PART A AGENDA ITEM 11 - The Princess Alexandra Hospital | NHS ...

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 4Minutes of the Meeting held on 31 st March 2011

The Princess Alexandra Hospital NHS TrustMinutes of the Public Trust Board Meeting (Part A)held on Thursday 31 th March 2011 in the Board Room, PAHPART APresent: Mr Gerald Coteman (GC) ChairMs. Melanie Walker (MW) Chief Executive OfficerMs Janet Dalrymple (JD) Non-Executive DirectorMr Richard Stead (RS) Non-Executive DirectorMr Chris Oakes (CO) Director – WorkforceMr Andrew Butters (AB) Director of FinanceMrs Paula Kerr (PK) Non-Executive DirectorClaire Feehily (CF) Non-Executive DirectorDr. Sylvia Thompson (ST) Non-Executive DirectorDr. Sandra Dimmock (SD) Medical DirectorMr Darren Leech (DL) Executive Director - DeliveryMrs Yvonne Blücher (YB) Executive Director – NursingMr. Marc Davis (MD) Director of Integrated Patient CareMembers of thePublic:Cathy GoodingCharles Jackson(CG)(CJ)West Essex LINkWest Essex LINkAlso inattendance:Raine Hunt (RH) Head of CommunicationsSteve Swayne (SS) Managing Director, KingsgateConsultancySimon Meddick {for part} (SM) Associate Director for Strategy &ContractingPenny Griffiths (PG) Minute Secretary31/03/01 HEALTH AND SAFETY BRIEFINGThe Board and members of the public received this briefing from GC.31/03/02 APOLOGIES FOR ABSENCEThese were received from Mr Chris Birbeck, Director of Patient Safety & RiskGC introduced and welcomed Mr. Marc Davis to the committee. MD thanked theChair and advised the committee that as Director of Integrated Patient Care,amongst other initiatives, he would be working on the transition to GPcommissioning. For part of his time, MD will also be working as an advisor tothe DoH.MW also introduced and welcomed Mr Steve Swayne, from KingsgateConsultancy, an organisation experienced in supporting NHS Trusts withsignificant financial challenges.31/03/03 TO NOTE CHANGES AND ADDITIONS TO INTERESTS DECLARED BYTRUST BOARD MEMBERSThere were none.31/03/04 APPROVAL OF THE MINUTES OF PART A OF THE BOARD MEETING HELDON 24 th FEBRUARY 2011 IN THE BOARDROOM TRUST HEADQUARTERS,PRINCESS ALEXANDRA HOSPITAL, HARLOW.Minute 24/02/05 Action points from last meetingMinute 27/01/121

DL advised the East and North Herts and West Herts PCTs have merged andare now NHS Hertfordshire.Minute 24/02/08 Maternity and NICU future provision – para 3Extra community midwife support has also been put in place to support NICUbabies being cared for at home.Should read:-Extra community midwife support has also been put in place to support NICUbabies being cared for after discharged home.Minute 24/02/08 Maternity and NICU future provision – para 9The recommendation is for an additional 18 inpatient beds with the ability to beused flexibly for ante and post natal care and for NICU to maintain capacity at 16with the potential to flex to 20 costs according to demand.Should read:-The recommendation is for an additional 18 inpatient beds with the ability to beused flexibly for ante and post natal care and for NICU to maintain capacity at 16with the potential to flex to 20 cots according to demand.Minute 24/02/08 Maternity and NICU future provision – para 11Although the increasing demand is good news for the Trust, the service currentlyruns at a deficit and will continue to do so for the next 2 years before moving intosurplus in year 3. AB reported for maternity £2.7m on additional income inforecast positions with income rising from £15.1m to £17.9m for 2013/14. Theoffers from the PCTs do not offer this level of additional income in obstetrics.The other key element is around cost reduction with the Women’s & Children’sBusiness Unit with the planned levels being very challenging.Should read:-Although the increasing demand is good news for the Trust, the service currentlyruns at a deficit and will continue to do so for the next 2 years before moving intosurplus in year 3. AB reported for maternity £2.7m of additional income inforecast positions with income rising from £15.1m to £17.9m for 2013/14.However, the offers from the PCTs do not offer this level of additional income inobstetrics. The other key element is around cost reduction in the Women’s &Children’s Business Unit with the planned levels being very challenging.Minute 24/02/10 – (Operational Update) Financial Performance Report –para 3Charnley Ward opened in February which will add to March costs. Risksassociated with Charnley Ward being open were discussed and it was now notcertain whether WEPCT would now pay the additional income to cover the costsof re-opening the wards. The additional risk of infection was noted and the highrisks associated in the costs of temporary staff.Should read:-Charnley Ward was open in February which will add to March costs. Risksassociated with Charnley Ward being open were discussed and it was now notcertain whether WEPCT would pay the additional income to cover the costs ofre-opening the wards. The additional risk of infection was noted and the highrisks associated in the use of temporary staff.31/03/05 ACTION POINTS FROM LAST MEETING• 23/12/04 - PATIENT EXPERIENCE REPORT – YBYB quarterly PET report to be brought to the March 2011 Board or PS&QTarget Date 31.03.11 Not yet completed and ongoing dialogue between YB and PK to beshared at PS& Q Committee2

• 24/02/07 - FIRST EVALUATION OF TRUST POSITION – NCEPODREPORT “AN AGE OLD PROBLEM” - SDNCEPOD Report “An Age Old Problem” to be submitted to the March PatientSafety & Quality Committee for scrutiny - SD.Target date 31.03.11For review and for the next Trustboard meeting in April. This document wasnot for submission to PS&Q (see minute 31/03/07 below for clarity)• 24/02/08 - MATERNITY AND NICU FUTURE PROVISION1. To be discussed at a Business & Performance Committee meeting inmore detail. YB2. CB to ensure that Maternity & NICU future provision is added to the RiskRegister Apologies for absence have been received from CB – deferred tonext meeting• 24/02/12 - FT APPLICATION AND CONSULTATION UPDATE – DL –• DL to inform Board Members of the date for the next FT Board DevelopmentSeminar DL advised this would be on the 26 th April• GC to speak to the Chair of the SHA regarding the tone of the letter receivedfrom the SHA dated 8 February 2011. GC confirmed that he had expressed the Board’s concern.• 24/02/13 - CLINICAL STRATEGY UPDATE -YB/DL to provide a Clinical Strategy update at the March Board. This item to be discussed under today’s main agendaitem 15 - Strategy31/03/06 PATIENT EXPERIENCE REPORT• YB read out the contents of a recent complaints letter which highlighted aproblem around both the attitude and customer service of a member of staffin the Eye Unit towards a patient.• The complaint focused on the details of an outpatient appointment at 9 a.m.for the complainant’s 17 year old needle-phobic daughter.• The member of staff had refused permission for the mother to stay with herdaughter while a cannula was inserted.• After 4 failed attempts, the patient was returned to the waiting area, asked tocalm down and have a drink of water and a further attempt would be made.• No drinks were available in the waiting area, and after 30 minutes themember of staff brought a glass of water. At one point the member of staffslammed a door closed in the patient’s mother’s face while still speaking.• The patient became increasingly anxious and upset and patient and motherfinally left at 13.00h.East of England Clinical Summit - 24 March 2011• YB, SD and GC (for part) had attended the summit which was agreed to havebeen most informative and included a presentation from Anthony Sumara,(AS) Chief Executive, Mid Staffordshire NHS Foundation Trust.• AS’s key message ‘Keep everything simple and don’t over complicatematters’ provided a down to earth and refreshing talk and included thefollowing sub-topics:- Values & behaviours Cutting data close to the patient3

Roles and Responsibilities How can GP Commissioners assure themselves about Quality &Safety? National Quality Board County Council relationship Governors Role• AS referred to the ‘from the bottom up’ approach which included the Boardowning the responsibilities and remaining focused and consistent. Hisexperience of Board members not having the confidence to go out intoclinical areas, avoiding jargon and communicating with all levels of staff andpatients was another lesson to be learned. The Board to Ward ‘Essence ofCare’ themed walkabouts are hoped to provide a good vehicle to allow TBmembers to interact in this manner.• AS also talked about prioritising and focusing on the real issues. Tunnelvision towards achieving a positive financial outcome had been a costlymistake.• Staff/patients that raise concerns (not necessarily in a whistle-blowing mode)should be congratulated and encouraged. The pressure group, Cure theNHS, raised all of the issues but was seen as an enemy of the Board and notas a constructive, critical friend.• YB reported that AS had spoken very well about these and other issues andadmitted to still being shell shocked from his experience.• YB suggested that the Board might have further discussions about this andgoing forward build on these issues, possibly using a standard tool.• PK endorsed YB’s remarks and agreed that this should be a work inprogress.• Going forward, external stakeholders are very interested in the Essence ofCare modules and this would give both internal and external assurance.• PK requested a broader update and transparency on the trusts progress inthe public part of Trustboard, i.e. pressure sores, what is the trust doingabout this issue? People will see that we are really being open. Part Bshould be reserved for looking in more detail, including tracking of patientservice lines.• Quantitive data is presented to PS&Q each month and the PS&Q dashboardfollows to the Trustboard.• Next month’s Essence of Care theme is ‘Care Environment’ and will befacilitated by YB and GC on the same day as PS&Q and the results couldthen be incorporated into the format of the meeting, together with the Ed andNED.• Assurance is needed by the Board that the hospital provides good patientcare. The current Board to Ward schedule should include all NEDs.Action• It was agreed that a discussion around this at PS&Q would be helpful and toevaluate in 3 months how the Board to Ward initiative is progressing.• It was agreed that PG would circulate the Essence of Care walkabout Boardto ward schedule to all NEDs and will arrange alternative dates/times,including out of hours, if those listed are inconvenient.31/03/07 Ombudsman report and care of older people – David Nicholson letter toTrusts• CB had presented the report to PS&Q and YB apologised for the letterreferred to from Mavis Nicholson not being included in the papers.• CB had reviewed a sample of 18 complaints received over a 3 month spanand found similar themes within those complaints.• The Essence of Care themes address the issues raised within the review4

carried out by CB and demonstrated improved practice will be presented tothe PS&Q.• SD advised that it was this document that went to the PS&Q committee inMarch and not the NCEPOD report “An Age Old Problem” as reported in theminutes for February under minute 24/02/07.• NCEPOD reports are huge reports that usually take about 12 months tocomplete and are reviewed at stages during that time• The Ombudsman report will be linked to the NCEPOD report. Issuesrequiring urgent action will be managed without delay and will be tracked withquarterly reviews at the PS&Q.31/03/08 Equality Delivery System (EDS)• As a member of the National Equality and Diversity Council MW wished todeclare an interest in this item. GC and MW have exchanged emailcorrespondence on this matter.• The EDS is a framework aimed at improving the equality performance forboth patients & staff and the expectation is that all NHS organisations signup to and support this scheme.• MW outlined how the EDS would allow the trust to work in their own way andincluded approval from local patient groups. Also putting measurable stakesin from external stakeholders and one stakeholder group is staff.• Absolute commitment must be given as this is likely to be embedded in theFT process, this will reflect the way we do business and how we are judged.• Older people’s services would be an ideal area to commence implementingthe EDS and provides a useful tool to address those issues. MW believesthe impetus behind the Board’s approval for this scheme should beconcerned with improving the patient’s experience.• The trust is significantly outlying above the national average for staff trainingand the recent staff survey returned a clear message that more needed to bedone in this area.• JD was encouraged by the EDS scheme as had been concerned for sometime about how the trust genuinely engages on E&D. JD also expressed heragreement that elderly services would benefit from this and would pave theway for other groups.• PK challenged as where the starting point should be. Elderly services couldcertainly be helped but concern around the ethnic diversity element shouldalso be a high priority.• JD referred to the Harlow Welfare Rights and Benefits group which hasrecently published a list of voluntary community services which would beable to provide assistance with this and other ethnic group issues.• CF felt that the language barrier was extremely dangerous and was moreimportant than the strategy.• RS expressed concern about the staff turnover rate and stressed thatemployees must be treated as individuals – this can’t be a bolt-on. The trustneeds to ensure that we employ people who have the correct approach toequality.• Action• MW will return with a proposal on the practical manifestation of this schemeand provide the Board with an action plan for implementation.• A lead for this will be identified at tomorrow’s Executive meeting.31/03/09 Annual Plan• SM advised the Board that the Annual Plan formed part of the SHA’sassurance that we are performing and delivering on Quality, Innovation,Productivity and Prevention (QIPP) and that we are working in a positive waywith our partners to achieve the targets.5

