide assurance on the control of any of the risksdetailed within the Board Assurance Framework? None directlyLegal Issues:NoneAction required by the Trust Board: To approve funding of the Laparoscopic Theatre to £130,000 andto ratify the Investment Policy. Otherwise for information

Once printed off this is an uncontrolled document. Please check the intranet forthe most up to date version.July 2010 RevisionCHARITABLE FUNDS INVESTMENT POLICYSummary of Changes:This version has been significantly revised to take into account the Trust’srequirements on the writing of PoliciesVersion: 4Document History V3 November 2008Approved byCharitable Funds CommitteeDate approvedRatified by:Date ratified:Name of originator/authorBoardLead DirectorName of responsiblecommittee/individualDocument Reference Pol 041Date Issued: September 2010Review date: September 2012Target Audience:Equality Impact Assessment:Revision; Nicky McKechnieOriginal Policy: Associate Director ofFinanceTom Travers, Director of Finance & ITCharitable Funds Committee / FinancialAccountantDirectors, Non Executive Directors andFund managersTBC________________________________________________________________Charitable Funds Investment Policy July 2010

CONTENTSSection Title Page1 Introduction 12 References and Definitions 23 Roles and Responsibilities 33.1 The Board 33.2 Charitable Funds Committee 33.3 Investment Manager 33.4 Trust finance staff 34 Consultation and dissemination 35 Monitoring compliance with the Policy 46 Investment Strategy 46.1 Investment Objectives 46.2 Risk Profile and asset allocation 56.3 Ethical considerations 56.4 Investment powers 66.5 Review of Policy 6Annex 1 Currently Approved Asset Allocation 7________________________________________________________________Charitable Funds Investment Policy July 2010

1 IntroductionCharitable Funds Investment Policy DocumentThis policy governs the investment strategy of the Trust’s charitable funds.Under the Trustee Act 2000 it is a legal requirement that, if the investment function isdelegated to an investment manager, the Trustees have a written investment policywhich is kept formally under review.The Health Services Act 1977 gives NHS bodies the authority to hold charitable funds.The Trust’s charitable funds are derived from donations, legacies and investmentreturns. The charity’s objectives are to utilise the charitable funds for the benefit of theNational Health Service for the benefit of Buckinghamshire Hospitals NHS Trust patientsand staff rather than to accumulate funds with which to achieve investment returns.For some time, new gifts of a charitable nature have been encouraged to be made to ageneral fund, which can be used for any general charitable purposes of the Trust.However there are some funds which have specific ‘restricted’ purposes. These generaland restricted funds are held under one ‘umbrella’ charity for Buckinghamshire Hospitals.Although there is a distinction between the funds for administrative purposes, from aninvestment perspective the assets of all underlying funds are pooled and then managedas a single coherent whole.Charitable fund trustees are under a duty to ensure that the funds are appropriatelyutilised and this means that the funds should not remain unused for a long period oftime, particularly when there are no future plans for spending. However, in relation to theTrust’s charitable funds, as with most NHS charitable funds, resources are onlyexpended slowly. After allocating funds that are likely to be required to fund identifiedexpenditure (‘short term monies’) the balance will be invested in an investment portfoliodesigned to be long term in nature (‘long term monies’).________________________________________________________________Charitable Funds Investment Policy July 2010 Page 1 of 9

2.References and DefinitionsThe main Charities Commission website further details on the responsibilities ofCharities and Trustees for investment policies and can be found at www.charitycommission.gov.uk/Charity_requirements_guidance/Charity_governance/Managing_resources. Only elements of the guidance that is relevant to this Charity have beenproduced here.Legal requirements covered within this Policy are outlined in the Charities Act 1993 andthe Trustee Act 2000.Definitions:The Charity: the Buckinghamshire Hospitals Charitable Fund, registered charity number1053113, a separate legal entity from Buckinghamshire Hospitals NHS Trust.Trustee: Charity Trustees are responsible for the general control and management of theadministration of the charity. The Charity has a corporate trustee – the Board ofBuckinghamshire Hospitals NHS TrustInvestment Manager: an individual or corporate body appointed by the Charity’sTrustees to advise and make investment decisions on behalf of the charity.Charitable Funds Committee – a sub-committee of the Board whose responsibility is tooversee the management of Charitable Funds.Common Investment Fund – an arrangement whereby the money invested by a numberof charities is pooled and invested in a range of investments in accordance with thepublished policy of the scheme. The size of each share is determined by the number of‘units’ each contributor owns and investment returns (or losses) are allocated in thesame proportion.‘Umbrella’ Charity – a charity registered under a single name and number under whichseveral funds are held and administered. These funds may have separate purposes andobjectives and the balance will be managed by different fund holders. Income andexpenditure is allocated to these fund balances individually, whereas investment returnswill be allocated in proportion to the fund balances held.Volatility of returns – there is a link between the rate of return that can be expected onan investment and the risk inherent in that type of investment. This is separate from thesystematic or market rate of return, where a whole class of investments will be affectedby an upturn or downturn in the market caused by macro-economic trends. The morerisky an investment is seen to be the higher the return that would be expected to beachieved. However there is also a potential for large losses on this type of investment,where safer investments would have much lower rates of returns. This link betweenlevels of risk and the rate of returns is known as the volatility of returns.________________________________________________________________Charitable Funds Investment Policy July 2010 Page 2 of 9

