Download 27 June 2013 - Pennine Acute Hospitals NHS Trust

TRUST BOARD
DATE:
THURSDAY, 27 JUNE 2013 AT 2pm
VENUE:
EDUCATION CENTRE, THE ROYAL OLDHAM HOSPITAL
AGENDA
1
ITEM
APOLOGIES FOR ABSENCE
JJ
2.00
2
MINUTES OF MEETING HELD ON 30 MAY 2013
JJ
2.02
3
MATTERS ARISING
JJ
2.05
4
DECLARATION OF INTERESTS
JJ
2.10
PATIENT SAFETY
5
PATIENT STORY
MC
2.15
6
PATIENT SAFETY
TK
2.25
7
PATIENT EXPERIENCE REPORT
i
Complaints and PALS
GB
ii
Discharge Update
HM
8
STRATEGY
LISTENING INTO ACTION
RP
2.45
9
PERFORMANCE, GOVERNANCE AND ASSURANCE
CORPORATE PERFORMANCE REPORT
HM
2.50
10
FOR APPROVAL/NOTING
IM&T STRATEGY
BS
3.00
11
RISK MANAGEMENT STRATEGY
GB
3.04
12
REGISTER OF SEALS
GB
3.07
13
ANNUAL REPORTS
Security Management
Emergency Planning
Research and Development
Fire Prevention Report
Equality and Diversity
Medical and Dental Education
Page 1 of 318
2.35
3.10
JW
JW
TK
JW
RP
TK
14
MINUTES OF BOARD SUB COMMITTEES
RISK MANAGEMENT COMMITTEE
14 May 2013
JS
3.15
15
CLINICAL GOVERNANCE and QUALITY COMMITTEE
17 May 2013
JS
3.17
16
DATE AND TIME OF NEXT MEETING
Thursday, 25 June at 2pm, Rochdale Infirmary
JJ
3.20
Page 2 of 318
THE PENNINE ACUTE HOSPITALS NHS TRUST
Trust Board Part 1
Mr J Jesky
Mrs M Carroll
Mrs S Dixon
Mr M Holly
Dr T Kenny
Mrs C Mayer
Mr H Mullen
Mrs M Ollerenshaw
Mr J Saxby
Mr R Pickering
Mr B Steven
Mr J Wilkes
Chairman
Director of Nursing
Non Executive Director
Non Executive Director
Acting Medical Director
Non Executive Director
Director of Operations
Non Executive Director
Chief Executive
Director of Human Resources
Deputy Chief Executive / Director of Finance & IM&T
Director of Facilities
IN ATTENDANCE:
Mr G Barclay
Mr A Lynn
Mrs A Wood
Assistant Chief Executive (Board Secretary)
Head of Communication
Associate Director of Nursing
APOLOGIES:
Mr E Ahmad
Mrs C Guereca
Non Executive Director
Non Executive Director
061/2013
MINUTE OF MEETING OF THE PENNINE ACUTE
HOSPITALS NHS TRUST BOARD HELD ON 25 APRIL 2013
The minute of meeting of the Board dated 25 April 2013 was received,
approved and signed by the Chairman subject to the undernoted amendment:
Item 056, amend J Jesky’s declaration of interest to read “Trustee” of Music in
Hospitals.
062/2013
MATTERS ARISING
018/2013
Patient Experience – Francis Report
Mr Saxby said that dates for the Listening into Action style events with
Executive and Non-Executive Directors were being finalised and would be
circulated.
Action: JS
047/2013
Safeguarding – Rochdale Borough Council
The Divisional Director for Women and Children’s was working with the Head
of Safeguarding to ensure that the support required could be provided to
Rochdale Council and the other Councils and CCGs.
049/2013
Patient Story
Mrs Carroll reported that the DVD on the ongoing consequences for patients
of health care acquired infections post discharge was being shown to staff.
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Item 2
30 May 2013
053/2013
Stakeholder Engagement Strategy
Mr Barclay reported that Mr Lynn had been in contact with the rheumatology
service. Mr Barclay also took the opportunity to inform Board members about
the new Pennine Information Points which had been established.
063/2013
PATIENT STORY
The Board heard a recorded patient story narrated by a stroke patient. Mrs
Wood said that the story highlighted a good patient experience, although the
patient had commented on the lack of active treatment over a bank holiday
weekend. Mrs Wood would be meeting with the Occupational Therapy
Manager to identify what treatments or activity patients could undertake
during these periods. Mrs Mayer said that this highlighted the need to move
towards seven day working. Mrs Wood added that she would also look into
the other issue raised by the patient about providing the opportunity for
communal eating by patients in ward areas.
064/2013
PATIENT SAFETY
Dr Kenny spoke to her report and stated that the most recent refresh of
HSMR mortality data available showed the Trust at 100, meaning that the
number of deaths was as expected for a Trust of this type. Mr Saxby said that
achieving this ratio was important as it had been an area that the Board had
spent a considerable amount of effort focusing on. Both Mr Saxby and Dr
Kenny recognised the significant contribution made by a wide range of staff to
achieve this ratio. Mr Saxby said that the Trust could now focus on further
reducing this ratio by improving clinical care and ensuring patients were
placed on the correct patient pathway.
The report was noted.
065/2012
PATIENT EXPERIENCE REPORT – PRIVACY AND DIGNITY
Mrs Carroll spoke to the report and stated that there had been a reduction in
the number of discharge surveys completed during March and April. She said
that this may have been due to the trial and then introduction of the new
national Friends and Family test.
The Trust had reduced scores in patients having someone to talk to about
fears and worries, the provision of discharge information and being advised of
danger signals to watch out for when returning home. The Trust had
improved scores on providing help with meals. Mrs Wood outlined a number
of actions including the possibility of introducing a patent reporting telephone
line and the method by which information was provided on discharge
prescriptions.
The report was noted.
066/2012
PATIENT EXPERIENCE REPORT – CLEANING
Mr Wilkes spoke to his paper which provided an update on cleaning
performance during the previous quarter. He said there had been a further
improvement in cleaning scores, an Internal Audit report had provided
significant assurance on cleaning arrangements and the report now included
details of scores for cleaning carried out by nursing and estates staff as well
as by domestic staff. The new cleaning contract had been mobilised and
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initial feedback had been positive. Mr Barclay said that cleaning scores for
each site were now displayed on Pennine Information Points.
The report was noted.
PATIENT EXPERIENCE REPORT – NATIONAL INPATIENT
SURVEY
Mrs Carroll spoke to the paper which summarised the Trust’s results as part
of the national impatient survey. The response rate from patients surveyed
had been 47% against a national average of 51%. The Trust had improved
on 35 scores, remained the same on 11 scores (or the scores were new
questions) and had deteriorated on 13 scores. The national survey results
showed improvements on discharge information (in contrast to the local
survey).
The survey also suggested deterioration in single sex
accommodation, despite the Trust not having any breaches in the period.
Mrs Carroll said that Divisional and Corporate improvement plans would be
developed to address the areas highlighted in the survey results.
The report was noted.
068/2013
CQC REGISTRATION
Mr Barclay spoke to his paper which confirmed that the Trust had maintained
unconditional registration with the Care Quality Commission throughout
2012/13. He also summarised the various unannounced inspections which
had taken place during the year.
The report was noted.
069/2013
LISTENING INTO ACTION
Mr Saxby spoke to the report and said that the repeat Pass it On event
highlighting the work of the first ten teams had been held at Fairfield General
Hospital. The next 20 teams had now started their work. Mr Saxby said that
a number of departments and individuals outwith the formal process were
seeking to become involved in the programme and it was therefore gaining
additional traction within the Trust.
The report was noted.
070/2013
CORPORATE OBJECTIVES 2013/14
Mr Steven spoke to the corporate objectives for 2013/14 which had been
developed by the Executive Directors and discussed at the May Board
Seminar. Mr Barclay outlined the process by which the corporate objectives
would be rolled out across the Trust and reflected in personal objectives.
The corporate objectives 2013/14 were approved.
071/2013
PERFORMANCE REPORT
Mr Mullen spoke to the report. The Unscheduled Care four hour target,
Cancer targets and 18 week targets had all been achieved in April. There had
been 10 C Difficile cases in April against an upper threshold of five. There
had been one MRSA bacteraemia.
Mr Steven said that the Trust had reported a deficit for April of £0.97m
compared to a planned deficit of £0.449m. The Trust was forecasting to
achieve breakeven by the year end. The Trust had identified CIPs with low or
no risk of delivery with an annual value of £7.942m. The CIP programme was
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Item 2
067/2013
currently under review and the Trust expects to achieve £31.917m for the
year.
Mr Pickering commented on the level of spend on temporary staff and said
that further guidance was being prepared on managing the workforce.
The report was noted.
072/2013
WORKFORCE PROGRAMME COMMITTEE TERMS OF
REFERENCE
The terms of reference were approved subject to reviewing the name of the
committee. It was agreed to invite the staff side to attend the committee and
to add the Associate Director (Elective Access) to those attending.
Action: RP
Mr Steven said that he had also established a Medical Workforce Committee
and would determine the relationship between that Committee and the
Workforce Programme Committee.
The terms of reference were approved.
073/2013
MINUTES OF BOARD SUB COMMITTEES
The minute of meeting of the Audit Committee dated 9 April 2013 was
submitted and noted. Mr Holly said that all internal audit reports, with the
exception of that related to the CIP programme, had provided high or
significant assurance. The number of days spent by internal audit had been
benchmarked against similar Trusts and a reduction of 100 days per annum
had been agreed as a result. The Audit Commission had advised that KPMG
would remain as External Auditors for 2013/14 but the contract would be retendered for 2014/15.
The minute of meeting of the Clinical Governance and Quality Committee
dated 19 April 2013 was submitted and noted. Mr Saxby commented on
morbidity and mortality meetings which were now all in place.
074/2013
DATE OF NEXT MEETING
The next meeting of the Trust Board will be held on Thursday 27 June 2013 in
the Education Centre, The Royal Oldham Hospital at 2pm.
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Item 5
Title of Report
Patient Stories – June 2013 Report
Executive
Summary
The purpose of this report is to inform and update members of the
Board on patients’ experiences across the Trust.
Actions
To support the programme of activities and to note developments
Requested:
Corporate Objectives supported by this paper:
2) Improving the patient experience
Risks:
Unable to meet government direction if programme does not continue.
Public and/or Patient Involvement:
As described within the report.
Resource Implications:
N/A
Communication: Information in the report is communicated across the Trust to
Divisions and Directorates as part of the general performance reporting.
Have all implications been considered?
Assurance
Information Governance Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Month and Year
Email
YES
x
x
x
x
x
x
x
x
x
x
x
NO
N/A
Marian Carroll
Director of Nursing
June 2013
[email protected]
Patient Stories Board Paper 06/2013
1
Page 7 of 318
Patient Experience – Patient Stories
1. Introduction
Stories can be used to communicate visions and needs in a powerful way; they offer
a compelling and practical means of exploring issues and experiences from different
perspectives, while promoting reflection and stimulating dialogue and debate.
The Trust Board will be presented with a patient story at each meeting that will allow
an in depth view of patients experiences when accessing the Trust.
2. Strategic Context
This report directly contributes to 2013/14 Corporate Objective 2 (Improving the
Patient Experience). The Trust’s vision and goals are underpinned by the corporate
objectives that support patient experience. Identifying the achievement of objectives
by identifying interactions with patients will give added assurance that these are
being met.
3. Patient Stories
Patient Story – June 2013