• The plan needs to be submitted to the SHA today following the Board’sapproval and final details are currently under completion regarding HSMRfigures, local contractual risks and governance risks. The expectation is thatour commissioners will sign this off and SM welcomed comments from theBoard.• Concerns were expressed around the revised finance section which hadbeen sent to the Board members last Friday. The particular areas forconcern were:-• Section 4.1.1. - Financial Objectives / Deliverables for 2011/12• Section 4.3.1 - Financial Risks• Section 4.4.2 - Operating Income by Service / Point of Delivery (POD• Section 4.6.1 - Past Year Performance and Future CIPs• The chair expressed concern about these items and was unhappy about theAnnual Plan being signed off in the current form.• Transitional funding is still to be agreed but this will be insufficient to closethe gap.• The trust is being asked to save in excess of 10% and it was noted that theLondon SHA have capped the cuts to 7%. The board was in agreement thatthe financial situation must be sustainable.• MW made the point that if the Board agrees to sign off, it is accepting thehigh level of risk associated with the Trust breaking –even in 2011-12 andthe bridging money will not secure the sustainability of this organisation, butmerely provide a short term solution.• ST thanked AB for the honesty of the financial overview and confirmed herview that the document should not be signed off and asked MW to ensurethat the SHA must be quite clear of what the situation is.• RS advised that he felt the plan could not succeed in its present form.• PK asked where the operational plan is which governs an organisation. Anorganisation cannot be managed without a framework to work by.• MW agreed that the trust does not have a clear clinical strategy and this isbeing addressed.• It was agreed that until the transitional funding issue was agreed, the AnnualPlan must not be signed off.Action• MW proposed to request an extension to today’s deadline for submission.• The Board agreed that MW would write a jointly signed letter from herselfand GC to the SHA highlighting the following areas of concern:-1. The Trust’s improved relationship with the PCT2. Transitional funding yet to be agreed3. Ambulatory care will allow for 3 wards (out of 12) to be closed4. CEO newly in post• MW to discuss this with the SHA at her induction meeting next week.31/03/10 Eliminating Mixed Sex Accommodation – Declaration of compliance• YB advised the Board that the trust had eliminated same sexaccommodation in line with the DoH’s requirement, except when it is in thepatient’s overall best interest or reflects their personal choice.• Patients sleeping in the same bay or using the same bathrooms constitute areportable breach to the PCT.• Penalties could be incurred for non- compliance and AB’s understanding isthat a tariff of £250 per day per patient for sharing a bay.Endorsed31/03/11 SHA – Exception Report6

• This item was discussed fully in B&PC and is for noting only31/03/12 Finance & PerformanceOperational update• This item was also discussed at B&PC, and YB described that the trust hadnot met the national target of 95% compliance around the 4 hour targetwaiting time. Mapped activity (inclusive of the Urgent Care Centre) was96.3%. Unmapped activity (stand alone A&E waiting time) was 94.2%.• On elective activity, the back log waiting over 18 weeks is over 600 and willtop 600 by the end of the year. Following discussions with both the SHA andPCT and with new arrangements in place with the PCT from tomorrow 1 stApril, we are working to plan recovery in 2011/12.• Diagnostics remains a key issue.• We are fully complaint on Cancer targets and are also expecting to becompliant for February.• AB reported that activity on new outpatient referrals continues to drop. Thefollow-up outpatient appointment has not dropped. A cap on the new tofollow up ratio will be in place for next year.• MW suggested that it would be helpful to bring to the Board what the capmeans by speciality. We have been set a considerable challenge by the PCTand it needs to be discussed in EMT.• Infection control – Norovirus still quite active on Care of the Elderly ward andthe Director of Infection Prevention & Control is concerned about the timethat the virus has prevailed. Some beds were closed but due to the level ofactivity and demand, have been re-opened with 4 hourly reviews.31/03/13 Financial Performance Report 2010/11• AB reported that month 11 had shown reduced costs with February returninga surplus position of £237k. We have signed off a block contract withHertfordshire NHS which is satisfactory. Looking at the March figures, afurther surplus is likely and this will bring us back to a break even for yearend.• As of lunchtime today, the trust had £3.3mn in the bank, achieving its eyarend EFL target.31/03/14 Budget Update 2011/12• Much of this item has already been discussed as part of the Annual Plan;other key points are:-• The BUs need to have ownership of their budgets, reflecting the challengesof progressing to FT status.• WEPCT have requested further reduced activity from emergency work,though the Emergency BU has advised that this isn’t achievable.• Potential cash flow issues with repayments to make on loan and dividendpayments etc. A further working capital loan may be required from the DH in2011-12.• PK asked how much staff and frontline think this is ‘business as usual’ ratherthan understanding the shift that is being made to make the Trustsustainable.• MW responded that the answer to that question depended on who andwhere you are. A staff briefing tomorrow and a further email communicationto be sent out trust wide also.• MW has had productive and ongoing discussions with Consultants abouttheir views and whether EMT is the appropriate forum for driving thatforward.• PK felt that such a massive dislocation of services including the closure of 3wards may require public consultation.7

It was agreed that the budget presented be adopted on a provisional basisto give the business units a financial framework within which to work fromthe 1 st April 2011, but that it is made clear to them that further savings willbe required from their budgets as part of the financial sustainability plansbeing prepared.The Board also asked for monthly updates on identifying the furthersavings required.31/03/15 FT Application Update• DL invited questions from the Board.• The question was raised around if there was enough money in the overallhealth economy to support the FT application.• Reference was made to the interesting dynamic with balance shifting fromPCT for support for the FT application as the SHA prepares for closure.• ST referred to the form at the back of the document which the SHA arerequired to complete and asked if this would be disclosed to the Board. DLconfirmed that this was his understanding.31/03/16 CHAIR’S REPORTArt Group• GC advised the Board that the newly formed Art Group had recently met.The purpose of the group is to re-introduce art in the hospital.• The first display of art from the Church Langley Primary School and HarlowCollege is being exhibited in the Outpatients Corridor.• Funding for the project has been secured from Essex CommunityFoundation Chairman’s Fund• GC will keep the Board updated on progress, including details of theproposed launch.Anaesthetists• GC brought to the attention of the Board a grievance submitted to the trustby the Anaesthetists regarding differential pay rates amongst consultantstaff.• GC read out a formal letter of apology sent to the Anaesthetists for the lengthof time it has taken to resolve and reverse the original decision whichcreated the differential pay rates.• GC reported that he had engaged in discussions with the anaesthetistsabout this and other general interface issues.• GC advised that he had been in positive discussions with many cliniciansabout increasing their involvement in hospital strategy and listening to andunderstanding their requirements.• ActionThis item will be discussed at EMT and will be brought back to the next Boardmeeting for updates.31/03/17 DATE & TIME OF NEXT MEETING1.30 p.m.Thursday 28 th April 2011Board Room, Trust Headquarters, PAHT.31/03/18 INPUT FROM PUBLIC AT CHAIR’S DISCRETION• CJ requested an update on the Dialysis Unit.• DL advised that the EoE Speciality Commissioning Unit have put an adverton their website asking for expressions of interest and refers to the Renalunit for Bed and Harlow area (or nearby).• The preferred site is PAHT and DL and SD had recently attended the8

opening bidder’s day and could report a keen display of interest. Updates tobe given as soon as available.• CJ asked about the impetus in keeping the public interested in the FTapplication and the suggestion of creating a ‘ghost’ governor’s board, similarto the approach that some of the aspiring Mental Health Authority’s haveadopted.• GC thought that this may still be a possibility, though not immediately andsuggested the GC and CJ discussed this outside of today’s meeting.• CJ asked how the trust was responding to the GP Commissioning initiative.CJ advised that a doctor’s newsletter was produced at Addison House.Does PAHT have a directory of services available as this could be includedand would be most helpful?• RH advised that our Directory of Services links in with the Choose and Bookprogramme. It was agreed that RH would forward an electronic web link toCJ.• JH referred to the portion of land outside the main gate on the Hamstel Roadwhich is frequently littered with 100’s of cigarette ends. Could the trust eitherpost a notice or provide a bin?• GC advised that the piece of land that JH referred to is the property ofHarlow Council.• Unfortunately notices are ineffective and educating people not to smokeoutside a hospital is the key issue.• GC, RH and CJ all to speak to the council regarding this matter.• In the light of the Urgent Care Centre (formerly the Walk-in Centre) nowlocated within the PAHT site, patients are being encouraged to visit theirGP’s. However, the difficulty arises at the weekend when the GP surgeriesSaturday morning appointments are for pre-planned consultations only andpatients cannot get to see their GP. This can result in an out of hour’s doctorbeing called in from London. Can the Board comment please?• SD responded that GP’s are aware of the concern regarding out of hoursservices which is a national problem, though trying to change the system to a7-day service is unlikely to happen.• The East of England Medical Director’s Forum is setting up a working group(which will include both SD and Dr. Christine Moss - Medical Director forWest Essex PCT) around 7 day working which will be principally aimed atPrimary Care services.Action• RH would forward an electronic web link of the trust’s Directory of Service toCJ.• Harlow Council to be contacted by GC, RH and CJ to discuss the issue ofsmoking and cigarette stubs littering the area immediately outside of thehospital.31/03/19 CLOSURE OF PART ATo resolve the representatives of the media and other members of thepublic be excluded from the rest of the meeting, having regard to theconfidential nature of the business to be transacted prejudicial to thepublic interest: Section 1 (2) Public Bodies (Admissions to Meetings Act)1960.9