3. Roles and Responsibilities3.1 The BoardThe Board as corporate Trustee of the Charity has the overall responsibility for settingthe investment policy for the Charity through setting an overarching set of objectives thatneed to be taken into account when deciding on specific investment allocations. It isresponsible for appointing the investment manager. It has delegated responsibility formonitoring and making amendments to the portfolio of investments to meet theoverarching objectives to the Charitable Funds Committee.3.2 Charitable Funds CommitteeThe Charitable Funds Committee sets the parameters for the investment decisions andthe percentage of funds to be held under the asset types The Committee has theresponsibility to monitor performance of the portfolio of investments through the receiptand review of reports from the investment manager. The investment manager will attendeach Charitable Funds Committee in order to give the members the opportunity to raisequestions about the performance of the investments and the appropriateness of movinginvestments into other areas. The Committee will update the Board with regard tosignificant changes or issues with performance of the investments.3.3 Investment ManagerThe investment managers appointed will be responsible for investing the available fundsas far as possible to fulfil the investment objectives laid out below. Investment managerswill advise Trustees on investment decisions and direction They will provide quarterlyreports to the Charitable Funds Committee. They will take into account any concernsraised by the Committee in the allocation or performance of the funds. They will take intoaccount the Trustees stance on ethical investment.3.4 Trust finance staffThe Trust, through its finance staff, carries out financial administration of the Charity. It isthe responsibility of the appropriate finance staff to ensure that the invitations to attendthe Committees are sent to the investment manager and that investment informationprovided is passed onto the Committee members. It is their responsibility to ensure thatthe Charity keeps accurate records of its investments, properly accounts for investmentreturns and movements in the value of investments.4. Consultation and disseminationThis Policy has been formulated by taking into account the guidance issued by theCharities Commission as well as the previously documented objectives of the Trusteesin achieving investment returns. It was presented to the Charitable Funds Committee on5 th August 2010 for their comments before they ratified it.The Policy will be published on the Trust’s intranet within the Finance Policies section.________________________________________________________________Charitable Funds Investment Policy July 2010 Page 3 of 9

5. Monitoring compliance with the PolicyThe Trustees wish to monitor the performance of the investments carefully and will seekquarterly valuations and reviews of performance. Whilst the precise mechanics willdepend on the independent professional advice given to the Trustees, it is proposed thatperformance should be measured against one of the industry standard measures suchas the WM Charity Survey.The Charitable Funds Committee will provide information in its Annual Report to theBoard on its actions in managing the investments. . If the Committee identifies that thereare shortfalls in the performance of its investments, and that these shortfalls are notbeing remedied by the investment manager, the Committee will report this to the Boardtogether with its proposals on remedying the situation. This may include a change ofinvestment manager.The Committee will, in turn, monitor compliance with this Policy by the investmentmanagers and finance staff.6 Investment Strategy6.1 Investment ObjectivesAs stated above, it is not the Trustee’s primary aim to accumulate funds and theinvestment strategy set out below is written with this in mind. Accordingly, a portion ofthe total funds will be held back as short term monies or working capital (assets whichare capable of being released to generate cash quickly, or cash) with the restconstituting the investible portfolio (long –term monies), which is the subject of this policypaper, being invested.The Trustees objectives are:• To maintain the value of the capital in real terms over the medium term (3-5years).• To realise capital gains (i.e. returns on the investments achieved) only if there is abona fide charitable purpose for them• To receive dividends and interest from the investments as income to the charityand utilise it as such.• To reinvest capital gains where no immediate charitable purpose exists• To take normal charitable expenditure from ongoing donations and interest frominvestments that is surplus to administrative expenditure• To fund unusual major capital projects on a case-by-case basis from one-offreductions in investment capital.That part of the portfolio which must, as a minimum, be kept in liquid funds should besufficient to cover three months of anticipated charitable expenditure. However theinvestment advisers have discretion to increase the liquid element of the portfolio ifmarket conditions should so dictate.________________________________________________________________Charitable Funds Investment Policy July 2010 Page 4 of 9