Patient Story captured by the medical division regarding the care received
by a 95yr old lady on admission and discharge from Accident and
Emergency following a fall.
Lessons learned


Need to improve communication and review referral to community
services
Patients take home medication requirements.
4. Lessons learned from Patient Story Programme
The Trust Board has been presented with a patient story at the beginning of the
Board Meeting since April 2012. Individual action plans for wards and departments
have been developed to support specific issues. Themes of issues that have been
identified occurring across the Trust are below.
Issue Theme
1. Communication
2. Medication on discharge
Actions taken
 Development of a Patient Communication and
Patient Information Policy
 Review of patient pathways and communication
processes
 A review is being undertaken of discharge
medication processes
 MAU and paediatrics at NMGH allocated a ward
dispensing pharmacist
Patient Stories Board Paper 06/2013
2
Page 8 of 318

Item 5
3. Information on discharge 
A review of patient documentation is being
undertaken to make sure information is
comprehensive and consistent.
Discharge documentation under review with
development of discharge checklist.
5. Conclusion
The Board is asked to support the programme of activities and to note actions taken
following review of this and previous care episodes.
Marian Carroll
Executive Director of Nursing
June 2013
Patient Stories Board Paper 06/2013
3
Page 9 of 318
Risks:
Board Risk Register: –
- Poor quality of care provided to patients as measured by HSMR if higher
than expected mortality is not noticed and addressed at Trust site and
speciality level.
Public and/or patient involvement:
N/A
Resource implications:
N/A
Communication:
Through the Governance structures
Dedicated section on Trust Internet site
Have all implications been considered?
YES
NO
N/A

Assurance

Information Governance Assurance

Contract

Equality and Diversity

Financial / Efficiency

HR

Information Governance Assurance

IM&T

Local Delivery Plan / Trust Objectives

National policy / legislation

Sustainability
Name
Job Title
Date
Email
Dr T Kenny
Acting Medical Director
June 2013
[email protected]
Page 10 of 318
Item 6
Title of Report
Patient Safety Report
Executive
Update for Trust Board on progress with the Mortality
Summary
Reduction Project.
Actions
The Board is asked to note the contents of this report and
requested
progress.
Corporate Objectives supported by this paper:
Objective 1 – Improving Patient Safety - Reduction in standardised mortality
Objective 2 – Improving the Patient Experience
HOSPITAL STANDARDISED MORTALITY RATIO (HSMR)
After the last refresh of data from Dr Foster the Trust HSMR is 95.38. When this is
rebased by Dr Foster we are projecting an HSMR of 100.
Item 6
The graph below shows the HSMR for in-hospital deaths for 2012/13 financial year.
The graph shows that we are currently below the national average indicated by the
red line.
The Trust mortality is managed through the Mortality Reduction Group which
includes both Clinicians as well as Managers.
The Quality Investigator tool from Dr. Foster is being rolled out to all Clinicians to
enable them to analyse their data at patient level and to investigate potential areas of
concern.
Page 11 of 318
Title of Report Patient Experience Report
Quarterly Integrated PALS and Complaints Report
For Quarter 4 (1 January 2013 – 31 March 2013)
Executive
Summary
The report analyses both quantitative and qualitative data relating
to complaints handling by the Trust for the period from 1 January
2013 – 31 March 2013 inclusive. It aims to highlight key themes
and common causes for complaints. It also highlights what actions
have been taken as a result of complaints. This report follows the
new more focused format of the previous report following positive
feedback relating to that.
Actions
Requested:
To provide more detail on patient experience, especially given that
the topic of this reports is “attitude”, and to provide some
comparative and cumulative data where available.
Corporate objectives supported by this paper:
 Improving the Patient Experience;
 Improving Clinical Effectiveness and Safety.
Risks:
 Failure to identify trends leading to repeat complaints;
 Failure to meet corporate objective of improving patient experience;
 Failure to meet CQC, NHSLA Risk Management and ALE standards.
Public and/or Patient Involvement:
Patient involvement in individual complaints.
Communication:
 Inclusion in Trust annual report (published externally);
 Discussed via Team Brief ;
 Copied to Trust and Divisional Clinical Governance Committees for more
detailed discussion;
 Patient stories presented at meetings of the Trust Board and monthly
Divisional Governance meetings;
 Discussion of patient experience/key themes at Ward/Directorate Manager
meetings.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Gavin Barclay
Job Title
Assistant Chief Executive
YES
X
X
X
X
X
X
X
X
X
X
NO
N/A
1
Page 12 of 318
Item 7
Resource Implications: None
Date of completion
12 June 2013
THE PENNINE ACUTE HOSPITALS NHS TRUST
Quarterly Integrated PALS/Complaints Report
1 January 2013 – 31 March 2013
(Quarter Four)
Introduction
The purpose of this quarterly report is to provide an overview of activity for both the
Patient Advice and Liaison Service (“PALS”) and the complaints department, which
handles formal written complaints for patients, in the period from 1 January 2013 – 31
March 2013
The report analyses both quantitative and qualitative data relating to complaints
handling by the Trust. It aims to highlight key themes and common causes for
complaints and to initiate wider discussion about how to improve the quality of the
Patient Experience. It also highlights what actions have been taken as a result of
complaints.
Strategic context
This report contributes to the Trust’s corporate objectives - Improving the Patient
Experience and Improving Clinical Effectiveness and Safety.
Background
The Trust board takes a very keen interest in complaints. The Trust has a target of
acknowledging every complaint within 3 working days of receipt. The Trust has also
set itself an objective of responding to 90% of complaints within 25 working days.
Weekly reports are sent to key divisional managers in order to monitor compliance
against both targets. In some circumstances it will not always be possible to provide
a response within 25 working days but where this is the case, the complainant should
be updated and a new timescale will be agreed. The Trust also liaises closely with
other NHS Trusts and PCTs as necessary (where a complaint involves more than one
healthcare provider or where input is required in order to comprehensively respond to
the complaint), to ensure that patients receive a full and detailed response, dealing
with all elements of the complaint and within the 25 working day target where
possible. This report covers the final period prior to the abolition of the PCTs.
2
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HEADLINE FIGURES FOR QUARTER FOUR
Key Data for PALS and Complaints
The information set out below represents the overall figures and key data for PALS
enquiries/contacts and formal complaints received for Quarter four. A more in depth
analysis of the statistical data is set out later on in the report.
PALS key data
In Quarter four:



PALS received a total of 403 contacts/enquiries during the quarter.
This was down from a total of 462 contacts/enquiries received during Quarter 3
(1 October 2012 – 31 December 2012) and a decrease of 173
contacts/enquiries compared with the same quarter in the previous year.
The top 5 reasons for contacting PALS (in descending order and excluding
other) were as follows:
1.
2.
3.
4.
5.

Accident and emergency (A&E) – 47 contacts;
Other surgical specialities – 30 contacts;
Requests for information – 25 contacts;
Communication – 24 contacts;
Clinical treatment – 18 contacts;
PALS received a total of 31 contacts/enquiries regarding the attitude of various
staff.
Item 7
Complaints Key data
In Quarter four:


The complaints department received 182 formal complaints during the quarter.
This was down from a total of 212 complaints received for Quarter 3 but an
increase of 16 complaints compared with the same quarter in the previous year
(when 166 complaints were received).
The complaints can be broken down into the relevant Divisions as follows:
1.
2.
3.
4.
5.
6.
7.
Medicine – 82
Surgery – 64
Women and Children – 21
Diagnostic – 10
Corporate – 3
Modernisation - 1
Facilities – 1
3
Page 14 of 318

Out of those sites that received complaints about attitude, Fairfield received 5,
North Manchester General Hospital received 4, Rochdale Infirmary received 2
and Royal Oldham Infirmary received 1. There were no complaints in respect
of attitude at Birchill.
The department grades complaints RED, AMBER or GREEN depending on the
seriousness of the complaint. Of the 182 complaints received, 4 were
classified as RED, 169 were classified as AMBER and 23 were classified as
GREEN.
152 complaints were concluded during this quarter within the Trust target of 25
working days, or an agreed timescale, which equates to 83.3% This was 86%
in January, 85% February and 79% March 2013.
The department has so far received 16 comebacks to complaints responded to
within this quarter (an effective rate of 9%). This is compared to a Trust target
of 25%. However, it often takes complainants some time to consider the
complaint response and to write their comeback (see below). As such, it is
possible that this report does not catch all comebacks generated in this
quarter. By comparison, when the last report was compiled we had received
33 comebacks. The total for that quarter is now 38.



The chart below illustrates and compares the number of PALS enquiries and
complaints received for each quarter from the previous quarter four:
Number of PALs enquires and complaints received
700
Number received per quarter
600
500
400
Complaints
300
PALs
200
100
0
2011/12 Q3
2011/12 Q4
2012/13 Q1
2012/13 Q2
2012/13 Q3
2012/13 Q4
Quarter/Year
4
Page 15 of 318
PALS -STATISTICAL ANALYSIS
The primary function of PALS is:





to advise and support patients to resolve any concerns they may have with
NHS care/treatment;
to provide information on NHS services and non NHS services;
to provide assistance to patients (for example problems with appointments);
to listen to patients’ concerns, suggestions or queries; and
to highlight to the Trust any issues, themes or trends in PALS queries.
The number of PALS enquiries is significantly lower than for the same quarter the
previous year. This may reflect the fact that for a short period PALS officers were
asked to deal with complaint files as well and therefore may not have been available
to deal with PALS enquiries.
Specialities with 10 or more contacts/enquiries in quarter four were as follows:
Accident and Emergency - 47
Trauma and Orthopaedics - 21
Other Surgical Specialties - 30
Ophthalmology - 19
General Medicine - 15
General Surgery – 12
Obstetrics - 12
Other specialities – 11
Radiology - 11
Other – 103
The main reason for contacting PALS was ‘Other’ [103 contacts/enquiries]. ‘Other’
includes attitudes of staff, cancellation of appointments, medical records,
communication, waiting lists and requests for information as categories. Requests for
information and communication issues were the top reasons for patients contacting
PALS in this quarter.
The chart below illustrates the number of PALS enquiries received in Quarter four
broken down by Specialty & Site (excluding requests for information, wait/cancelled
appointment and positive comments i.e. Compliments received):
5
Page 16 of 318
Item 7