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 5Action points arising from past meetings

Action Log – Trust Board – Part AItem No. Title Current situation Resp. foraction23/12/04 Patient Experience YB quarterly PET report to be broughtReportto the March 2011 Board or PS&QYB24/02/07 First evaluation ofTrust position –NCEPOD report “Anage old problem”NCEPOD Report “An Age OldProblem” to be submitted to theMarch Patient Safety & QualityCommittee for scrutinySDAction OutstandingNot yet completed andongoing dialogue between YBand PK to be shared at PS&Q CommitteeFor review and for the nextTrustboard meeting in April.This document was not forsubmission to PS&Q (seeminute 31/03/07 in fullversion of the minutes forclarity)TargetDate31.03.1131.03.11ActualCompletion DateCompleted24/02/08 Maternity and NICUfuture provision31/03/06 Patient ExperienceReport31/03/06 Patient ExperienceReport31/03/08 Equality DeliverySystem (EDS)1. To be discussed at a Business &Performance Committee meetingin more detail. YB2. CB to ensure that Maternity &NICU future provision is added tothe Risk RegisterIt was agreed that a discussionaround this at PS&Q would be helpfuland to evaluate in 3 months how theBoard to Ward initiative isprogressing.It was agreed that PG would circulatethe Essence of Care walkabout Boardto ward schedule to all NEDs and willarrange alternative dates/times,including out of hours, if those listedare inconvenient.a. MW will return with a proposal onthe practical manifestation of thisscheme and provide the BoardCB1Apologies for absence havebeen received from CB –deferred to next meeting28.04.11YB 30.06.11PG ASAPMW 28.04.11

with an action plan forimplementation.b. A lead for this will be identified attomorrow’s Executive meeting.31/03/09 Annual Plan a. MW proposed to request anextension to today’s deadline forsubmission.b. The Board agreed that MW wouldwrite a jointly signed letter fromherself and GC to the SHAhighlighting the following areas ofconcern:-1. The Trust’s improvedrelationship with the PCT2. Transitional funding yet tobe agreed3. Ambulatory care will allowfor 3 wards (out of 12) tobe closed4. CEO newly in postc.MW to discuss this with the SHA ather induction meeting next week31/03/16 Chair’s report –anaesthetists31/03/18 Input from public atChair’s discretionThis item will be discussed at EMTand will be brought back to the nextBoard meeting for updates.RH would forward an electronic weblink of the trust’s Directory of Serviceto CH.MW ASAPGC 28.04.11RH ASAP31/03/18 Input from public atChair’s discretionHarlow Council to be contacted byGC, RH and CH to discuss the issueof smoking and cigarette stubslittering the area immediately outsideof the hospitalGC/RH/CH ASAP2

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 7Patient Surveys

The Princess Alexandra Hospital NHS TrustTrust Board Meeting28 April 2011Compliance ChecklistExecutive SummaryGovernanceEqualities ImpactFinanceLegal ImplicationsCommunications IssuesRisk and Health and Safety IssuesIssue:This paper outlines the situation of the most recent National Inpatient Adult and Cancer Survey 2010.Summary:There are five common themes that correlate across all our feed back. These are:1. Role and approach of Doctors.2. Involvement in decision about their care.3. Access to nursing staff.4. Information and communications.5. Admission and discharge.Recommendations:Ask the Trust Board to note the detail in the paper and to endorse the recommendations.Author:Date:Yvonne Blucher, Executive Director for Nursing & Patient Care 18 April 2011

INPATIENT AND CANCER SURVEY 2010 SBARPatient Safety and Quality Meeting – April 2011SituationFeedback from patients through National surveys and other local feedback indicatethat the Trust’s perception of the care being provided at the hospital and theexperience of our patients is misaligned.The organisation needs to identify a robust method of addressing concerns for thebenefit of our service users.There is a need to ensure ownership for improved patient experience within BusinessUnits with the provision of assurance to the Trust Board through the PerformanceMonitoring Group and the Patient Safety & Quality Committee.BackgroundResults form National surveys are variable with a range of good and bad feedback.Five key themes have been identified and are also reflected in the last quarterfeedback from NHS Choices.The 2010 National Inpatient Survey – 48% Response RatePresented the Trust with the opportunity to benchmark its performance againstprevious years, and other hospitals in England and Wales.80% of our patients rated our care as good or excellent.Overall• Overall the care and treatment was rated as good or excellent by 80%.• 89% of respondents felt that doctors and nurses worked well together• 96% felt the room/bathroom was very or fairly clean• 88% of people believed there was enough privacy when being examined ortreated• 79% felt that risks and benefits were clearly explained• 74% of people had confidence in the doctorsSignificantly Better than Other Trusts• Same sex accommodation• Cleanliness of bathroomsSignificantly Worse than Other Trusts• Wait for admission to a bed or ward• Planned admission• Choice of Hospital food• Quality of information from doctors• Lack of involvement in decisions about care• DischargeThe 2010 National Cancer Patient Survey – 67% response rate ROBCommissioned and designed to monitor national progress on cancer care, and toprovide information that could be used to drive quality improvement.Patient Survey SBARApril 2011: Raine Hunt, Sharon Cullen & Rob Duncombe1

The Princess Alexandra Hospital was placed in the bottom 16 Trusts in the county,and in the lower 20% for 38 out of 59 questions.Overall• One of the 16 poorest performing Trusts on cancer patient experience inEngland• In bottom 20% of Trusts for 38 questions out of 59 questions• Sits in top 20% for admission date of operation not being changedAreas For Improvement• Information provision• Communication – and in particular breaking bad news• Awareness of the needs of cancer patients• Involvement of patients and their carers in all decision making• Pathway management and speed of treatment / access to diagnostics.NHS Choices Online Feedback – 9 comments Quarter 4 (January to March2011)• 6 people would recommend the hospital• 3 people would not recommend the hospital• Services commented on were paediatrics, general surgery, general medicine,gastro, accident and emergency medicine, maternity, gynae and orthopaedics• Concerns raised and praise given about the treatment offered, length of stay,information and communication, attitude of nurses and doctors.AssessmentCommon Themes:Five areas have been identified that correlate across all of our feedback. These are:Role and approach of doctors♦ Results highlighted a level disregard for the patient♦ Lack of confidence and trust♦ Poor hand hygiene (from Patient Survey)Involvement in decision about their care♦ People want to be more involved in their careAccess to nursing staff♦ Timely access to ward staff following a call button♦ Availability of Clinical Nurse SpecialistsInformation and communications♦ Interpersonal communication between patients and professionals,appropriateness of tone, manner and message♦ A lack of information offered by doctors and nurses, poor informationregarding care, treatment, support groups and the nursing teams.Admission and discharge♦ Time taken to admit, the quality of the admission♦ lack of co-ordination of discharge arrangements♦ Significant waits for medication on discharge form hospital♦ Significant waits for transport on discharge from hospitalPrevious approach to addressing patient feedbackHistorically the process of introducing and monitoring actions to enhance patientexperience has been collated corporately. The Trust has not experiencedimprovements in patient feedback with this methodology.Patient Survey SBARApril 2011: Raine Hunt, Sharon Cullen & Rob Duncombe2

Recommendations1. Develop and agree Trust wide objectives and actions - Each Businessunit to provide a representative to identify and agree common goals andactions to address shortfalls identified through patient feedback.2. Formal monitoring of the implementation of the Delivery plan by eachBusiness Unit – Evidence of achievement against the delivery plan to bepresented to The Trust Performance Management Group (PMG)3. Development of a Patient Experience Dashboard – sitting under thePatient Safety and Quality Dashboard; Business Units will demonstrate theimpact on patient care of the actions being delivered in the plan.4. In house half year patient survey and secret shopper exercise – Mirroringthe national survey to enable early indications of improvements againstresults of the National survey.5. Customer Care training – Continue with customer care training through staffinduction day but also introduce targeted training for medical staff or staffidentified through complaints as requiring additional support.6. Staff development and learning – introduce a ‘patient story’ exercise toenable staff to understand the impact of their role on patient care.Patient Survey SBARApril 2011: Raine Hunt, Sharon Cullen & Rob Duncombe3

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 8Staff Survey

The Princess Alexandra Hospital NHS TrustTrust Board Meeting28 th of April 2011Part ACompliance ChecklistExecutive SummaryGovernanceEqualities ImpactFinanceLegal ImplicationsCommunications IssuesRisk and Health and Safety Issues√√√Issue: Staff SurveySummary: The attached paper sets out a summary of the Trusts results on the StaffSurvey.Overall the trust has improved on its level of appraisals and feedback on some areasof training.In comparison there is less satisfaction with the quality of the appraisals and morestaff are thinking about leaving the Trust.There were only 9 areas where the trust was doing significantly better than othertrusts compared to 31 where we were significantly worse. Some areas of feedbackparticularly around the perception of the Trust’s commitment to patient care are ofsignificant concern.The Trust is currently implementing an Organisation Development Programme whichhas already highlighted a number of these issues. Through the OrganisationalDevelopment Programme and the response to the staff survey the Trust is committedto take action to address these concerns. Plans to improve the quality of PRDPs andstaff engagement are already progressing.Recommendations: The board is asked to support the attached action plan and toagree its integration with the Organisational Development Programme.Author: Chris Oakes – Director of Workforce Date: 14.04.11

Staff Survey 2010Trust AnalysisIntroductionThis document sets out the key findings from the trust wide survey of staff members. Looking atcomparisons against the previous year and the national average, it also draws on the main pointswhich highlight the Trusts biggest improvements and areas for concern.BackgroundOnce a year, all Trusts are required by the Department of Health (DOH) to survey their staff.Results are used to inform improvements in working conditions and practices.The Princess Alexandra Hospital NHS Trust commissions Picker Institute Europe to survey its staffmembers. The not-for-profit organisation currently surveys 29 acute trusts across England andprovides analysis against the average.A sample of 800 staff members are randomly selected from the internal Electronic Staff Record(ESR) system. The sample reflects the different grades, departments and specialisms across theTrust.The results are used by a variety of organisations to benchmark our performance. For example,the Care Quality Commission (CQC) monitor results of at least 12 of the questions and thesefindings are used in collaboration with other feedback from the Trust to help them understand howthe organisation is performing. They are used in the monitoring of on-going compliance andreviews. The DOH also use the results to inform commissioning, service improvementand performance measurement, and to review and inform NHS policies.In 2010 the CQC set a 60% response rate for acute trusts although the national average onlyreached 50%. The Trust achieved 62.9% - the highest response ever to date, and came 4 thnationally amongst the trusts surveyed by ‘Picker’.Response Rates Broken DownIt is worth noting that whilst the top level results are intended to give a fair reflection of the overallworkforce, the survey should also be analysed by business unit where differences in responsescan be taken into consideration.Business UnitNumber of staffsent a surveyNumber of staff tocomplete thesurveyResponsePercentageElective 219 108 50.5%Emergency 187 113 62.8%Cancer 148 101 73.7%Women’s health 82 57 75.0%Corporate 73 58 82.9%Children’s health 51 25 55.6%Estates/Hotel 40 17 42.5%The survey covers the following subjects:Work-Life BalanceTraining, Learning and DevelopmentYour Job and OrganisationError, Near Misses and IncidentsViolence, Bullying and HarassmentOccupational Health and SafetyInfection Control and HygieneHealth and Well Being1

