UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST



UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST

Minutes of the Public Trust Board Meeting held on 26 February 2009

Present

John Savage – Chair

Kelvin Blake Alex Nestor

Iain Fairbairn Graham Rich

Lisa Gardner Irene Scott

Patsy Hudson Lindsey Scott

Selby Knox Jonathan Sheffield

Paul Mapson Emma Woollett

Paul May Robert Woolley

Alex Nestor

In attendance

Chris Monk Jackie Cornish

Mike Nevin Peter Wilde

Sarah Pinch Jeanette Jones

Sara Arnold Pat Fields

Yvonne Quinn (minutes)

25/09 Apologies were received from Jim Catterall and Lis Kutt.

26/09 There were no new declarations of interest.

27/09 Minutes

The minutes of the meeting held on 28 January 2009 were approved and signed by the Chair as a correct record, subject to the following amendments: Patsy Hudson was added to the attendance list and Mark Callaway’s name had been incorrectly spelt.

28/09 Chief Executive’s Report

Three candidates had been shortlisted for the Chief Nurse and Director of Governance interviews to be held on 6 March 2009.

Interviews for the Director of Human Resources and Organisational Development would be held on 9 March 2009. Six candidates had been long-listed for a preliminary discussion.

Bristol Heart Institute. The Trust had taken possession of the new building on 23 February 2009.

29/09 Control of Infection Report. Lindsey Scott reported on the following:

Clostridium Difficile. The Trust remained on target to achieve the trajectory at year end for Clostridium Difficile. The number of cases in January achieved the outturn predicted with 15 target cases and 25 overall cases reported. To date, there had been 16 cases reported in February. The Norovirus outbreak had worsened during week commencing 16 February and additional actions were being taken to control the outbreak and re-open wards. Clostridium Difficile dashboard. Divisions had been asked to scrutinise the history of hand hygiene performance ward by ward and report back on an exceptional basis any trends or issues to address. Pat Fields and Christine Perry were to lead this activity.

Clostridium Difficile targets and trajectories for 2009/10 and 2010/11.

NHS South West had issued proposed targets for 2009/10 and 2010/11. The target for 2009/10 was 194 cases and for 2010/11 97 cases. They were to be based on admissions and set a new definition of hospital associated infections identified once the patient had been in hospital over three days as compared to two days previously. The new target would be extremely challenging and the Trust continued discussion with NHS Bristol on the implications of this. The Trust was committed to challenging itself, but considered financial penalties should be related to national targets. Graham Rich reported that discussions with NHS Bristol about the CQUINS quality bonus system were continuing.

MRSA. The Trust continued to achieve the target initially agreed for post-48 hour cases with three cases recorded in January. The issues reported at the previous meeting on the incorrect trajectory agreed with the Bristol Primary Care Trust for post-48 hour MRSA bacteraemias were unlikely to be resolved until the end of March 2009. Root cause analysis had been undertaken for each case reported and no underlying themes had been identified. MRSA Screening. Implementation of the elective patient MRSA screening requirements continued. Specific areas where improvements in compliance were needed have been identified and action plans were in place to address these by the deadline for 100% compliance at 1 April 2009.

Cleanliness. Irene Scott commented on the pressure on cleaning teams to give rapid response for infection control high-risk areas which had diverted action away from areas of low risk. However, good progress had been achieved overall.

Norovirus. The Trust continued to experience high levels of Norovirus infection. Analysis of cases and ward closures had shown that patients were presenting a longer than average incubation and excretion period for this organism. The 72 hour trigger for ward reopening had been altered by necessity to 96 hours to allow for these longer incubation periods. Hydrogen peroxide cleaning had been implemented. The levels of Norovirus activity had begun to decrease during the previous two weeks and wards had been able to reopen.

Emma Woollett asked if there was any correlation between the high vacancy factor and the number of clostridium cases on Ward 26. Lindsey Scott explained that Ward 26 was the cohort ward for the infection and inevitably displayed higher incidence.

Kelvin Blake asked if the information collected from Executive Walkrounds was being fed back into the action plans. Lindsey Scott confirmed there was a process for feeding back any actions from all Executive Walkrounds and the information collected was monitored to identify any trends or issues to be addressed.

The Board noted the current position in respect of infection control and the work being undertaken. Staff were congratulated for the recent progress in gaining control of the position.

30/09 Report from the Finance Committee. Lisa Gardner reported on the following:

Women’s and Children’s Action Plan. There had been some discussion in respect of the Division’s forecast overspend for the year which had been revised to £3.314m. The mitigation plan was not delivering the improvements previously expected. Jackie Cornish continued a high level of contact with staff within the Division in ongoing action to resolve the position.