PALs enquires by specialty and hospital site 1
January to 31 March 2013 (excludes requests for
information, wait/cancelled appointments &
positive comments)
Other Diagnostic Services
Breast surgery
Paediatrics
Community midwifery
Podiatric Surgery
Genito-urinary medicine
Endocrinology
Anaesthetics
Pain service
Not applicable
Haematology
Thoracic / respiratory medicin
ENT
Urology
1 Manchester Community
Maxillofacial / oral surgery
All Sites
Rheumatology
Fairfield
Colorectal surgery
N.M.G.H.
R.I.
Rehabilitation
R.O.H.
Gynaecology
(blank)
Other Medical Specialties
Gastroenterology
Other Specialities
Trauma and orthopaedics
Cardiology
General surgery
Radiology
Ophthalmology
Obstetrics
General medicine
(blank)
Other Surgical Specialties
Accident and Emergency (A&E)
Other
0
10
20
30
40
50
60
6
Page 17 of 318
COMPLAINTS-STATISTICAL ANALYSIS
The following sets out a more detailed analysis of the complaints data for Quarter
four, including a breakdown of complaints received by reference to division,
wards/departments, sites and risk category. The aim is to identify areas where a
disproportionate number of complaints are received so that the Trust can identify any
reasons for this and take remedial action. Following on from the previous quarterly
governance meeting, it was decided that any departments that had two or more
complaints within the quarter would be identified and this would be investigated and
an action plan would be agreed (if one had not been previously formulated) and
improvements made in the particular service / ward. This is to ensure that particular
problem areas within the Trust are identified and improvement strategies
implemented as necessary to prevent recurrence. This information is also available
on the Ward Indications Dashboard.
Number of Complaints Received by Ward and Site – Areas with Over Two
Complaints Received Quarter Four – 1 January 2013 – 31 March 2013
The following wards/departments at Fairfield General Hospital received two or more
complaints for this quarter:
Fairfield General Hospital, areas over with over two complaints
1 April 2012 to 31 March 2013
Item 7
25
20
15
10
5
0
Accident & Emergency
Ward 6
Ward 19
Ward 7
Grand Total
7
Page 18 of 318
Accident and Emergency received the highest number of complaints at Fairfield
General Hospital. Ward 6 received the second highest number. Accident and
Emergency also received the highest number of complaints for the same quarter the
previous year. However Accident and Emergency are is likely to receive the highest
number of complaints due to the high number of attendances.
Out-Patients (Surgery) was the second highest in the previous quarter, but does not
feature on this graph. Ward 21 was the third highest in the previous quarter and also
does not feature. This may reflect that those departments have taken steps to
improve on basis of the complaints.
Ward 6 has received 4 complaints and Ward 19 has received 3 complaints this
quarter. Neither of these were present on the last quarter report. This will need to be
reviewed to see if they appear of the next quarterly report.
The following wards/departments at North Manchester General Hospital received two
or more complaints for this quarter:
North Manchester General Hospital areas with over two complaints
1 April 2012 to 31 March 2013
50
45
40
35
30
25
20
15
10
5
I5
To
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Gr
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Accident and Emergency received 10 complaints, which is the same as previous
quarter. Out-Patients surgery, which had 11 complaints in the previous quarter, has
reduced the number of complaints to only 3. DSU theatre and D5, which did not
feature on this graph in the previous quarter, have 5 complaints each for this quarter.
Out-patients medicine, which also did not feature in the previous quarter, has 3
complaints this quarter.
8
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The following wards/departments at the Royal Oldham Hospital received two or more
complaints for this quarter:
Royal Oldham Hospital areas with over two complaints
1 April 2012 to 31 March 2013
50
45
40
35
30
25
20
15
10
5
0
Accident &
Emergency
AMU
T7
T5
Gynae Out
Patients
Labour
Ward
A2
Orthopaedic Out-Patients
Clinic
- Surgery
G2
T6
Grand Total
Item 7
Accident and Emergency has 10 complaints compared to 13 in the previous quarter.
AMU is the second highest with 8 complaints. AMU did not feature on this graph for
the previous quarter, although did it feature in the three quarters previous to that.
Ward T7 has also experienced an increase in complaints from 3 to 6.
9
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The following wards/departments at Rochdale Infirmary / Birch Hill Hospital received
two or more complaints for this quarter:
Rochdale Infirmary/Birch Hill areas with over two
complaints
1 April 2012 to 31 March 2013
9
8
7
6
5
4
3
2
1
0
Ophthalmology
Day Surgical Unit
Booking & Scheduling
Service
Clinical Assessment
Unit
Grand Total
Ophthalmology, Day Surgical Unit, Booking and Scheduling and clinical assessment
unit all receive two complaints. Out-patients surgery, which had received 5
complaints in the previous quarter, does not appear on this graph, which hopefully
illustrates an improvement.
Overall it appears that, generally, those areas which had high numbers of complaints
for the previous quarter have managed to reduce their figures, which can be seen as
a positive outcome. It is concerning that some which appear to have achieved
significant improvements, which meant that they did not appear on these graphs in
the previous quarter, are now registering a significant number of complaints again. It
may be improvements in some areas, which did lead to a temporary reduction in
complaints, have not been maintained.
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In light of the Board focus on identification and investigation of departments/services
with 2 or more complaints, we have compiled a table of those areas in the Trust which
have had 2 or more complaints in each of the last 4 quarters.
Departments with two or more complaints each quarter during 2012/13
120
100
80
Column Labels Q1
Column Labels Q2
60
Column Labels Q3
Column Labels Q4
40
20
0
Accident &
Emergency
Out-Patients Surgery
Labour Ward
Out-Patients Medicine
T7
EAU
(Emergency Ass
Unit - H3)
Ward 7
F5 (N)
Grand Total
The Accident & emergency at every site had 2 or more complaints in each quarter.
Only the Out-Patient’s surgery for Royal Oldham Hospital fitted these criteria. The
labour ward at Royal Oldham was the only labour ward that met this criteria. No one
site had 2 or more complaints for each quarter for Out-patients Medicine. T7 is at
Royal Oldham. EAU-H3 is at North Manchester General Hospital, as is F5, and Ward
7 is at Fairfield.
All new complaints received are risk assessed using the Complaints Grading matrix
(initial risk rating). This risk assessment is a three-step process; the first step is to
consider the potential consequences of a complaint; the second step is to assess the
likelihood of recurrence, the third and final step is to grade the complaints Red (High
risk), Amber (medium risk) and Green (low risk).
For example a catastrophic event which is likely to happen again would be graded as
a High Risk (Red) complaint.
Following completion of the investigation the complaint is risk rated again (based on
the findings) and given a final risk rating. This may or may not be the same as the
initial risk rating. During the course of investigating the complaint it may become
apparent that the risk rating originally set was inappropriate; in that scenario the risk
rating can be amended.
11
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Item 7
Complaints by Risk Category
The chart below illustrates the number of complaints received for quarter four by
reference to risk rating (some complaints have been graded as yellow, i.e. very low
risk. This category does exist on the system but should not be applied. These
complaints are in effect green risk rated):
Complaints received by initial risk rated category
60
Number of complaints
50
40
30
20
10
0
2011/12 Q3
2011/12 Q4
2012/13 Q1
2012/13 Q2
2012/13 Q3
2012/13 Q4
Quarter
The majority of complaints received in quarter four were risk rated as Amber. This
correlates with the general picture since the majority of complaints received in each
quarter are graded as Amber.
The number of Red rated complaints has remained the same as in the previous
quarter, and reflects what appears to be a gradual reduction in the number of Red
complaints.
12
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Complaint Outcome by Division
The charts below show the status of complaints received in quarter four broken down
by division.
Once a complaint has concluded (either following a local resolution meeting or once a
formal written response has been sent) the outcome will be recorded. A complaint
will be “upheld”, “upheld in part” or “not upheld” or may be marked as ‘withdrawn’ or
‘in litigation’. Those from this quarter not yet concluded will be categorised as
“ongoing”. Some complaints (very few) will be withdrawn and others will be referred
on to litigation as the complainant is seeking financial redress for what they perceive
to be clinical negligence.
The statistics illustrate that across the divisions the majority of complaints are “upheld
in part” or “not upheld”.
Those which are “ongoing” as at the end of the relevant quarter are likely to be
complex, involving more than one division. There are also issues regarding
involvement of Trusts or PCTs. As PCTs have disbanded from 1 April 2013, there
have been issues in obtaining further comment from identifying who will be dealing
with the outstanding complaints and this remains an issue at present. In some cases
it proved difficult to provide a response within 25 working days. Those marked “blank”
are likely to be those cases which have not yet concluded.
Charts illustrating outcomes by division are set out below:
Outcome of Complaints – Medicine
35
Item 7
40
Litigation
30
Not Upheld
25
Ongoing
20
Upheld
15
Upheld In Part
Withdrawn
10
(blank)
5
0
2011/12 2011/12 2012/13 2012/13 2012/13 2012/13
Q3
Q4
Q1
Q2
Q3
Q4
13
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Outcome of Complaints - Surgery
35
Litigation
30
No Consent
25
Not Upheld
20
Ongoing
15
Upheld
Upheld In Part
10
Withdrawn
5
(blank)
0
2011/12 2011/12 2012/13 2012/13 2012/13 2012/13
Q3
Q4
Q1
Q2
Q3
Q4
Outcome of Complaints – Women & Children’s
30
25
Litigation
20
Not Upheld
Ongoing
15
Upheld
10
Upheld In Part
(blank)
5
20
11
/1
2Q
3
20
11
/1
2Q
4
20
12
/1
3Q
1
20
12
/1
3Q
2
20
12
/1
3Q
3
20
12
/1
3Q
4
0
14
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Outcome of complaints – Diagnostics
8
7
6
Not Upheld
5
Ongoing
4
Upheld
3
Upheld In Part
(blank)
2
1
0
2011/12 2011/12 2012/132012/13 2012/13 2012/13
Q3
Q4
Q1
Q2
Q3
Q4
Item 7
Overall the largest single outcome was “upheld in part” (65) with “not upheld” next
(56). Only 24 complaints were considered completely “upheld”. These figures do not
include those complaints received in the 4th quarter which have not yet concluded.
15
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Equality and Diversity Monitoring
An equality and diversity monitoring questionnaire (with a pre-paid envelope) is sent
to all complainants with the acknowledgement letter to complete and return
(completion of the questionnaire is voluntary). In addition, there are two equality and
diversity questions on the satisfaction questionnaire sent to a random sample of
complainants (15% of the total number of complaints received each month) one
month after completion of their complaint investigation (ethnic group and disability).
The table below shows the breakdown of the responses received by equality strand
from people who made a complaint in quarter three (please note that the complaint
may be made by someone on behalf of someone else who received care/treatment
and may not be in respect of care/treatment received during January to March 2013).
The reason for collecting this data is to monitor the services provided by the Trust
which cover a large and diverse population and the results will hopefully help the
Trust to identify any shortcomings or areas where improvements can be made. This
also ensures that information relating to the complaints service is accessible to the
population served by the Trust.
The table below sets out the results for quarter four:
Age
0-19
20-39
40-59
60-79
80 +
Gender
M
F
Religion/Belief
Other
Atheist
Buddhism
Christianity (All Denominations)
Islam
Judaism
Not Stated
Prefer Not To Say
Sexual Orientation
Prefer not to say
Heterosexual
Not Answered
Disability
O Not Stated
A Prefer not to say
N No
Y Yes
% Cases
6%
19%
27%
26%
21%
38%
62%
4%
7%
1%
75%
5%
2%
7%
4%
% Cases
5%
4%
91%
86%
0%
6%
8%
16
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86%
2%
1%
4%
1%
1%
1%
2%
2%
1%
1%
86%
2%
Item 7
Ethnic group/Race
AA British - White
BB Irish - White
CC Any Other White
FF White & Asian - Mixed
JJ Pakistani - Asian Or Asian British
KK Bangladeshi - Asian Or Asian British
MM Black Caribbean - Black Or Black
British
NN Black African - Black Or Black British
PP Other Black - Black Or Black British
RR Chinese - Other Ethnic
SS Other Ethnic Category - Other Ethnic
ZZ Not Stated
0 Other
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Comebacks to Complaints
In quarter four 16 comebacks were received. This represents a significant reduction
against the previous quarter (38) and the equivalent quarter of the previous year (29).
Diagnostics for Women and Children have received only 1 comeback this quarter, but
Medicine and Community Service and Surgery have also achieved reductions of 60%
and 50% respectively.
Whilst there are several reasons for comebacks, it is hoped that the significant
reduction may reflect an improvement in the quality of the responses being provided.
It is hoped that a more detailed response to the complainants questions may make
them less likely to revert requesting further information.
Some complainants will comeback more than once. Generally, where this occurs, the
Trust will have exhausted all options and the complainants’ best recourse will be to
refer the matter to the Parliamentary Health Service Ombudsman (PHSO).
It should be noted that the comebacks received in each quarter (even each financial
year) does not correspond with the number of complaints received generally and is
not necessarily a meaningful statistic since complainants may not always comeback
to a complaint immediately; in fact some comebacks are received several weeks and
months (some up to a year) following receipt of the complaint response. The figures
of 18 comebacks quoted above for complaint responses sent in quarter four is not
necessarily the final figure.
The chart below illustrates the number of comebacks received in each quarter by
division:
Comebacks by Division
25
20
2011/12 Q3
15
2011/12 Q4
2012/13 Q1
10
2012/13 Q2
2012/13 Q3
5
2012/13 Q4
0
Diagnostic / Clinical
Support
Medicine & Community
Services
Surgery
Women And Children
Parliamentary Health Service Ombudsman (PHSO)
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Complainants dissatisfied with the Trust’s response have the right to ask the
Parliamentary Health Service Ombudsman (PHSO) to consider their complaint.
However, the complainant must be able to provide reasons for their continued
dissatisfaction (in writing).
The PHSO will consider the complaint file, medical records and any other relevant
information as necessary. The PHSO may decide not to investigate further and no
further action will be required from the Trust. Alternatively, recommendations might
be made for the Trust to consider or the PHSO will decide to conduct a full
investigation which might result in the Trust being required to make an apology, pay a
modest sum in compensation and / or produce an action plan to describe what
actions are planned to rectify the situation, prevent further occurrences, etc.
The Trust received 11 letters from the PHSO this quarter.
Of the 11 letters received 3 were not upheld (i.e. the Ombudsman declined to
investigate further). In addition, the Trust have been able to close 9 outstanding
PHSO cases this quarter which had been investigated. All of these were not upheld.
The ombudsman had advised that from 1 April 2013 she would investigate more
complaints that previously. We are waiting to see what impact this has on workload.
It has been indicated that the PHSO will be investigating more claims, but this may
mean simply that more information is provided to the complainant. In the past the
PHSO effectively carried out an investigation, but would then indicate that they no
longer intended to take this matter forward. We think the new approach may mean
more recommendations from the PHSO regarding improvements or changes to
practice, even if the complaint is not upheld, and the Trust will be required to
demonstrate it has acted upon these.
PHSO Closed January to
March 2013
PHSO January to March 2013
9
8
7
6
5
4
3
2
1
0
Item 7
The chart below illustrates the status of PHSO letters / involvement for quarter four:
10
8
6
4
2
0
Not Upheld
(blank)
Not Upheld
19
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QUALITATIVE DATA- PATIENT STORIES
Each quarterly report presents qualitative information on one emerging theme and
associated sub-themes. The theme for this quarter is attitude. This forms the focus
of the patient stories set out below.
The patient stories represent a random sample of complaints of various risk grades
concerning medical care and treatment which were received in quarter four. The
sample was created by running a report identifying complaints falling under the theme
‘attitude of staff’. One complaint per sub-theme was selected for analysis. Details of
the complaint are paraphrased from the letter of complaint written by the patient and
/or the patient’s representative.
Attitude of staff is potentially one of the more difficult areas for the Trust to address
and try and reduce the number of complaints. As will be seen from the examples
below, some of what patients may consider rude or abrupt may be intended to be
short and to the point. Similarly comments perceived by patients as off hand or
lacking in solemnity may be intended by the staff as friendly and informal, with the
intention of putting the patient at ease. In addition, the attitude of patients to medical
staff, and their expectations of them, has changed markedly over the last 20 years.
This may have an impact on staff who are used to interacting with patients in a certain
way.
Theme – attitude to staff
(i)
Sub- theme: Attitude of Medical Staff
Complaint
Rochdale Infirmary – Urgent Care Centre
Patient story – “…I was at the far end of that room and the doctor stood by the door
and never approached me at all. There were several yards between us as he asked,
“What’s with you today?” a rather abrupt approach I felt.
It was clear he hadn’t read my notes or he would have known. I began to explain
about what appeared to be a foreign object in my throat and he interrupted saying,
‘Hang on. I’ll find out where you need to be seen. We don’t have a throat doctor here.’
I called him back and asked him what he was talking about, I had already been there
around two and a half hours and I didn’t want to be put to the back of the queue in
another part of the Infirmary.
‘Just wait a minute’ he stated irritably and walked out…”
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Outcome/Response (taken from the written response)
 You were seen by Dr X, one of the locum middle grade doctors in the
department. Your concerns over the doctor’s attitude have been noted. As the
doctor is a locum and does not now work for the Trust, your concerns have
been passed onto the doctor via the agency for further investigation. I can
confirm though that we have not had any complaints in the past regarding his
attitude or behaviour.
Dr X obtained your history and explained that he would have a look at you but
that you might need to be referred to the ENT specialist at Fairfield General
Hospital as he considered that you required a more specialist examination
which Rochdale Infirmary were not able to provide. It is noted in your records
that you were unhappy with the waiting time and subsequent referral. As you
will appreciate, in order that each and every patient receive the best care
possible and not be discharged from our care until a thorough investigation into
their symptoms has been completed, it is sometimes necessary for such
referrals if the required specialist treatment is not available within the first
department visited by the patient.
Actions taken
 Feedback was given to the staff member involved (a locum) via his agency
Summary – This patient was unhappy at being told to report to the Urgent Care
Centre, and then subsequently told she would have to go elsewhere. She was also
unhappy with the amount of time she had to wait to be seen by a doctor (over 2
hours). With this in the background she was perhaps more likely to object to the way
she was addressed by some members of staff.
Complaint
Patient story – “…on two occasions I have been treated at Fairfield for urine retention.
Once in Dec 12, on this occasion a Doctor who was not looking after me made
remarks at the nursing station about the amount of time I’ve been in A & E and
because a junior Doctor had noted my urine output was 100 when in fact it was
1000…this Doctor went on to say that why put a catheter in when it’s obvious I didn’t
need one. This was before even speaking to me or any nurse that looked after me.
His attitude is disgusting…”
Outcome/Response