Results Compared to Last YearHave we improved since the 2009 survey?A total of 128 questions were used in both the 2009 and 2010 surveys. Compared to the 2009survey, we are:• Significantly better on 12 questions• Significantly worse on 9 questions• The scores show no significant difference on 107 questionsAreas the Trust has significantly improved on over the last 12 monthsTraining, Learning and Development2009 2010No taught courses in past 12 months 35% 29%No on-the-job training in past 12 months 64% 57%No mentor in past 12 months 76% 70%No e-learning/online training in past 12 months 76% 61%No keeping up to date with developments in work area 42% 35%Impact of Actions Taken Since 2009 – (assumptions have been made that changes to workingpractice have influenced the survey results)• Training department re-labelled some of the mandatory training courses to tie in with thelanguage used in the survey• A mentorship programme was launched in 2010• The e-learning centre was opened in the same year.Your Job and Organisation2009 2010No appraisal/KSF review in last 12 months 36% 20%No Personal Development Plan agreed in last 12 months 12% 7%Dissatisfied with my level of pay 44% 36%Not consulted about changes that affect work 32% 25%Senior managers do not encourage staff suggestions for improving 36% 26%serviceWould not know how to report fraud, malpractice or wrongdoing 23% 10%• Significant Trust wide focus on completion of PRDPs (reports being discussed at monthlybusiness unit meetings).• Communication from the executive board regarding changes which affect staff has beenincreased and formalised by the way of In Touch with Corporate Affairs briefings andextraordinary Chief Executive presentations.• Increase in the number of senior managers attending Staff Brief to gather information todisseminate to their teams.Violence, Bullying and Harassment2009 2010Trust does not take effective action when staff physically attacked by 7% 4%the publicAreas the Trust has significantly worsened on over the last 12 monthsWork-Life Balance2

2009 2010Trust not committed to staff work/home balance 19% 25%Training, Learning and Development2009 2010No training in how to handle violence to staff/patients/service users 27% 33%Your Job and Organisation2009 2010Appraisal/performance review: left feeling work not valued 34% 42%Often think about leaving current employer 27% 33%Care of patients is not Trust's top priority 14% 21%No opportunities for career progression 31% 39%Would not recommend Trust as place to work 12% 17%Errors, Near Misses and IncidentsIn last month, saw errors/near misses/incidents that could hurtpatients/service usersHealth and Well BeingIn last 3 months, have come to work despite not feeling well enough toperform duties2009 201027% 34%2009 201058% 65%Results Compared to the National AverageHow do we compare to other trusts?In this year's survey, a comparison can be drawn between PAHT and the average for all 'Picker'acute trusts on a total of 140 questions. The survey showed that we are:• Significantly better than average on 9 questions• Significantly worse than average on 31 questions• The scores were average on 100 questionsAreas the Trust faired significantly better than the averageYour Job and OrganisationTrust AverageNo Personal Development Plan agreed in last 12 months 7% 11%Team members do not have to communicate closely with each other 5% 7%to achieve the team's objectivesDo not do more than is required 1% 3%Discrimination from patients / service users, their relatives or other 5% 8%members of the publicDiscrimination from manager / team leader or other colleagues 8% 10%Violence, Bullying and HarassmentTrust AveragePhysical violence from manager / team leader or other colleagues 1% 2%Occupational Health and SafetyTrustAverage3

No access to occupational health services 0% 1%Infection Control and HygieneTrust AverageHot water, soap etc not available to staff 2% 5%Infection control does not apply to me 5% 8%Areas the Trust faired significantly worse than the averageWork-Life BalanceTrust AverageTrust not committed to staff work/home balance 25% 21%Training, Learning and DevelopmentTrust AverageNo on-the-job training in past 12 months 57% 50%No mentor in past 12 months 70% 61%No shadowing someone in past 12 months 70% 61%No e-learning/online training in past 12 months 61% 41%No keeping up to date with developments in work area 35% 25%No equality and diversity training 45% 26%No training in what to do if there is a major incident/emergency 38% 31%No computer skills training 52% 40%No training in how to handle confidential information 34% 20%No training in advising patients on condition/medication 40% 33%No training in how to deliver a good patient / service user experience 45% 38%Your Job and OrganisationTrust AverageDo not have adequate materials, supplies and equipment to do my 33% 25%workNot enough staff at Trust to do my job properly 50% 43%Often think about leaving current employer 33% 28%Dissatisfied with extent Trust values my work 34% 29%Relationships at work are strained 30% 26%Care of patients is not Trust's top priority 21% 13%Senior managers are not committed to patient care 15% 12%No opportunities for career progression 39% 34%Not supported to keep up-to-date with work developments 21% 18%Little / no support for training in area of work 32% 24%Would not recommend Trust as place to work 17% 13%If friend/relative needed treatment would not be happy withstandard of care provided by Trust13% 9%Errors, Near Misses and IncidentsTrust AverageTrust does not treat fairly staff involved in errors 14% 6%Trust does not treat error reports confidentially 7% 4%Trust blames/punishes people involved in errors/near misses or 14% 11%incidentsStaff not informed about errors in Trust 32% 26%Staff not given feedback about changes made in response to reportederrors30% 24%4

Violence, Bullying and HarassmentHarassment, bullying, or abuse from patients / service users, theirrelatives or members of the publicHealth and Well BeingQuite a lot of difficulty/could not do daily work because of physicalhealth in past 4 weeksTrust Average19% 15%Trust Average8% 5%Areas where PAHT’s performance is• Above average• Has improved since last yearKey Points for ConsiderationYour Job and OrganisationPAHT 2010 PAHT 2009 NationalAveragePRDP agreed in the last 12 months 93% 88% 89%Areas where PAHT’s performance is• Below average• Has worsened since last yearWork-Life BalancePAHT 2010 PAHT 2009 NationalAverageTrust not committed to staff work/home balance 25% 19% 21%Your Job and OrganisationPAHT 2010 PAHT 2009 NationalAverageOften think about leaving the Trust 33% 27% 28%Do not feel ‘care of patients’ is the Trust’s top 21% 14% 13%priorityNo career opportunities 39% 31% 34%Would not recommend the Trust as a place to work 17% 12% 13%5

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUSTSTAFF SURVEY 2011ACTION PLANAction By who By when1 Produce Action PlanProduce 4 page brief and 2 page commsVT2 Present Action Plan and briefing to Executive Team CO 08.03.113 Present Action Plan and brief to EMT, feedback by 21.03.11 / present to Staff Side CO 15.03.114 Comments from EMT incorporated as appropriate VT/CO 21.03.115 Staff brief on survey circulated VT w/c 04.04.116 Present to April Trust Board CO 28.04.117 Planning Day – HR / Training / Comms / BU Reps / Chris Birbeck CO w/c 09.05.118 Finalise corporate and business unit action plans CO 29.05.119 Sign off Action Plans Execs/CO w/c 06.06.1110 Monitor implementation of plans OD ProjectBoardJune – on-going

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 9Consideration of Strategic Risk Register – March 2011

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 10Report from Chair of Compliance Committee

Paper for Trust Board 28 th April 2011Report from Compliance Committee: 14 April 2011Key issues discussed• Risk register –now being strongly led by CEO at weekly ED meetings. Somemovement noted. Major review by ED team this month , Expectation RMprocess will become tighter and more dynamic• HSE action plan – Three issues outstanding – Small handling aids funding toremedy approved, Sharps – action plan in place and audit of retractableneedle use programmed, bariatric equipment – not funded and so actual riskto be defined and mitigation plans back to next meeting,• Information governance – compliant with tool kit except in two areas- stafftraining and corporate document management system – action in traincompliance by July• CQC – no major areas of concern• Stat/man training and PDRP – end year performance well in excess ofrequirement . Focus now on quality via PS+Q and also ensuring role specificstat man also tracked. Eg. COSH• RM strategy – further work to do• NPSA alert – one breach ( by one day ) . RCA underway to understand whyand report back• NHSLA- most department breach March milestone and capacity issues putachievement of programme to deliver at risk• Infection control – compliant with plan 2011/12 – issues for 2011/12 due toway target set and conflict between best practice increasing testingparameters some more people tested and meeting target . Work underway atregional/national level to clarify /resolveKey risks• NHSLA level 2 – patient care, reputational , financial ( £250K) and regulatory( authorisation) . further risk definition and mitigation plans to be brought back• HSE- Bariatric – patient care, financial , regulatory , safety - further definitionand mitigation to be brought back• Infection Control –to be defined in light of further information and broughtback with options / mitigationRefer / link to other board committees• PDRP – quality – to PS+Q• Sharps audit retractable needles – in audit plan – to Audit committeeJanet DalrympleNon-Executive Director and Chair of the Compliance Committee18 April 2011

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 11Report from Chair of Patient Safety & Quality Committee including PS&Q TOR

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 12Operational Update 2011/12

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUSTTRUST BOARD 28 th April 2011Issue: MONTH 12 OPERATIONAL REPORTStatus:FOR INFORMATION1. IntroductionThis paper provides Trust Board members with the Operational Report at the end ofMarch 2011.2. AccessA&EDespite the challenges faced by the Trust in terms of capacity both in the ED andacross the Trust the ED is able to provide a safe and effective environment in whichto deliver care to the emergency patients.The acuity and complexity of patients has increased.The numbers of patients being seen has increased.There are fewer patients attending the walk in centre/UCC to map against the Trust shospital activity. A cohort of patients who were previously being seen by theWIC/UCC are being streamed away which has changed the Trust s case mix in theED.Despite the Trust working with the PCT on schemes to reduce activity such asCARS/Case management within the EAU this has not had the desired effect ofreducing the number of admissions to hospital.These issues combined are driving the Trust s under performance.18 weeksAt 3/4/11 our admitted backlog was 670 patients over 18 weeks. Whilst this is slightlylower than we originally projected in December 2010, it presents a significantchallenge for 2011/12. A clearance trajectory has been agreed with ourcommissioners and shared with the SHA. We continue to meet with non-admittedperformance standard.Both of the recovery plans here will be performance monitored at a weekly 18 weekmeeting chaired by the Associate Director for Elective Services and tracked atDirector level through PMGs.DiagnosticsIn terms of the diagnostic element of the pathway, we again saw breaches of the 6week standard in March. Working through the backlog here will be important foradmitted 18 week delivery too, so again a clearance trajectory has been agreed withour commissioners.