Financial Overview. Whilst the overall financial position to 31 January was satisfactory with the Trust remaining on target to secure a surplus for the year of £13m, there was concern about the underlying downward trend in Divisional financial performance in recent months and the potential difficulties this might create for 2009/2010. It would be critical to ensure that budgets were set at meaningful starting positions.

Service Level Agreement Performance Fines. There had been an improvement in the current month in the reduction in the net cost of potential Service Level Agreement Performance fines/rewards.

Activity. Activity for elective inpatients and outpatients had dropped slightly over the Christmas and New Year period. Work continued to ensure robust forward planning for activity next year.

Capital Programme. Capital expenditure was £25.397m against a profiled spend of £30.179m, representing a variance of £4.782m. Robert Woolley reported on work to enable more proactive investment on a programmed basis for replacement equipment. Some allocation had been identified to enable the design of a comprehensive replacement programme. The balance between strategic and operational capital was an issue.

Capital Prioritisation Minutes. The minutes of the Capital Prioritisation Group held on 23 February 2009 were presented. There was discussion about planning for future capital programmes and the risk analysis work being undertaken by Divisions.

Treasury Management. At 31 January 2008 the Trust had net current assets of £16.988m; an increase of £12,626m since March 2008, and a cash balance of £40.298m, which was a very healthy position.

The Trust’s financial risk rating remained at 4 (actual rating 4.75 but limited to 4 in the first year of Foundation Trust status).

The Committee had been presented with an Energy Costs report which detailed recent updated actual and forecast energy costs for 2008/2009 and the revised forecasts for 2009/2010.

Selby Knox commented on the net overspend recorded for the Clinical Divisions and asked to what extent it was due to the extra activity being undertaken or to other factors. Paul Mapson reported that it was a change in position, due more to pay and the additional temporary capacity that had been put in place to cope with the extra activity. This would be addressed in the plans for the following year.

Paul Mapson reported that the Primary Care Trust had not yet confirmed income activity for 2009/2010. Divisions were preparing plans to deliver estimated activity, including staffing, cash releasing efficiency savings plans and outlying activity.

The Board noted the Trust’s financial position.

31/09 Performance Report

Workforce. Alex Nestor reported on the following:

Sickness Absence. There had been an increase sickness absence in December in excess of those targeted for cash releasing efficiency savings. All Divisions had action plans in place and were working extremely hard to achieve the targets. The review of the ‘Supporting Attendance Policy’ was almost complete. The absence rates continued to be monitored on a regular basis.

Cash Releasing Efficiency Savings. Trust-wide savings resulting from cash releasing efficiency savings were 84.1 fte, which was an under-achievement of 12.4 fte. The Division of Medicine still needed to identify other savings to offset the nursing and midwifery savings to achieve its target by the end of March.

Nursing and Midwifery Agency Costs. Although agency spend for January 2009 had reduced from the previous month to £204,343, this figure was 85% higher than the annual average January to December 2008. There had been an unprecedented increase in demand of 62% compared with December. The number of vacancies and Norovirus outbreaks had contributed to this. A need to improve recording of reasons for booking bank and agency staff was being pursued.

Annual Appraisal Compliance. Divisions were achieving 77% overall, which was below the target. The position continued to be closely monitored by the Trust Operational Group. The Board noted that no Healthcare Commission standard existed for this and that the target of 80% was set locally.

Statutory and Mandatory Training. The Trust was currently 59% compliant for induction. A review of Induction processes had been undertaken and a recommendation that new starters attend Induction on their first day would be presented to the Trust Executive Group. Managing Violence and Aggression Level 3 was currently 28% compliant and actions to address this were noted in the report.

Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations 1995. Concern remained that 75% of reportable incidents still had not reached the Safety Department within the 10 day time frame. A number of actions being undertaken were noted in the report and areas not performing would be targeted.

Kelvin Blake asked what the correlation was between unfilled shifts and sickness. Irene Scott stated that the unfilled shifts were due to the increase in the beds opened which in turn increased the demand on bank and agency and the Bank Office had been unable to meet all requirements. The increase in sickness rates had resulted in further increased demand on bank and agency.

Kelvin Blake sought reassurance that the Trust was managing the situation and that the quality of care being delivered to patients was not being affected in any way. Jonathan Sheffield drew the Board’s attention to the mortality figures in 3.2.1 of the report. The figures had gone up in 2008 when there had been a number of unfilled shifts and an increase in incident reports relating to staff shortages had been seen. The Board was reassured that this trend had not been replicated in the current year. Chris Monk confirmed that full discussions were undertaken in respect of all gaps in shifts to ensure minimisation of any risk to patients across the Division.

Patient Experience. Lindsey Scott reported on the following:

Complaints. 85% of formal complaints had been responded to within 25 working days, against the target of 100%. Specific Divisions where the breaches had occurred had been instructed to improve the position.