I understand that Dr X, Consultant in Emergency Medicine, profusely
apologised to you at the time of your attendance for the behaviour of both
doctors in his team. I too would like to express my sincere apologies for the
remarks made by this doctor and the attitude of the junior doctor during your
attendance, and hope that you never experience treatment like this at the Trust
again.
Actions taken
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Item 7
Fairfield – Accident & Emergency

Apologies made at the time by the staff involved who acknowledged their error,
further apology made in the response letter.
Summary – This patient was unhappy at the comments made by a Doctor who had
not previously treated or spoken to them relating to the number of visits the patient
had made to A & E. The staff involved at the time acknowledged that their comments
had been inappropriate and offered a direct apology which was made again in
correspondence to the patient. It is understandable that a patient will be unhappy with
personal comments being made about their case from a Doctor who has not been
involved with them at all.
Complaint
Fairfield – Ward 7
Patient story – “..I am writing to express my disgust at the way my Mum was spoken
to by one of your consultants.
..She began asking Mum lots of questions that had already been asked earlier that
morning. By now Mum was exhausted, frail and het mouth was extremely dry. Mum
looked to me for help with answering the questions..Doctor X completely blanked my
presence and carried on talking to Mum as if I was not there.
..The Doctor proceeded to ask Mum if she felt that she would benefit from any help or
aids at home. Mum stated that we have been trying to get her a walk in shower for
months so maybe that was something she could help with. At this the Consultant
smirked and said, “I don’t think you’ll be getting one of those, but we might be able to
find a bowl to help you wash.”
Outcome/Response

When Dr X went to speak to your mother she clarified the details of her
presenting complaint to ensure these were correct and to establish the current
problem. Dr X explains that it was helpful to have you present to help your
mother to answer questions, though it is important to put the patient at the
centre of the consultation. Dr X therefore directed her questions to your
mother as much as possible.