CancerAs projected at the last Board, all national targets for cancer were delivered inFebruary and we expect the same consistent delivery in March.3. ActivityNon-elective activity (Emergency and Obstetric combined) for year was 11% overplan and 6.5% up from last year. This mirrored the movement in A&E attendanceswhich increased by 1.7% on last year and 7% over plan.Inpatient elective activity was 21% less than planned and 9% lower than last year.Day cases were 5% over planned and 1% down on last year.First outpatient attendances declined by 8% from last year and were 10% under planwhereas follow ups continue to rise (3% up on last year and 7% over plan).Our contact income increased by 4.9% from last year and was 5.1% over plan.4. QualityInfection ControlIn March we had a worrying increase in C diff cases and three deaths associated. (3pre and 6 post 72 hrs) Dr Visuvanathan called a meeting of senior clinicians,managers, Antimicrobial Pharmacist and ICT to see if there were any trends andfurther actions to take. One room was thought to be a risk of transmission so it wasdecontaminated with hydrogen peroxide at a cost of £1700. Other enhanced cleaningwas instigated on affected wards Dr Visuvanathan will be working further withclinicians to review the antibiotics policy. A new test which will detect C diff in stoolsthat are not liquid may help us to detect C diff in ill patients that do not have classicsymptoms. This may prevent deaths in patients that have the disease but havenegative stool specimens.Norovirus continued throughout March which can explain the increased acquisition ofC diff cases (some patients had both).No further cases of MRSA bacteraemia.1 pre and one post 48 hour ESBL bacteraemia.6 cases of MSSA bacteraemia, 1 was post 48 hour and 5 pre.MRSA screening compliance remains a challenge for all patients. The emergencypatient admitted flow, a revised standard operating procedure, is being introduced.Further training of staff is currently being undertaken by the Matron.For the planned admitted flow, all patients who go through a pre-assessment processare screened.HSMROverall risk rating for the period Feb10 - Jan 11 = 95.1 with the risk rating for January11 at 98.3. A number of alerts have been reviewed at April MRG and discontinued;Amputation of leg, electroconvulsive therapy. New alert added in April; RespiratoryFailure due to increased number of deaths during period October 2010 - January 11.Review being undertaken by Emergency Business Unit.

5.WorkforceEstablishmentThe current vacancy is rate 7.00%. This may change due to the new financial yearestablishment settings.Sickness AbsenceHas been on the rise since August 2010 and went above the target level fromOctober 2010. We began to see a reduction in the first two months of the new year,the figure for February is 4.1% the rolling average is still on target at 3.9%.TurnoverHas been rising over the last 6 months to 12.7% in March. This allows for flexibility inrelation to future workforce changes.PRDP / Statutory Mandatory Training91% compliant for the month of March 2011, which was 11% above the target rate.Statutory / mandatory training is at 87% and also above the compliance level.Agency Usage/SpendOverall temporary staffing has continued at a relatively low level only increasing by£30k from February to March. Bank usage has increased jn the last two monthsmoving from £430K in February to £508k in March; however the vacancy rate hasincreased from 6.7% to 7.0%.6. GovernanceThe Governance Risk Rating has risen to 1 from 0.5 last month as a result of theA&E performance dropping below 95%.Recommendations:The Trust Board is asked to review and note the Operational Report.Author: Andrew Butters, Director of Finance Date: 14 th April 2011Chris Oakes, Director of WorkforceDarren Leech, Executive Director of DeliveryYvonne Blucher, Executive Director, Nursing & Patient CareChris Birbeck, Director of Patient Safety & Risk

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 13Financial Performance Report 2010/11

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUSTTRUST BOARD 28 th April 2011Issue: MONTH 12 FINANCE REPORTStatus:FOR INFORMATION1. Introduction:This paper provides Board members with the Trust financial performance report tothe end of March 2011.2. ReportI am pleased to report that the Trust met all its financial duties in 2010/11:break-evenmanage within its external funding limitmeet its capital resource limitachieve a capital cost absorption rate of 3.5%The Trust is reporting a £652k surplus position for March which leaves a final year todate surplus of £415k. The details can be seen in Appendix 1.Income increased in the month from February, primarily as a result of other incomerising as final invoices were raised for services provided in the year, such as drugrecharges (£221k). Income from other PCTs also rose by £100k in the month.This was offset by an increase in expenditure of £510k for the month, in comparisonto February (Appendix 2). Overall pay expenditure increased by £441k from Februaryto March. This was mainly due to the one off cost of the CEA awards of £390k. Themonthly bill is still £251k (249%), lower than the average monthly pay bill in the firsthalf of the year with the greatest improvement (£94k) in Scientific & Therapeutic staff.Temporary staff remains a focus for reducing costs. The agency pay bill represents2.69% of the total pay bill in March, a reduction from a high of 8.1% earlier in theyear. Non-pay costs also increased by £69k from February to March, the majority ofthis relating to a £420k adverse adjustment due to lower stock levels, this been offsetby a one off adjustment of £300k for the reduction in the annual leave accrual.The rolling star chamber meetings with budget holders to stimulate and monitorsavings plans continue. The progress to date in identifying and progressing savingsplans is set out in the following table:Gateway Analysis M12 M11 M10Idea - not costed in any detail (0) 683 683 672Costed plan exists, but not actioned (1) 848 848 1,306In progress (2) 289 574 457Budgets adjusted (3) 5,204 2,244 1,863Total 7,024 4,349 4,298The Gateway analysis now includes the impact of the reduction in bank and agencycharges in the year (£2.6mn), since these have been included in the 2011-12budgets.

The Trust ended the year with £4.4 million in the bank. A balance sheet is attachedas Appendix 4.The Financial Risk Rating has remained at 3 (Appendix 5).Author: Andrew Butters, Director of Finance Date: 19 th April 2011

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 15Report from Chair of Business & Performance Committee

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 16Report from Chair of Audit Committee

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 17FT Application Update

The Princess Alexandra Hospital NHS TrustTrust Board Meeting28 th April 2011Part AExecutive SummaryCompliance Checklist (to be completed by Trust Secretary)GovernanceEqualities ImpactFinanceLegal ImplicationsCommunications IssuesRisk and Health and Safety IssuesIssue:Foundation Trust UpdateSummary:This paper provides the board with an update on activitiesrelating to the trusts aspiration to achieve Foundation Trust(FT) status.It also includes a report showing the outcomes from our 12week consultation process.Recommendations:To note the content of the update and to consider theresponses to consultation questions.Author:Darren Leech, Executive Director of DeliveryDate: 14 th April 2011

Trust Board 28 th April 2011Foundation Trust (FT) UpdateIntroductionThis paper provides the board with an update on all activities relating to the Foundation Trustapplication process.ConsultationThe consultation process ended earlier this month. A full report on the consultation processand the indicative outcomes is attached. The board are asked to note and consider thefeedback from the consultation process.Project plan and SHA deadlinesIn terms of the schedule of deadlines agreed with the SHA previous, we did submit draftchapters on 31 st May, as evidence of progress. At the time of writing we have not receivedany formal feedback, only recognition that we met the deadline.As per the last briefing, the SHA have indicated their desire to have a “Board to Board” and Iunderstand that the date of this is now set for the 7 th June 2011.IBP and Board DevelopmentTo summarise for colleagues, we have continued to map progress for each IBP chapter and“where we are” in table format. Feedback from Executive and Non-Executive colleagues hasbeen forthcoming and useful during the drafting process. This summary reference documentis attached for information.I have prepared a specification for third party scrutiny and support for IBP chapterdevelopment and expect us to have secured this input by the beginning of May. Related tothis, the specification for the proposed “shadow historical due diligence (HDD)” processindicatively planned for June is also being prepared based upon a specification helpfullyprovided by colleagues at the SHA.We have a scheduled development session relating to clinical strategy on the 26 th April, towhich the whole board has been invited along with local GPs and lead clinicians. This eventwill be a discussion format event, designed to be the first of a series of events to help usformulate a robust and well supported clinical strategy.I will be attending, along with colleagues an SHA organised “FT Masterclass” at Fulbourn onthe 20 th April. I understand that this event aims to share the experiences of colleagues atKing’s Lynn, who are one of the few acute trusts recently authorised by Monitor. I intend tocirculate notes and any materials to board colleagues after the event.Darren LeechExecutive Director of Delivery 14 th April 2011

ConsultationReportYour Views On Our Application ToBecome an NHS Foundation TrustApril 2011

1.0 IntroductionThe Princess Alexandra Hospital NHS Trust held a 12 week public consultationwhen we asked for people’s opinions on our plans to become an NHSFoundation Trust, and whether our priorities were right for the hospital and thecommunity we serve.An extensive engagement exercise was initiated, and information was madeavailable throughout the hospital, and widely distributed to public organisationsand voluntary groups across the county.Public meetings were held within the hospital and two other local towns, and staffwere invited to an open session or to hear about our plans at their owndepartmental meetings.This is the second formal consultation that the Trust has undertaken, and thetotal number of responses between the two exercises is 406. The majority ofkey stakeholders across the region have responded to either one or both ofthese.The Trust’s intentions remain well supported by a public membership of 4950people, including representation from the main stakeholders who have beenidentified as potential governors.The consultation ran from Monday 17 January until Monday 11 April.

2.0 Engagement ActivityThe Communications Team worked alongside the Executive Director of Delivery,Associate Director for Planning and the Patient and Public Involvement Coordinatorto undertake the activity.The activity compromised of online and offline channels including press releases,an advertorial in the local newspaper, website banner and a page on the PAHwebsite and twitter. The detailed campaign breakdown can be found in AppendixOne.• Over 35,000 visited the PAH website• 663 people viewed the Foundation Trust home page• 16,000 letters were sent to patients• 4,000 public members were contacted• 150 stakeholders/VIPs were sent information• 37 individuals, group or organisational representatives attended one ofthree public meetings. Including:o West Essex Community Health Serviceso Hertfordshire LINKso Essex LINKso The Rivers Hospitalo Addison House GP Practiceo Harlow Hospital League of Friendso St Clare Hospiceo Hertfordshire County Councilo Harlow Stroke Associationo Harlow Against Cutso Patient Councilo PAH Volunteers• Corresponded with over 4,000 public members via letters and emails.• Presented our intentions at 13 internal hospital meetings.3.0 The QuestionsSix questions were asked to help determine if the objectives the organisation hadset are supported by the community.1. Do you agree with our plans?2. Are there any other key areas or issues which you would like the Trust toconsider over the next five years?3. Do you agree with the proposed minimum age for a member being 14?4. Do you agree with our proposal for an out of area Governor?5. Do you agree with the proposed structure for the Council of Governors?