Patient Access and Targets. Irene Scott reported on the following:

Emergency access 4-hour target. The Trust was not currently achieving the 98.0% standard. However, performance had improved during January, with achievement of 97.1% with Walk in Centre attendances included. 100% would need to be achieved each day during the remainder of quarter 4 to achieve 98% for the year as a whole. It was forecast that the 98% target for the year would not be achieved.

31-day and 62-day Cancer Standards. The Trust was underachieving against the existing 31-day (98%) and 62-day (95%) standards for the year to date (97.6% and 93.4% respectively at the end of December). The Trust had achieved in excess of 98% for the 31-day standard in quarter 3.

Diagnostic Waiting Times. The Trust was currently not achieving the 6-week wait for key diagnostic tests. Numbers of patients waiting over 6 weeks had reduced from 495 at the end of September 2008 to 178 at the end of January 2009.

Monitor’s Compliance Framework. At present the Trust is rated ‘Amber’ with a score of 1.5.

32/09 Accident and Emergency 4-hour Performance.

The paper presented provided a review of factors affecting performance against the 4-hour emergency access target during quarter 3 of 2008/2009 and actions taken to address this. It had been prepared in response to concerns raised by Monitor in a letter dated 10 February 2009 which had been circulated to the Trust Board. Monitor’s compliance framework set out the obligation for all NHS foundation trusts to achieve at least 98% achievement of a maximum waiting time target of four hours in accident and emergency from arrival to admission, transfer or discharge. UHBristol had declared non-achievement against this target in quarter 3 2008/2009.

Monitor required a full explanation, supported by relevant analysis, setting out the reasons for the failure to achieve, including evidence that the Board had taken appropriate action following the breach in quarter 3. The response also required details of the Trust’s plans to ensure ongoing achievement of this target.

Comments were invited from the Board.

Paul May expressed strong concern that the report presented was not an appropriate response to the letter from Monitor and did not address the issues effectively. It was recognised that the paper required further drafting in order to focus on key areas to be addressed and timescales for achievement. Graham Rich and Irene Scott agreed to prioritise a re-draft of a more appropriate response which was required to be submitted by the close of Friday 27 February 2009. It would include actions that the Trust intended to take.

An urgent need for increased capacity in the Medical Assessment Unit, and an increase in the number of acute physicians within the accident and emergency department were critical factors in the ability to expand this function.

Selby Knox questioned the fact that the Trust had acknowledged that the size and capacity of the Medical Assessment Unit had been inadequate for some years and was concerned that this had not been addressed.

Irene Scott reported that an action plan had been developed and agreed by the Trust Board in early 2008. All actions in that plan had been delivered. It had always been acknowledged that the Medical Assessment Unit did not have sufficient capacity and needed expansion. An expansion of the Medical Assessment Unit required an increase in medical capacity and the physical constraints to the site were severe. The current year activity position was very different to the previous year. There had been an unprecedented increase in emergency admissions (upwards of 10% compared with the same period last year). The step increase had been significant from October 2008, and at a level that had not previously been seen. All the work that the Trust had been doing, and continued to do, was essential in order to improve length of stay, improved discharge processes and senior level clinical decision-making at the start of the process.

Iain Fairbairn commented on the need to be better at identifying any shortcomings in the Trust’s planning. The Trust must be more analytical in looking at issues that arise day to day and learn to be more strategic rather than just relying on extra effort from staff. It was acknowledged that staff were working extremely hard, but the Trust should be looking at systems and processes. Irene Scott stated that the Trust continued to work closely with Divisions about their role and were working to change the way processes were implemented throughout the organisation to improve performance.

Lisa Gardner stated that the benchmarking figures that had been previously supplied had been useful and would be keen to see those again. The benchmarking figures demonstrated that the Trust was below bed base for the Medical Assessment Unit. There was now, in the coming year, the opportunity for ward 7 to be used. Weekend working was a challenge and much had been in job planning to address this. It was estimated that 5 additional consultants were required to expand the Medical Assessment Unit and provide regular weekend working.

Chris Monk reported on the need to change the way in which patients were treated in accident and emergency to speed up and shorten the length of stay. An acute physician model had been developed and approved for the Medical Assessment Unit which would allow for the appointment of acute physicians and put the Trust in a much better position for 2009/2010. There had been an exceptional increase in emergency admissions and there was concern as to whether this would happen again next year.

Paul Mapson reported that there was huge pressure on the whole system. As well as the increase in emergency admissions outpatient activity had greatly accelerated and this imposed huge pressure on consultant time and availability.

Kelvin Blake stressed the need to clearly understand the indicators and to have more effective decision-making processes in place to ensure the failures did not happen again. Emma Woollett asked if the structure for managing this issue was correct across the Trust since it was a trust-wide issue with the need for trust-wide strategic decisions.