She felt that the main priority was to ensure your mother was as comfortable
as possible and was looked after as she would like to be. Dr X felt that she was
approaching the end of her life and may only have a few days to live. She
comments that you were planning to have a walk in shower fitted but this was
likely to take too long and be the cause of disruption at home with not much
benefit. Your mother was having difficulty even transferring a few steps at that
point and Dr X explained that often bed baths are easier.

Dr X offers her apologies if her explanation appeared cruel.

Please be assured that the issues you have identified have been discussed
with the staff involved so that improvements to the way in which care is
delivered can be made and lessons can be learnt. Dr X is grateful to you for
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drawing this situation to her attention, which has given her the opportunity to
reflect on her practice.
Actions taken


Apologies made in the response letter, issue discussed with staff involved.
Consultant advised that she would reflect on her practice.
Summary – This patient’s daughter’s complaint included a complaint about the
attitude of a particular consultant, which was in stark contrast to the welcoming
attitude of the staff who had previously seen her mother. The Consultant appeared to
fail to acknowledge when the patient was in distress and at times spoke and acted in
a way that was perceived as cruel to the patient and her daughter. The patient was in
the later stages of cancer and it is acknowledged that at such a time the patient and
family will understandably be more sensitive to the comments and attitudes of the
medical staff.
(ii)
Sub- theme: Attitude of Nursing Staff
Complaint
NMGH – Accident & Emergency
Outcome/Response
 Having spoken with the nurse who initially treated your son, I have confirmed
that questions were asked to ascertain if your son was suffering from any of
the symptoms detailed above, as well as to understand the reason for the
delay in time between the original accident and your visit to A&E.
The nurse asked these questions in order to understand whether there were
any particular injuries or concerns which gave you cause to bring your son to
A&E at that point in time, given the duration of time which had passed since
the accident in question. I agree with your comments that A&E is designed to
be used at any time of the day by whomever may need it’s services and can
assure you that the questions asked were merely to establish whether your
son was suffering from any new symptoms since the accident which needed
immediate treatment. The questions were in no way meant to appear as a
barrier to you bringing your son to A&E at that time of night, either at that point
in time or at any point in the future.
I have been asked to apologise to you and your son on behalf of the nurse who
treated X for the impression which you obtained that she was dismissive or
rude. She wishes me to assure you that this was not her intention.
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Item 7
Patient story – “…Upon arrival may I add your reception staff were magnificent and
welcoming upon arrival at around 22.30pm. When seen by the first nurse I presume
she was quite rude and was asking questions like “why have you brought him
[complainant’s son] in now” “what do you want us to do” also making statements such
as “its unusual to bring a child to A&E this time of night” I tried to explain that mum
was worried and wanted her son checked out, but her manner and attitude remained
the same…”
In addition, the nurse has asked me to apologise if the questions which she
asked during your attendance seemed inappropriate. As we are sure that you
are aware, especially with your knowledge of this area given the nature of your
employment, there are obviously issues regarding the safeguarding of children,
especially when the attendance at hospital is late at night and after a delay
from the accident having occurred. The nurse recalls that you advised her you
were not unduly concerned but that your attendance was to reassure X’s
mother which was why she asked the number of questions which she did. She
just wanted to ensure that there were no symptoms which caused you to
attend A&E the day following the accident.
Actions taken
 Apologies made in the response letter, and issues discussed with the staff
involved.
Summary – Some of the questions asked by the staff, which were done to try and
establish diagnosis and identify any Safeguarding issues with the child, were not well
received by the complainant, who works in a Safeguarding background. Staff have to
balance their Safeguarding obligations against how they may be perceived by
parents. This is always likely to be an emotive issue for parents attending with injured
children, and therefore a source of complaints.
Complaint
NMGH – Accident & Emergency
Patient story – “I was referred to NMGH…to have x rays done on my son as they had
seen a bruise on my son’s ear…we were sent away back into the ward room, we
waited for photos to be taken. The person who took the photos started questioning
me like I had done this to my own son.
…he had his x rays and we went back to the ward where I was treated like I was
guilty by nurse X. I asked on several occasions what was happening and was told,
“what now Mum?” and “we will tell you when we can won’t we?”, but the attitude and
tone she used made me feel stupid and judged, and was said in front of other people.
Before I left for dinner she said she would have to check if I could leave the hospital
as I may ‘do a runner with him’, as he isn’t in my care, but my mother’s whom I
allowed to stay with until this clears up. After dinner I came back to the ward and
frequently asked what was happening only to be told “I don’t know yet I’ll tell you
when I know. I have other patients to sort out,” all said with attitude.
Outcome/ Response

Dr X, Consultant Paediatrician apologises for the way in which you were
treated at NMGH. He thanks you for taking the time to bring these issues to
our attention.
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
I apologise that you were upset by the photographer’s questions and we will
request that clinical photographers do not ask questions about what medical
condition it is they have been asked to photograph.

Staff Nurse X states that you asked if you could take Y off the ward and she
advised that you could not take H off the unit without checking with Social
Services. This is normal precaution that is taken to safeguard children but I
apologise if Staff Nurse X’s manner in saying this upset you.

Staff Nurse X…is very sorry that you found her attitude upsetting. We take all
reports regarding staff attitude seriously and this type of behaviour is
unacceptable. It is also unacceptable to speak to families in front of others and
I apologise for your experience. Staff Nurse X and all staff have been reminded
about the need to speak to families with confidentiality and in a non-judgmental
and supportive manner, particularly when dealing with sensitive issues. This
will also be highlighted at the next ward meeting.
Actions taken
 Apologies made in response letter, nurse spoken to directly.
 Further refresher training provided to staff.
 Issues raised in ward meeting to address concerns directly.
Summary – the complainant was upset with how one Nurse had treated her son was
referred following an injury he sustained. Social services were already involved with
the family. Safeguarding procedures were followed exactly but the attitude of the
nurse involved when communicating with the complainant fell below standard. It will
always be difficult to strike a balance between following Safeguarding procedures and
dealing face to face with the families, but obvious sub standard care such as failing to
speak to the families confidentially can be and are immediately rectified.
Complaint
Patient story – “..throughout our meetings with X I have become very concerned
about her abrupt attitude towards my daughter and her condition. It may be that she
does see lots of patients with this condition but this should not make any difference,
every patient should be respected and listened to, this certainly has not happened…I
am so angry over the way my daughter has been treated by X I feel myself getting
worked up every time we go to the clinic.
This whole experience has now left my daughter feeling so undervalued that she
does not want to attend clinic in case she has to see X…This is still having an effect
on my daughter who feels uncomfortable about attending clinic every time in case it is
this nurse who sees her.”
Outcome/ Response

Sister X always treats patients with care and respect and she does not believe
that she has ever been abrupt with patients. However, if P has perceived her
approach as abrupt then she apologises. She has never had a complaint from
a patient in 12 years of seeing patients in clinic alongside Drs… nor in 12 years
25
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Item 7
NMGH – Out - patients Surgery
working as a Nurse Endoscopist in Day Surgery Unit (DSU) at NMGH and
across the Trust. Patients she sees in clinic are always given her full attention
and respect. Sister X trusts that the standard and content of her clinic letters
reflects this.