6. Do you agree that the Governors should serve a three year term, and thatelections should be held every three years?4.0 The Results24 consultation acknowledgements were received from individuals, groups andorganisations covering: East Hertfordshire Council, Harlow Council, St ClareHospice, South Essex Partnership NHS Trust, MP Mark Prisk’s Office andAddison House GP Practice. The 12 formal consultation responses i.e. answersto the questions are shown in the table below.Table 1: FT Consultation ResponsesQuestions Yes No NoAnswerComment Themes1. Do You Agree With Our Plans 12 1. Concerned early release is afalse economy until adequatecommunity staff and trainingare available2. Are There Any Other Areas of IssuesYou Would Like the Trust To Consider?3. Do You Agree with the ProposedMinimum Age for a Member Being 144. Do You Agree With Our Proposals forAn Out of Area Governor?5. Do You Agree With the ProposedStructure for the Council of Governors?6. Do You Agree That Governors ShouldServe a Three Year Terms and ThatElections Should be Held Every ThreeYearsGeneral Comments5 6 1 1. Dementia2. Renal Unit3. Give relevant information topeople who are carers4. Improve internalcommunications and clericalservices to medics andpatients9 3 1. Yes this encourages youngpeople2. Too young and may bevulnerable12 1. Provided they havespecialist knowledge9 1 2 1. Mental Health Rep2. Media Rep3. Police Rep4. Extra Medical Governors5. Educational ProvidersQMUL9 2 1 1. Suggested 1/3 governors bere-elected each year and servea three year term to getcontinuity1. It is imperative that shadowcouncil of governors is set upnow to show memberssomething positive is beingdone.

Evidence of the consultation and engagement process is available in AppendixTwo.The formal consultation findings showed that:• Question 1: 100% of people agreed with our plans• Question 2: 41% said there are other areas they would like the Trust toconsider• Question 3: 75% of people agreed with the proposed minimum age as 14Do You Agree With the Proposed Minimum Age for AMember Being 14?108No ofResponses6420YesAnswerNo• Question 4: Everyone supported the proposal for an out of area governor• Question 5: 75% agreed with the proposed structure. Instead suggestedgovernors should be representatives from the police, other educationalinstitutions and more medical professionals.Do You Agree That Governors Should Serve a ThreeYear Terms and That Elections Should be Held EveryThree YearsNo ofResponses10864209211 2 3Answers• Question 6: Two people disagreed with the proposal for serving a threeyear term.

5.0 Comments and ThemesThere were a number of recurrent themes and comments raised throughout theduration of the twelve week consultation exercise. These are detailed below:• Care in the Community – people were curious about how care could bemoved from a hospital setting if there was a lack of adequate provision inthe community.• Achievement of Foundation Trust Status – questions were asked aboutthe application timetable and the Government’s intentions with FoundationTrusts. There were obvious concerns raised about the future of the Trustif the application was unsuccessful.• Level of investment within the NHS – the plans that were presentedprompted debate and dialogue about the future of the NHS and how carewill be delivered within a smaller budget.• Engagement with the local community, including the representativeson the Council of Governors – a few of the consultation responses havehighlighted the need to extend the number of governors to cover otherstakeholders e.g. the police, media, mental health trusts and othereducational institutions.• Membership and members - various questions were raised over themembership targets, current numbers to dates and how we are planningon getting more young people on board.A detailed breakdown of the consultation events and the questions that wereraised can be found in Appendix Two.6.0 Membership Figures353 public members were recruited and 37 people left (deceased or movedaway). The Trust has 4950 public members to date, and 3380 staff members,and remains well on track to achieve the 2012 target of 9000 members.During 2010/11 the membership database was under-represented in over 75s,socio economic group E, and men. In anticipation the Trust focused its efforts onrighting these figures.According to Membra, the only under-represented area remains for men, afurther 75 people need to be recruited for the membership figures to correlatewith the demographic profile of the local population. This will be the focus offuture membership drives. A further demographic breakdown of our membershipcan be found in Appendix 4.7.0 Conclusion and RecommendationsThe Trust’s intentions continue to be supported by the local community,organisations and charitable groups, and the Trust is on trajectory to meet the2012 membership targets.

The following are suggested for areas of debate in light of the feedback:• Composition of the Council of Governors to ensure that key groups arerepresented• Age that members can join• The outcome for the Trust if FT status is not obtained and how that iscommunicated to the wider community• Ongoing engagement and involvement of members

Appendix One: Campaign BreakdownThe Princess Alexandra Hospital NHS Trust’s FT Stakeholder Engagement Plan 2011Month Activity Audience IntendedNos – ifknownJanuaryInternal EngagementCommentsInternal Meeting: Extraordinary Staff and Consultants All PAH Staff 100 Agenda Item – doneInternal Meeting: Chief Executive Staff Briefing Senior Managers 45 JanuaryFebruary 4 thSMH 11 th - JWDInternal Meeting: Trust Board Meeting Board 20 27th January 2011Internal Meeting: Extended Management TeamExecutivesAssociate DirectorsClinical Directors24 th February 201130 1 February 2011Internal Meeting: Nursing and Midwifery Nurses 20 3 March 2011Internal Meeting: MAC Doctors 18 11 th FebruaryInternal Meeting: Patient Council/LINKs Members 8 10 th February 2011Internal Meeting: JLNC Staff 15 March 2011Internal Meeting: Business Units Board Meetings BU senior managers 150PR & Comms: Website and IntranetStaffThe PublicPR and Comms90,000average permonthFront page from Thurs 3 FebPR and Comms: FT Consultation Mailout/Email Out Members 8,000 Thurs 27 th January & w/c 1 Feb –PR and Comms: Intouch with Corporate Affairs All 3,000 Tues 18 JanuaryPR and Comms: FT roadshow (campaign boards and displays) PAH Staff, Patient and Visitors Displayed from 24 January

External EngagementFebruaryExternal: Patients Patients From 7 February 2011External: Eoe SHA SHA Board Endorsement via IBP sign offExternal: Meeting with Local MPs: Robert Halfon (cons), BillRammel (lab), David White (lib dem) & Eddie Butler (BNP).External: NHS West Essex & NHS Hertfordshire Provider andCommissioner armMPs 4 Sent Monday 14 th January (2 nd class)PCT Boards 30 Sent Monday 14 th JanuaryExternal EngagementExternal: Harlow 2020 Partners 8 Sent Monday 14 th JanuaryExternal: Harlow College College Executives Sent Monday 14 th JanuaryExternal: Harlow League of Friends Volunteers 40 Agenda Item - FebExternal: Harlow Renaissance Board 3 Sent Monday 14 th JanuaryExternal: The Deanery Senior Staff Sent Monday 14 th JanuaryExternal Healthcare EngagementExternal Healthcare: Essex & Herts Health Overview and Board Sent Monday 14 th JanuaryScrutiny CommitteeExternal Healthcare: PELC (out of hour’s GP) Senior Staff Sent Monday 14 th JanuaryExternal Healthcare: Moorfield’s Eye Hospital Senior Staff Sent Monday 14 th JanuaryExternal Healthcare: Herts Urgent Care Centre Senior Staff Sent Monday 14 th JanuaryExternal Healthcare: Ramsey Healthcare, Holly House Senior Staff Sent Monday 14 th JanuaryPractice, Nuffield House, Spire Hartswood, Spire RodingExternal: Harlow, Essex & Bishops Stortford Chamber of Members Sent Monday 14 th JanuaryCommerceExternal Healthcare: Runwood Homes Senior Staff Sent Monday 14 th JanuaryExternal Healthcare: St Clares/Isobel Hospice Senior Staff Sent Monday 14 th JanuaryExternal Healthcare: Uttlesford, Harlow and Epping PBCLeadsPartner Sent Monday 14 th January

External Healthcare: Addenbrookes, East and North Herts, Board Sent Monday 14 th JanuaryMid Essex, Whipps Cross, Barnet and Chase FarmExternal Healthcare: Basildon, UCLH and North Mid Board Sent Monday 14 th JanuaryExternal Healthcare: North Essex Partnership NHSFoundation Trust/SEPTExternal Healthcare: Dentists, Nursing Homes andPhysiotherapistsBoard Sent Monday 14 th JanuaryExternal Healthcare: EoE Ambulance Service NHS Trust Board Sent Monday 14 th JanuaryExternal Charities EngagementExternal Charities: Age Concern Members Sent Monday 14 th JanuaryExternal Charities: Alzheimers Society Members Sent Monday 14 th JanuaryExternal Charities: Epping Breatheasy Members Sent Monday 14 th JanuaryExternal Charities: Epping Forest CVS Members Sent Monday 14 th JanuaryExternal Charities: Essex Blind Charity Members Sent Monday 14 th JanuaryExternal Charities: Harlow Centre for Voluntary Support Members Sent Monday 14 th JanuaryExternal Charities: Harlow Sight Support Group Members Sent Monday 14 th JanuaryExternal Charities: Harlow & Loughton Stroke Support Members Sent Monday 14 th JanuaryExternal Charities: Harlow WRVS Members Sent Monday 14 th JanuaryExternal Charities: MS Society – East Herts and West Essex Members Sent Monday 14 th JanuaryExternal Charities: Parkinsons Disease Society – Harlow Members Sent Monday 14 th JanuaryExternal Charities: West Essex Mind Members Sent Monday 14 th JanuaryExternal Council EngagementExternal Council: Hertfordshire and Essex County Council Councillors Sent Monday 14 th JanuaryExternal Council: East Herts District Council Councillors Sent Monday 14 th JanuaryExternal Council: The Bishops Stortford Town Council, EppingCouncil, Harlow Council, Uttlesford CouncilCouncillors Sent Monday 14 th January

PR and CommsPR and Comms: Advert in the three local newspapers General Public 258,000 Press Release – Sending 16 FebPR and Comms: Radio Feature via Heart Radio General Public Radio InterviewPR and Comms: Monthly Health Column in the Newspaper Local Population Feature - FebPR and Comms: Hospital Radio Interview Hospital Patients 500 Radio InterviewPR and Comms: FT Consultation Meetings email out Members regarding meeting dates 8,000 17 Feb 2011PR and Comms: Patients Appointment Letters Meeting Dates JanuaryInternal Meetings: Staff Communications PAH – 23 Feb - 30MarchPR and CommsPR and Comms: Roadshows in local libraries General Public Campaign material issuedPR and Comms: Have your Say Events:BSHarlowEppingLocal People 100

Appendix Two: Consultation and Engagement EvidenceEngagementActivity Topic/Issue EvidenceMeeting Extraordinary Staff and CEO Briefing (January 2011) PresentationMeeting CEO Briefing (January 2011) CEO Briefing DocumentMeeting Trust Board Meeting (January 2011) Trust Board PapersMeeting EMT (1 February 2011) EMT PaperMeeting Nursing and Midwifery Meeting (1 February 2011) MinutesMeeting MAC (11 February 2011) MinutesMeeting Patient Council (10 February 2011) MinutesMeeting JLNC (15 March 2011) MinutesMeeting Womens and Childrens BU Meeting (21 March 2011) AwaitingMeeting Facilities BU Meeting (1 March 2011) MinutesMeeting Estates BU Meeting (24 February 2011) AwaitingMeeting Governance BU Meeting (15 February 2011) AwaitingMeeting Workshop Meeting MinutesMeeting Public Meeting Rhodes Centre AttendanceMeeting Public Meeting Trust Board Attendance - ScanMeeting Public Meeting St Margarets Hospital Attendance - ScanMeeting General Staff Meeting PAH PresentationPR & Advertising PAH Website Image ScreenshotPR & Advertising PAH Intranet ScreenshotPR & Advertising Website/FT hit rateGoogle Screenshow -AwaitingPR & Advertising Staff Dates Poster PosterPR & Advertising FT Consultation Mail Out with Patient Letters LetterPR & Advertising FT Consultation Mail Out to FT members LetterPR & Advertising FT Consultation Email Out to FT members EmailPR & Advertising FT Consultation Mail Out/Email to VIPS LetterPR & Advertising FT Consultation Mail Out to Consultants LetterPR & Advertising Intouch With Corporate Affairs Email FT Annoucement EmailPR & Advertising Intouch Weekly Bulletin BulletinPR & Advertising Global Email Advertising the Dates EmailPR & Advertising Press Release Press ReleasePR & Advertising FT Roadshows Presentation PresentationsPR & Advertising Monthly HealthColumn TextPR & Advertising FT Consultation Document Consultation DocumentPR & Advertising FT Consultation Follow Up Correspondence Email EmailPR & Advertising FT Consultation Follow Up Correspondence Letter LetterPR & Advertising CEO Departing Message LetterPR & Advertising New CEO Welcome Message Email