John Savage reminded the Board that the Divisions were under severe pressure, the issues were extremely complex and this should be clearly set out in the report. University Hospital Bristol was an inner-city operation which attracted admissions because it performed well. It was a complex situation and constrained, not least, by very difficult buildings. The crucial questions were what must be done to solve the issues; the cost and target dates for achieving improvement and the Board would need to be robust in prioritising the necessary measures.

Irene Scott stated that physical capacity was a serious concern. It was critical to get the capacity planning right. The opening of the Bristol Heart Institute would provide the ability to move patients out of the old building; in essence creating additional capacity, but reminded the Board that whilst is was not desirable, should activity continue to increase beyond plan, the Trust might need to consider continued use of facilities in the Old BRI building.

Selby Knox commented that everything that underpinned this was about demand and capacity and suggested that there should be a thorough analysis of where the 10% increase had come from.

Chris Monk reported that the Trust had responded to the increase. There was a plan to appoint more acute physicians. This action would take time to achieve but the Trust could be more certain about performance for the next year.

Graham Rich commented that the biggest short-term impact on this issue would be when Norovirus was under control. There were short-term, medium-term and long-term improvements and actions. Long-term actions included pro-actively planning to keep more wards open in the old Bristol Royal Infirmary next year. Peter Wilde stressed the need to carefully consider any agreement to do more elective or specialist work in the Trust which would have an impact. This consideration should be part of the solution.

John Savage reminded everyone that target achievement was absolutely necessary and was the Board’s collective responsibility. The Board gave approval to the Executive Directors to take all appropriate action to achieve the targets and improve performance. The timescales in the response were to be realistic with no promises made that could not be achieved.

A copy of the response would be circulated to the Trust Board.

33/09 Draft Quality Strategy. Jonathan Sheffield reported on the following.

The paper presented detailed the requirement for Trusts to produce a Quality Report by the end of 2009/2010. However, it was noted that legislation required to introduce this would not be issued until late summer 2009 by which time Trusts would have agreed the datasets for Commissioning for Clinical Quality and Innovation quality tariffs and Divisions would need to be clear on information sets and timelines for production of relevant sections in the Quality Report. The purpose of the paper presented was to outline the base content of a quality strategy and to agree timelines and next actions.

The Strategy would be based on three key criteria: patient experience, patient safety and clinical effectiveness. Discussions would take place with Divisions to determine the key performance indicators for quality.

Paul May welcomed the report and the approach being taken. He suggested that the Executive Walk-rounds should be widened to include patient experience.

Irene Scott confirmed that a report would be presented to the Trust Board in March 2009 in respect of Transformation. By using the right tools and embedding the quality agenda into Trust Transformation, it would be a powerful tool for change and improvements in the services delivered to patients.

The Board received the report and approved the strategic proposals.

34/09 Healthcare Commission Follow-up Review 2008/2009. Lindsey Scott reported on the following:

The report presented detailed the results of the Healthcare Commission’s follow-up review on services for children in hospital. The results demonstrated that the Trust had made improvement, or was consistently high performing in all indicators bar one. This area was in respect of the proportion of consultant anaesthetists having paediatric life support training within the previous three years. The Board was assured that this failure was not in respect of patient safety, relating, as it did, to anaesthetists who would not normally work with children dealing with them in the Bristol Eye Hospital.

The Board received the report as a positive reflection.

35/09 Organ Donation and Transplantation

The Board received the report presented and confirmed agreement to the recommendations noted.

36/09 The State of Preparedness : Major Incident and Civil Contingency Planning

The report presented outlined the Trust’s activities during 2008/2009 that related to the requirements of the Civil Contingencies Act 2004, its associated regulations, statutory and non-statutory guidance. It also informed the Board of continuing work and future plans surrounding Emergency Preparadness.

Irene Scott advised that the Emergency Planning Officers post had been vacant for a period of 5 months in 2008/2009. The post had previously been a shared position with North Bristol Trust. Following the departure of the post holder it was agreed to be more appropriate and beneficial to both Trusts to each recruit Emergency Planning and Liaison Officers. Considerable work on emergency planning had been undertaken within the Trust. A review of the Trusts Major Incident Plan was underway and the Pandemic Flu Plan was being finalised.

The Board received the report and was assured that a robust structure was in place to manage civil contingencies across the Trust.

37/09 Carbon Management Programme

The report presented described the outcome of a programme of work that had been undertaken with the Carbon Trust, with the purpose of designing a 5-year programme of Carbon Footprint reduction through to April 2014. Paul Mapson reported that the Trust would hope to secure some funding from the Carbon Trust for this work.

The Board received the report and congratulated all those involved for the work that had been undertaken to get to this position.

38/09 Any Other Business

It was noted that the meeting was the last for Lindsey Scott’s. On behalf of the Board John Savage thanked Lindsey for the service she had given and all that she had achieved during her time with the Trust.

40/09 The Date for the Next Meeting was Tuesday 31 March 2009.

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