It concerns Sister X that when P saw Dr Y in clinic on 7th September 2012,
she did not complain to him then or complain to Sister Z or PALS at that time
or Sister Z at the IBD clinic 29th October 2012 or Dr B at the time of her
colonoscopy 12th September 2012.

If P or your family were unhappy with her conduct there were numerous
opportunities for you to raise this with other staff given the number of times P
has been seen since June 2012.
Actions taken
 Apologies made where due to patient in response letter.
 Complete break down of the reasoning behind nurses’ medical decisions made
to complainant in response letter.
 Issues raised with relevant staff nurse.
Summary – the Complainant was unhappy with one particular nurse following a
number of meetings between her and her daughter over a period of time. The Nurse
involved refuted some of the claims made against her, but provided a detailed
reasoning behind her professional choices. Further information provided to parents as
to why decisions have been made and discussions had with their children can place
the medical staff’s actions into better context for the family.
Complaint
Rochdale Infirmary – Day Surgical Unit
Patient story – “..After about 10 minutes there was a knock at the door. A Sister and
RGN X entered. The Sister did not introduce herself and proceeded across the room
waving pieces of paper in front of me saying, “why have you caused this, why have
you caused this trouble?”
I have never been spoken to like the Sister spoke to me in that room by a
professional ever. Her lack of professionalism was appalling.”
Outcome/Response

In respect of Sister X, she has worked as a senior Sister in day surgery for me
for a long time and I have never had any complaints regarding her
professionalism.

On this occasion Sister X had received complaints form both yourself and her
staff in respect of your admission. I apologise if you felt that my staff’s attitude
towards you was unprofessional or insensitive in any way. This was never their
intention. During my investigations I have not found any evidence to support
that their attitude was unprofessional or insensitive towards you. The staff felt
that they were unable to deal with your challenging behaviour and had to
escalate their concerns to Sister X.
26
Page 37 of 318

I sincerely apologise that the service you received during your admission to RI
was not up to the standard you expected. The unit is known for the high
standard of care provided and both the staff and I are proud of the professional
way they approach the work they do. I am sorry that this was not your
experience.

I can assure you that X conducted a thorough investigation and I hope this has
addressed the issues you had following your meeting.
Actions taken



Ward staff spoken to and through investigation completed.
Apologies made in response letter, but many of the allegations not upheld.
Meeting with complainant had to resolve issues face to face.
Summary – upon the patient’s admission he was unhappy with being advised he
should not have brought valuables with him to the hospital. The situation escalated
until the senior Sister had to become involved. The investigation found that the staff
had behaved appropriately and it was the complainant’s aggressive behaviour that
had been the problem. The Trust fully supported their staff whilst empathising with
and apologising to the complainant. A meeting was arranged and held when the
Complainant was not happy with the initial response.
(iii)
Sub- theme: Attitude of Surgical Staff
Complaint
Fairfield Hospital – ENT Out-patients
This man is the most rude and incompetent person I have ever met. For some reason
he takes delight in giving me bad news by then smirking and shrugging his shoulders.
This is extremely patronising and idiotic of him.”
Outcome/Response
 I very much regret the upset you were caused and very much wish to learn
from your experience in order to engage with the doctor concerned and
improve his approach. I therefore must offer my sincere apologies to you that
you were clearly upset by the experience…
I can assure you that I personally take these matters very seriously and you
are quite right to expert courteous and effective treatment from the health
service….Gaining the perspective from our service users is valuable to us and
often highlights issues that may otherwise go unnoticed.
Actions taken
27
Page 38 of 318
Item 7
Patient story – “I have been having on-going treatment for my persistent glue ear.
This has so far resulted in surgery twice… The consultant whose care I am under is
Mr X. I find Mr X easy to talk to and not patronising. However, for the past couple of
appointments I have had the misfortune to be seen by Mr Y.

Staff member spoken to, and full apology provided.
Summary – The complainant had obviously built a good rapport with their initial
treating clinician, and the change may in part explain their unhappiness with the
manner of the new treating doctor.
28
Page 39 of 318
Learning from Complaints
Follow up from previous complaint report
At the meeting of the Clinical Governance and Quality Committee the Complaints and
PALS report for 1 October 2012 – 31 December 2012 was discussed. This had
taken place after the board had reviewed the report and made it clear that they
wished to focus on any areas with two or more complaints identified within this report.
It was indicated the divisions would look into this specifically.
Following on from the Quarter 3 report the Emergency Medicine department is
investigating the high level of complaints against A & E. Whilst it is anticipated that
this may be due to the high level of patients seen, the Trust felt it was important to
look into this and report back to identify any patterns.
The Trust board also considered the Quarter 3 report and asked all divisions to look
into any departments or services which had 2 or more complaints within the previous
3 month period. This is done again to look for patterns, but also importantly to identify
whether specific clinicians or staff are involved repeatedly. The complaints report and
data identifies departments/services and types of complaint, but it was considered
further investigation should take place to establish whether these were linked. This
information is due to be fed back to the June Governance committee. The intention is
use this information to inform a wider consideration of trust procedures etc. Individual
complaints are used to provide learning points for individual staff, but further
emphasis on identifying trends has been emphasised by the Trust board.
Women & Children’s Pilot
The Women & Children’s Pilot to identify suitable complaints for face to face meetings
continues. Whilst it is not possible to say that there is a direct link it is of note that
there has been a significant reduction in the number of comebacks within the Women
& Children division for the last quarter.
29
Page 40 of 318
Item 7
A request was made for cumulative totals in relation to complaints over the period of
the year. This report identifies those departments who record 2 or more complaints in
each of the previous 4 quarters.
Title of Report
Executive
Summary
Patient Experience Report
Review of Patient Appointment Letters/Update on Discharge Management
Arrangements
 Initial collation of letter templates throughout the Trust has taken
place in preparation for a review following patient complaints and
comments regarding the quality of Trust letters. The review has
identified that the Trust has in excess of 1200 different template
variations that do not fit a typical image or format for the Trust.

Steady progress continues with reminding all staff of the importance
of timely and relevant discharge information.
The Trust Board is asked to note the contents of this Report.
Actions
requested
Corporate Objectives supported by this paper:
Patient Experience, Safety, Trust Reputation.
Risks to all projects:
N/A
Public and/or patient involvement:
Patient involvement – patients have been consulted at forums and have been asked to continue to
assist with the review.
Resource implications:
Item 7
No additional resource required but will require involvement from a variety of stakeholders in a
series of meetings.
Communication:
Trust Board
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
YES




NO
N/A





Hugh Mullen
Director of Operations
19 June 2013
[email protected]
1
Page 41 of 318
Purpose
The purpose of this report is to inform the Trust Board on the progress to date of the
patient appointment letter review. The report illustrates the volume and content variation of
correspondence sent to patients and highlights different practices that are adopted across
the Trust. The plan to review, amend and streamline letters where appropriate is outlined
to improve the quality and meaningfulness of the information sent to patients. The report
seeks to inform the Trust Board of the scope and work undertaken to date and the
implementation and the future direction of the project.
Current Position
The Patient Administration System (PAS) has primarily been the main source of end user
letters; the management of the letter templates is the responsibility of the Directory of
Services (DoS) Team; a service within the Elective Access Division. Areas not within the
Elective Access Division manage their letters internally either via a separate Trust system,
i.e., CRIS or through departmentally held templates which have predominantly been
developed within Microsoft (MS) Word.
The content and information relayed to patients within the letters appears to be speciality
or departmental specific; however there are a number of letters that are generic and
provide standard information. Some letters contain a vast amount of information on a wide
range of topics such as car parking, ambulance and transport services, interpreter services
and results of investigations in addition to the appointment details, others very little. The
format and presentation of Trust letters identified also varies significantly across
departments providing little or no Trust wide corporate image or consistency of
information.
Patients and members of the public have identified to the Trust that the quality and the
information provided in the Trust’s letters to patients could be significantly improved.
Progress
To review the standard and quality of all information letters to patients, every letter the
Trust generates to send to patients were identified; all Trust users were contacted
requesting they collate all patient appointment letter templates and forward them to the
scoping group. Simultaneously all letter templates from the Patient Administration System
(PAS) were collated. Templates have also been provided by departments using other
Trust electronic systems such as Prism; a system utilised within the Cardio-Respiratory
and Neurophysiology Departments.
Neighbouring Trusts have been contacted to establish how communication to patients is
managed in other NHS organisations. The Trust’s IM&T Department has been consulted
to identify if any technical solutions are available to streamline the current templates.
Findings