Appendix Three: Consultation feedback and questions24 th February 2011 @ Princess Alexandra Hospital• Why are your Trust Board meetings only held during the day?• Who are your key stakeholders (specific relation to stakeholdersnominating a governor)?• How will you communicate with such a vast audience?• Is it right that only FT members can nominate Governors?• If you move care into the community will you close wards?• How will you overcome the issue of people passing on their badexperiences via social networks?• Will manager’s pay be monitored (as an FT)?• With regards to improving community care sometimes people getdischarged too early and return back to the hospital.• Do you use intermediate care beds?• As an FT will staff pay be varied from the national rates?1 st March 2011 @ St Margaret’s Hospital, Epping• If you move care into the community that means social care surely?• Is Sydneham House shut?• If you use surpluses to reinvest, what happens if you run out of cash?• If we open the market to private companies then surely we are opening upthe potential for more adverse incidents because of a lack of consistencyin care?• If we give GPs more money and authority. How will it affect the patients?• It appears that consultants are being paid to do more for less?• What is happening with retinal screening in the community?• Will the hospital decrease in size if the demographics profile is shifting?• How will the step change in policy affect staff?10 th March 2011 @ Rhodes Centre, Bishops Stortford• Do all Trusts have to be FTs by 2013?• Why can’t we seem to get more young people along to these events?

• How will local businesses appoint a governor?• Do you have to increase your membership through the duration of thisconsultation?• How many members are you looking to recruit?• Will young people really be able to add to the process based on theirlimited experience?• If you are having trouble attracting young people, why don’t you attend thelikes of the CazFest and so forth?• How are we informing, men in particular, about the likes of prostatecancer?• How will you reduce your activity?• How many people did you invite to this meeting?• Will you use models such as the virtual care ward?

Appendix Four: Public membership breakdownPublic% of MembershipAge 4,950 100.000-16 6 0.1217-21 149 3.0122+ 4,351 87.90Not stated 444 8.97Age 22+ 4,351 87.9022-29 382 7.7230-39 621 12.5540-49 573 11.5850-59 624 12.6160-74 1,289 26.0475+ 862 17.41Gender 4,950 100.00Not Stated 229 4.63Male 1,770 35.76Female 2,951 59.62Ethnicity 4,950 100.00White - British 3,730 75.35White - Irish 59 1.19White - Any other White background 225 4.55Mixed - White and Black Caribbean 5 0.10Mixed - White and Black African 12 0.24Mixed - White and Asian 5 0.10Mixed - Any other mixed background 15 0.30Asian or Asian British - Indian 98 1.98Asian or Asian British - Pakistani 26 0.53Asian or Asian British - Bangladeshi 17 0.34Asian or Asian British - Any other Asian background 36 0.73Black or Black British - Caribbean 25 0.51

Black or Black British - African 96 1.94Black or Black British - Any other Black background 19 0.38Other Ethnic Groups - Chinese 8 0.16Other Ethnic Groups - Any other ethnic group 44 0.89Not stated 530 10.71ACORN Socio-Economic Category 4,950 100.00Wealthy Achievers [1] 1,218 24.61Urban Prosperity [2] 304 6.14Comfortably Off [3] 1,283 25.92Moderate Means [4] 996 20.12Hard Pressed [5] 792 16.00Not available [NA] 357 7.21ONS/Monitor Classifications 4,950 100.00ABC1 2,779 56.14C2 914 18.46D 972 19.64E 285 5.76HealthACORN Group 4,950 100.00Existing Problems [1] 341 6.89Future Problems [2] 278 5.62Possible Future Concerns [3] 2,271 45.88Healthy [4] 1,944 39.27Not Available [NA] 116 2.34Total membership 4,950 100.00

IBP CHAPTER PRODUCTION : position @ 14.04.11IBP Chapter First Draft NED Review 3 rd Party SHA Review Final SHAcompleteReviewsubmission1. Executive Summary End April End May N/A End May End October2. Trust Profile Complete CompleteReviewed @ NEDsession 22.023. Strategy Complete CompleteReviewed @ NEDsession 22.024. Market Assessment End MarchIn production5. Service D’mentPlansEnd AprilWith Exec Team forreview6. Finance & LTFM End March End AprilHeadline review withNEDs 15.037. Risk End AprilWith Exec Team forreview8. Leadership andEnd AprilIn productionEnd AprilEnd AprilEnd MarchSent for review 31.03End MarchSent for review 31.03End OctoberEnd OctoberEnd April End May End May End OctoberEnd May End June End May End OctoberEnd MayEnd MarchSent for review 31.03End OctoberEnd May End June End May End OctoberEnd May End June End May End OctoberWorkforce9. Governance Complete End April End April End March End OctoberCirculated to NEDs forSent for review 31.03comment 04.04Assurance Documents. End May End May N/A End May End OctoberO CompleteO InitiatedO Beyond deadline

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 18Chair’s Report

THE PRINCESS ALEXANDRA HOSPITAL NHS TRUSTCHAIRMAN’S MAIN APPOINTMENTSApril 20115 April Attended Estates Department Team meetingMet with NED CandidateHad meeting with Communications regarding the Chairman’s Blog6 April Attended NHS Employers Board Meeting Leeds12 April Met with Sandra Canning, Chair of Hospital League of FriendsAttended Hip Fracture MDT13 April Met with Dr Salam Al-SamMet with Chief Executive14 April Had Telecon with NED CandidateAttended Compliance CommitteeMet with Janet Walter from NHS IMASMet with Director of QIPP and Performance20 April Visited the Canal Boat Project – local charitable organisationHad meeting regarding Art in the HospitalAttended Essence of Care Walkabout with Director or Nursing andPatient Care21 April Attended the Audit Committee meeting26 April Attended Clinical Summit Board SessionAttended Business & Performance Committee meetingAttended Board Development Seminar27 April Met with Dr MichailHosted meeting with Hertfordshire County Council re ShadowHealth and Wellbeing Board

Trust Board Meeting – 28 th April 2011PART AAGENDA ITEM 19Minutes from Research & Development Committee

Research & Development Committee MinutesMeeting name& venueMeeting date& timeAttendeesApologies forabsenceNot PresentIn AttendanceResearch & Development Committee – Training Room 2, Parndon Hall, PAHFriday 11 th February, 2011 – 08.00 hrs. to 09.00 hrs.Dr. Sylvia Thompson – Chair – R&D CommitteeRob Duncombe – Chief Pharmacist & A.D. Cancer & Core Business UnitTerry Clarke – Lay Member – R&D CommitteeCarol Keel – Site Research Nurse Co-ordinator – CLRNChris Cook – Research & Innovation (Interim Clinical Effectiveness) ManagerJohn Hassler – Management AccountantAndrew Foster – Clinical Skills FacilitatorAdrian Cullen – Head of Cancer ServicesShelley Brown – Specialist Biomedical Scientist – Cellular PathologyRichard Brown – Senior Biomedical Scientist – Cellular PathologyHannah Prince – Library ManagerTessa Light – Research Co-ordinator – Cancer ServicesEvelyn Holmes – Haemato-Oncology PharmacistDr. Dev Dutta – Consultant Anaesthetist – Vice Chair – Medical LeadDr. R. Sethuraman – Consultant AnaesthetistDr. Salam Al-Sam – Consultant HistopathologistDr. Vasi Sundarasen – Consultant HistopathologistDr. Deya Elsandabesee – Consultant for Women’s HealthAlly McInroy – Head of Customer Services & ComplaintsJill Troup – Head of Cardiac & Stroke ServicesPaul Roberts – Manager – Cluster 3 – Essex & Herts Comprehensive Local Research NetworkAction Taken/Outstanding (from previous meeting)Action Complete191110/13 – Provision of Chemotherapy Nurse to Galen house additional tothe £88k contingency funding – does not fall within the remit of the criteriaresearch funded posts.Page 1 of 5By Whom By When

171210/03 Proposal to be considered for a Research Nurse post in ICU toenable further research – CK investigated – support for data collectionrequired – Data Manager involvement agreed140111/04 - ST sent feedback to Dr. Y. Barlow to advise on the way forwardwith the Nationally Validated Trigger Tool at PAHTAction Outstanding221010/09 – R&D Portacabins – Chase schedules with Project Management100910/09 – Honorariums & Process to be developed for ST/TC & CAC BU280510/10 – Update Terms of Reference191110/04 - Submission made to the CLRN to support Dr. Jader –Consultant Histopathologist for her involvement in Breast Research trials,and involvement with the HTA Licence191110/06 – Operational Capability Statement - Timeline to be confirmedwith the Cluster 3 Manager of the CLRN – ongoing – RSS Framework groupto meet in April, 2011Ongoing – MHRA Inspection171210/03 - PA Sessions for ICU & Cancer Services to be processed in thenew financial year.171210/03 - £88k contingency funding to provide pathology support thecancer trials becoming increasingly pathology heavy, also PharmacyTechnician post to support the Research Trial Pharmacist171210/05 - DD’s clinical commitments are presently clashing with the R&DCommittee meeting dates - to be reviewed.171210/10 Further enquiries regarding the proposed changes to the nationalresearch strategy to be made.CCCCCCCC/STCCALLJHST/CCCCTC11.2.11OngoingOngoing11.3.11OngoingOngoing30.4.11Urgent11.2.11OngoingAgenda Ref. Topics Minutes By Whom By When110211/02 Minutes of Agreed as a True and Accurate RecordMeeting110211/03 MattersArisingNone – all noted in Actions table above.Page 2 of 5

110211/04 ProjectReviewsFull Review574 – AF/ST/JHExperiences of Patients Participating in a Rheumatology Trial- Manju Joy - Research NurseApprovedSubstantial Amendment489-220208 – HP/AC/JHNational Diet and Nutrition Survey 2008-2012MRC Human Nutrition ResearchAmendment 9 dated 19/08/2010Amendment 10 dated 08/11/2010Approved to ContinueCLRN Studies110211/05 TranexamicAcid for TotalKneeArthroplastyand Timing ofAdministration110211/06 Allocation ofProjectsReceivedWhitehall IIPR Agreed that the Trust’s local declaration form can be used to support SSIto prevent further delay.The draft proposal for this study had been presented to the Committeepreviously by Dr. Sethuraman with a view to further guidance being available.RD suggested that the study could be simpler as it was based on a NICEstudy and requested that RS met with him to discuss further. CC to forwarda protocol template to RS.NoneCCRSCCPage 3 of 5