Subject to the recommendations of our independent adviser, the funds will be investedon a discretionary basis by the purchase of pooled funds, ordinarily Common InvestmentFunds [CIFs] or others where they are not available.The investment principles of the Trustees are to ensure: -(a)(b)(c)(d)(e)(f)A balance between income (interest or dividends) and capital growth whilstadopting an appropriate medium to long-term risk profile, accepting that this willimpose a degree of volatility (*A) in performance.The maintenance of the ‘real’ value of the capital within the portfolio afterallowing for the effects of inflation but before any strategic change in historicexpenditure levels.That they are prepared to realise capital gains if achieved and if there is a bonafide charitable purpose for them.An income of approximately £150,000 p.a. from the portfolio, which is currentlyequivalent to a yield of about 3% p.a.That the administrative burden on the Trustees is kept to an acceptableminimum.That they receive independent professional advice on the set up andmonitoring of the performance of the investments.6.2 Risk Profile and asset allocationThe Trustees are bound by the rules for Charities on investments and have adopted astrategy, which avoids speculation and high risk, while accepting a reasonable degree ofvolatility of returns (*B). They will spread the investments over a number of differentinvestment classes such as UK Equities, overseas Equities, Bonds, Property and cashand have considered and agreed a limited amount of exposure to non-traditional assetslike hedge funds, subject to clear restrictions.The precise asset allocation is decided by the trustees based on the independentprofessional advice given to them and based on the industry ‘norms’ for similar types ofCharities. The currently approved allocation is set out in annex 1.6.3 Ethical ConsiderationsThe Trustees have considered whether to impose any ethical restriction on theinvestment of the Trust’s assets by their investment managers and are mindful that theirprimary duty is to seek the best returns within the limits of the overall investment policy.The Trustees have decided to avoid direct investment in certain types of stocks and tothis end they will specifically avoid direct investment in stock adverse to health (e.g.Tobacco). They will also seek to minimise investments in areas where conflicts ofinterest could be seen to occur, such as with pharmaceutical companies.The Trustees accept that the investment in common investment funds (and similarproducts) may give the charity indirect exposure to such stocks. Any indirect exposure ismonitored and will not exceed 5% of the total portfolio value.________________________________________________________________Charitable Funds Investment Policy July 2010 Page 5 of 9

6.4 Investment PowersThe appointed fund managers or funds will be given discretionary powers andempowered to buy and sell securities on behalf of the trustees, subject to the overallinvestment policy as set out in this document. All such transactions must be reported tothe Trustees in the next quarterly review.6.5 Review of PolicyThe Charities Committee will review this policy annually and the Trustees will approveany proposed changes.A* This is defined as movements in performance of 5%B* This is defined as movements in performance of not more than 10%________________________________________________________________Charitable Funds Investment Policy July 2010 Page 6 of 9

Annex 1Currently Approved Asset AllocationIn line with the current professional advice to the Charitable Funds Committee, theagreed asset allocations are as follows:-1 Equities:UKGlobalAsset Type Agreed %52.5102 Fixed Interest Bonds 103 Property Funds 54 Hedge Funds 155 Cash 7.5This approved asset allocation will be subject to periodic change, based on the advice ofthe trustee’s investment advisors.________________________________________________________________Charitable Funds Investment Policy July 2010 Page 7 of 9

AGENDA ITEM NO 22.4TRUST BOARD 28 SEPTEMBER 2010Title: Report from Organ and Tissue Donation CommitteeTo be presented by: Brenda Kersting (NED and Committee Chair)Executive summary and key issues for the Board:The Organ and Tissue Donation Committee has been established in line with a national initiative by the OrganDonation Taskforce. It held its inaugural meeting in June and a second meeting in September. TheCommittee will meet quarterly and report to the Board in September and March.MembershipThe Committee is chaired by a Non Executive Director and membership includes the Medical Director,Specialist Nurse Organ Donation, Clinical Lead for Organ Donation and clinical and operationalrepresentatives from emergency medicine, ITU, anaesthetics and theatres.Terms of ReferenceThe committee agreed local terms of reference based on the national template. In essence the committee’spurpose is:- To influence policy and practice in order to ensure that organ and tissue donation is considered in allappropriate situations. To identify and resolve any obstacles to this.- To ensure that a discussion about donation features in all end of life care, wherever located andwherever appropriate, recognising and respecting the wishes of individuals.- To maximise the overall number of organs donated, through better support to potential donors andtheir familiesFacial Tissue DonationThe committee has agreed that the Trust will participate in facial tissue donation – this is unlikely to besignificant as the London team is funded for only 6 retrievals this year.Committee PrioritiesThe Committee’s agreed priorities are:- Review of existing guidelines and production of a clinical guideline for both acute sites on referral forpotential organ or tissue donation in respect of both heart beating and non heart beating donors. This willbe modelled on a national template but modified to meet local needs- Develop a theatre pathway for organ retrieval- Enhance staff awareness particularly through the intranet

- Develop quarterly activity audits and learning from missed opportunities and successful donations- Review information and support available to potential donors and their familiesThe Specialist Organ Donation Nurse is part of an on-call regional team which manages the retrieval processand in particular the relationship with potential and actual donor families, and provides support to staff.Audits of Potential and Actual DonationsAll deaths are audited to determine whether a potential donation opportunity has been missed, and donationactivity is recorded. In the period March to August 2010 the figures for BHT have been:Site Potential Donations Actual DonationsWycombe 2 1Stoke Mandeville 1 0These figures are not final as three sets of notes are still to be reviewed.Risk and Assurance:Does this paper identify a new risk to the achievement of trust objectives? NoDoes this paper provide assurance on the control of an identified risk? NoCommittee review and approval:Has the paper been reviewed and/or approved at a Board or executive committee? NoLegal Issues:Does the paper contain a legal issue or evidence compliance with legislation? NoAction required by the Board:To note