110211/07 Update ofOngoingProjects110211/08 NIHRResearchSupportServicesFramework110211/09 R&D FinanceReportReport circulated.Suggested Minimum Requirements for the Letter of NHS Permissions –Portfolio StudiesIt was agreed that much of the information suggested on the template wasalready provided on PAHT’s approval letters, however the idea ofstandardised information adopted nationally was welcomed. Issues raisedwere:-• To be used for both portfolio and non-portfolio?• Finance permission to be given rather than approval, with a genericstatement to be included to reflect this.ST/CC to compare this to the existing Trust approval letter and to considerthe funding statement within it.RSS FAQsThe committee are to read and take queries and further questions for clarityto CC.Substantial AmendmentsDue to a required turnaround of 30 days for substantial amendment approvalthe NLCRN requested information, via email, from the various NHS Trusts onhow the individual Trust Substantial Amendment processes operate, statingthat UCLH Amendments for cancer studies are automatically approved if noobjections are raised within 7 days. This has been raised as a major PS&Qissue with Essex & Herts CLRN and their opinion sought. ST/CC/CK are tomeet with the NLCRN & CLRN in March to discuss this along with otherissues, however in the meantime assurance was given that PAHT will notadopt this method of substantial amendment approval.Activity Report/CEO ReportST referred to this CLRN document which reflects that research at PAHT hasbeen a resounding success over the past year, suggesting that researchwould probably now remain sustainable rather than grow much further. PRintimated that activity will probably decrease as keeping up that standardwould prove difficult, but to develop research into new areas that have notpreviously been research active is the way forward. Future portfolio trials willbe weighted in the forthcoming year so that more Randomised Control Trialsare adopted across the region rather than the observational type studies thatPage 4 of 5ST/CCALL

ing in high recruitment. In the very near future the CLRN are going to takea snapshot look at recruitment on a weekly basis and report to the teams in atimely manner. It was agreed that the lack of accommodation to facilitate theresearch nurse support and clinical space must be raised again as a highpriority. ST concluded that PAHT’s ranking was now in the top quartile andsat above some of the recognised important research active Trusts acrossthe region, thanking the Committee for their hard work over the last year.FinanceJH explained the details of the R&D budget statement, the CLRN being inagreement that the contingency funding could be rolled forward into the nextfinancial year along with the PA sessions. It was agreed that the researchbudget was looking very healthy. The Quarter 3 CLRN return was agreed.110211/10 Any OtherBusiness110211/11 Date of NextMeetingST/CC/CK had recently attended the Essex & Herts CLRN AnnualConference, which was well thought through with opportunities fornetworking, workshops and information stands. The CLRN held a prizegiving ceremony at the beginning of the day with PAHT winning 2 out of the 6prizes, these were for An outstanding achievement by the team and seeingthrough the implementation of particularly challenging initiatives, the secondbeing An outstanding achievement by the team.PR asked if the GCP course at PAH could be distributed further as therewere 20 places available and only 7 members of staff registered.New IT systems are to be adopted in the coming year; training will beavailable at the end of June, 2011.CC raised a governance issues with the substantial amendmentdocumentation for IBIS II trial, it appears that an amendment dating back toSeptember 2009 had been overlooked; at first glance it looks as though theCommittee were not quorate and therefore the review should have beendone electronically via email but had been missed. CC to investigate andfeedback.The Research Lead for the NEMHPFT has approached ST with a view toPAHT leasing some of their property to resolve the Research Nurse officeaccommodation situation. ST/CC to meet with him to take forward.Friday 11 th March, 2011 in Training Room 4, Ground Floor, Parndon Hall,PAHT.9th April, 2011Page 5 of 5

Research & Development Committee MinutesMeeting name& venueMeeting date& timeAttendeesApologies forabsenceNot PresentResearch & Development Committee – Training Room 4, Parndon Hall, PAHFriday 11 th March, 2011 – 08.00 hrs. to 09.00 hrs.Dr. Sylvia Thompson – Chair – R&D CommitteeRob Duncombe – Chief Pharmacist & A.D. Cancer & Core Business UnitTerry Clarke – Lay Member – R&D CommitteeChris Cook – Research & Innovation (Interim Clinical Effectiveness) ManagerEvelyn Holmes – Haemato-Oncology PharmacistDr. R. Sethuraman – Consultant AnaesthetistDr. Salam Al-Sam – Consultant HistopathologistDr. Vasi Sundarasen – Consultant HistopathologistRichard Brown – Senior Biomedical Scientist – Cellular PathologyHannah Prince – Library ManagerTessa Light – Research Co-ordinator – Cancer ServicesCarol Keel – Site Research Nurse Co-ordinator – CLRNAndrew Foster – Clinical Skills FacilitatorShelley Brown – Specialist Biomedical Scientist – Cellular PathologyDr. Dev Dutta – Consultant Anaesthetist – Vice Chair – Medical LeadDr. Deya Elsandabesee – Consultant for Women’s HealthJohn Hassler – Management AccountantAdrian Cullen – Head of Cancer ServicesAlly McInroy – Head of Customer Services & ComplaintsJill Troup – Head of Cardiac & Stroke ServicesAction Taken/Outstanding (from previous meeting)Action Complete171210/05 - DD’s clinical commitments are presently clashing with the R&DCommittee meeting dates - to be reviewed.110211/05 CC to forward a protocol template to RS.By Whom By WhenPage 1 of 5

Action Outstanding221010/09 – R&D Portacabins – Chase schedules with Project Management100910/09 – Honorariums & Process to be developed for ST/TC & CAC BU280510/10 – Update Terms of Reference191110/04 - Submission made to the CLRN to support Dr. Jader –Consultant Histopathologist for her involvement in Breast Research trials,and involvement with the HTA Licence191110/06 – Operational Capability Statement - Timeline to be confirmedwith the Cluster 3 Manager of the CLRN – ongoing – RSS Framework groupto meet in April, 2011Ongoing – MHRA Inspection171210/03 - PA Sessions for ICU & Cancer Services to be processed in thenew financial year.171210/03 - £88k contingency funding to provide pathology support thecancer trials becoming increasingly pathology heavy, also PharmacyTechnician post to support the Research Trial Pharmacist171210/10 Further enquiries regarding the proposed changes to the nationalresearch strategy to be made.110211/04Whitehall II Study - Trust’s local declaration form to used tosupport SSI to prevent further delay.110211/08 ST/CC to compare this to the existing Trust approval letter and toconsider the funding statement within it.110211/10 CC to investigate and feedback on IBIS II Substantial AmendmentGovernance issue.110211/10 ST/CC to meet with Research Lead for NEMHPFT to discussrenting accommodating for research team.CCCCCCCC/STCCALLJHST/CCTCCCST/CCCCST/CC11.2.11OngoingOngoing11.3.11OngoingOngoing30.4.11UrgentOngoing11.3.11Agenda Ref. Topics Minutes By Whom By When110311/02 Minutes of Not available.Meeting110311/03 MattersArisingSee Actions table above.Page 2 of 5

110311/04 Dates ofFutureMeetings110311/05 Trial of NewChecklist –NLCRN110211/06 ProjectReviewsDD sent an email stating that the dates causing problems were 15 th May, 21 stOctober, 18 th November and 16 th December, 2011. It was agreed that thesedates would be changed to either the week before or after enabling DD toattend.The Committee agreed that this would be a good standard tool to use.ST/CC to take to the Colchester meeting with the CLRN/NLCRN to discussfurther and to incorporate substantial amendment documentation.Full Review - NoneSubstantial Amendment - For R&D committee general review:497-220808 – Non Portfolio StudyLong Term Sequelae of Radiation Exposure from Computed Tomography inChildren and Adolescent – a No Local Investigator StudyJane Salotti – Institute of Health & Society – Newcastle UniversityCC explained that the PI wished to obtain ECC NIGB approval for anamendment to the study protocol. They have recently secured furtherfunding for the study and extending data collection to cover 1985-2010. Datacollection will remain retrospective across many of the sites already includedin this study and will increase the cohort size to 400,000 from 250,000. Thenew end date of the study will be 31/09/2015 and the data storage extendedto 15 years from the new study end date.Study methods are unchanged. Approval for the amendment has beenreceived from the Newcastle & North Tyneside Research Ethics CommitteeAs this was a continuation of the original study and low risk as a datacollection No Local Investigator Study it was agreed that this could continueand therefore approved.CCST/CCPage 3 of 5

110311/07 Data Support -ICU110311/08 ProposedResearch inDermatology110311/09 Allocation ofProjectsReceivedCK does not have the capacity to provide further support, however with FIREnow coming to an end it has been agreed with the existing team on ICU thatthey can now lend support to the SPOTLIGHT Study which was approved inOctober, 2010.CC explained the background to this item. Following the meeting she hadwith Mr. Verdolini and the Specialist Nurse for Dermatology, Mr. Verdolinihad forwarded some papers on the research he had been participating in. Ofthe three papers submitted two were case series and one a case study, thisbeing a substantial paper but not research. These studies were not carriedout at PAHT, there were concerns that the patients had not been consented,however this could have been in Italy where research governance law isprobably significantly different to the UK. ST to discuss with Dr. SandraDimmock – Medical Director as this Consultant wishes to develop researchhere at PAHT, in the meantime Mr. Verdolini would be invited to attend afuture R&D Committee meeting to discuss further.576 - An evaluative investigation into the experiences that mentors who havehad mentoring pre-registration student nurses, who have had learningdifficulties in their clinical placements (e.g. Dyslexia) - Debbie Cubitt –Practice Education Facilitator - PAHTCC 15.4.11TC/RB110311/10 Update ofOngoingProjectsReport circulated.Metasin Study – VS requested further clarity from the R&D Committee of theconditions to the approval for the study particularly the clarification requiredthat Metasin is being used purely for research purposes and reassurancethat no Metasin results are being used in clinical decisions. After muchdiscussion it was agreed that assurance was given to the R&D Committeethat:-• Metasin has been internally validated at PAHT using existing Trustand nationally recognised and approved mechanisms.• Histology is being run alongside Metasin in order to validate clinicaldecisions.It was agreed that once these assurances had been made in line with therequirements of the conditional approval and submitted to the R&D office, fullapproval would be given.The remainder of the Agenda was deferred to the April, 2011 meeting.Page 4 of 5VS

110311/11 NIHRResearchSupportServicesFramework110311/12 R&D FinanceReport110311/13 Any OtherBusiness110311/14 Date of NextMeetingDeferred to April, 2011 Meeting2011/2012 CLRN BudgetDeferred to April, 2011 MeetingNoneFriday 15 th April, 2011 in Training Room 2, First, Parndon Hall, PAHT.9th April, 2011Page 5 of 5