Over 1200 different letter templates have been identified across the Trust.
2
Page 42 of 318





Templates from PAS, CRIS & Prism are available.
Templates have been provided by a wide range of areas that have been developed
in MS Word and are stored on departmental shared / individual drives.
A high number of templates are of poor quality, containing vague information to
patients.
PAS holds the largest volume of templates; however this is a rigid system in terms
of template development and management. The way in which letter templates can
be developed has been investigated by IM&T who are providing a position
statement and a series of recommendations for future development.
Other local Trusts (University Hospital of South Manchester NHS Foundation Trust
and Tameside Hospital NHS Foundation Trust) have streamlined the letters sent
out to patients to an absolute minimum. The information held in the body of the
letter is minimal and any other supporting information, i.e., date, time, venue of
appointment; detailed in an accompanying leaflet/booklet.
Way Forward










Identifying key stakeholders to be involved in the group reviewing end user letters.
The group will include Patient Representatives, representatives from the Elective
Access Division and Clinical Divisions. All professions should be represented. Bury
Society for Blind and Partially Sighted People have expressed an interest in
participating in the project.
Developing a structured plan and approach to reviewing the letters.
Liaison with the Trust’s Allied Health Professional (AHP) services to firstly manage
clinics within PAS and secondly develop standard letters across the services.
Liaison with the Community Teams to standardise appointment letters.
Developing Terms of Reference for the group and arranging regular meetings for
the group to review letters accordingly.
Establishing the desired format of the letters going forward, including the corporate
image and the level and detail of information patients require in their letter to enable
them to be prepared for the upcoming appointment at the Trust.
Condensing, changing and amending letters as advised by the group.
Liaising closely with the Directory of Services (DoS) Team to remove or delete all
obsolete letters from PAS.
Communicating changes to all Trust users, and to patients via the relevant patient
forums and to GP surgeries.
Developing a plan to review information leaflets to patients as part of this group.
Identified actions will be managed within a robust project plan supported by a
comprehensive communications and engagement strategy. It is expected that the duration
of this project will be nine months from July 2013 to March 2014.
3
Page 43 of 318
Item 7
The scoping group has identified a series of actions to progress the project. These
include:
Conclusion
This project provides the Trust with the opportunity to actively engage with our patients,
carers and their families and produce meaningful information for our patients.
Recommendations
The Trust Board is asked to note the comments of this report.
Hugh Mullen
Director of Operations
June 2013
4
Page 44 of 318
Title of Report
Listening into Action
Executive
Summary
This paper provides an update on the Listening into Action
Programme. The report updates on the Quick Wins and the First
Ten Teams.
Actions
Requested:
The Board is asked to note the progress being made and to
consider any further action that can be taken to support the
programme.
Corporate objectives supported by this paper:
Objective 4 - Workforce
Risks:
Board level risk - Poor staff engagement / morale affecting patient care.
Public and/or Patient Involvement:
Not relevant for this paper.
Resource Implications:
Not relevant for this paper.
Communication:
Through Trust communications channels and branded LiA publicity.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
NO
N/A
John Saxby
Chief Executive
June 2013
[email protected]
Item 8
Name
Job Title
Month and Year
Email
YES
X
X
X
X
X
X
X
X
X
X
Page 45 of 318
The Pennine Acute Hospitals NHS Trust
Listening into Action - Progress Report – June 2013
General Developments
3 Matrons from East Cheshire NHS Trust are visiting the Trust on 1 July to meet with the LiA Team
who reduced the documentation used for patients brought in as acute admissions. They are keen to
learn from the team in order to make the same changes in their Trust.
The new KSF PDR documentation has been developed by the Education and Training Department
with involvement from the LiA Team, and this will be issued with the LiA Logo. The issue of PDRs
was raised at the CEO hosted Conversations last summer.
A “Team Leader” profile will feature each week on the weekly bulletin so that staff can see who is
involved in LiA, learn why they got involved in the first instance and what effect the process has had
on them personally and their team.
As part of the need for sustainability of the initiative, LiA involvement in strategic planning running
alongside local service improvement is seen to be a necessary development. The involvement of
front line staff in designing the Trust Nursing & Midwifery Strategy was the first attempt to advance
this. The Security Management Team is now planning a Big Staff Conversation to involve staff in
designing the Trust Security Management Strategy.
Next 20 Teams
By the end of June 15 Staff Conversations will have taken place with over 200 staff from both inside
and outside the Trust coming together to make improvements for patients and staff. Work is
intensifying now as the teams are taking forward the ideas from the Conversations, and choosing
their “Quick Wins” and their big impact changes. These teams are more adventurous and innovative
as the LiA Team have learned many lessons from the First 10 Teams, and they are able to provide
even more expert guidance to the Next 20 Teams







The Pharmacy Team at FGH had their Conversation on 11 June and is in the process of
making better use of the Pod System for patients with mobility problems who attend the Out
Patient Department.
The Critical Care Team at NMGH had their Conversation on 7 June and they are devising and
setting up systems to ensure that patients who are admitted to the unit have a named
Consultant Physician with regular follow up.
The IM&T Department who held the first Conversation of the cohort on 22 April are well on the
way to completing their mission, and they have transformed the way they respond to problems
in clinical areas and improved the IT kit on wards
The Theatre Team at NMGH who had their Conversation on 21May have done a comparative
study of all Trust Anaesthetic Rooms and have agreed standardisation to ensure safe and
effective working in the Anaesthetic Rooms at NMGH.
The Neo-natal Team are having a Conversation on 25 June and they want ideas on how they
can improve the discharge information given to the parents of premature babies. They have
invited some parents to this event.
The A&E Team at Oldham had their Conversation on 24 May and invited members of the
Ambulance Service, as they are setting up a Rapid Ambulance Triage system that will reduce
waiting times and improve flow for patients.
The Unscheduled Care Team at Oldham have a Conversation planned for 4 July, and they
want ideas on how they can sustain the amazing outcomes they had when an Older People’s
Assessment Team was piloted on the site. Again, this team have invited staff from outside the
Trust to help them with ideas.
Page 46 of 318











The team from the Acute Medical Unit at Oldham had their Conversation on 10 June and
included staff from the Ambulance Service and GP Practices to ensure that they got as much
input as possible to help them improve the patient pathway from the A&E Department to AMU.
The Trust Security Management Team held their Conversation on 10 June and staff from the
Greater Manchester Police Force and the Mitie Security firm were welcome contributors to
address the issue of reducing violence within the Trust.
The Chaplaincy Team held their Conversation on 28 May and they now have an action plan in
place to modernise the service by integrating into ward teams and becoming part of main
stream services.
The Floyd Unit Team at Birch Hill Hospital had their Conversation on19 June and invited staff
from all disciplines to ask how they can improve team working on the unit to benefit the
services provided for patients and their families.
The Programmed Investigation Unit Team at Rochdale held their Conversation on 3 June and
with staff from Health Records, doctors and nurses they are now acting on suggestions to
ensure that all patients’ case notes arrive on the unit before the patient.
The Ultrasound Department Team based at FGH, but who work across sites, held their
Conversation on 4 June. They are now putting plans in place to ensure that patients do not
wait excessively for their scans, and that clinical need is always a priority when scheduling
takes place.
The Occupational Therapy Department at NMGH are due to hold their Conversation on 21
June and they have invited staff from inside and outside of the Trust as they want to know
how the referral part of the discharge process for patients can be improved.
The Elderly Care Team at NMGH has planned their Conversation for 8 July and they want to
know how they can improve the communication within their team.
The Payroll Team will have their Conversation on 3 July as they want to find out what ideas
people have about extending the salary sacrifice scheme.
The Radiology Team at Oldham had their Conversation on 20 June and they are now devising
an improved pathway for patients who attend the department from the wards.
The Obstetrics and Gynaecology Team at Oldham held their Conversation on 5 June and they
have many actions to take forward to ensure results are checked and followed up in a timely
manner, and to improve the provision of ALS discharge summaries for GPs.
In addition to the 20 formal teams there are now more informal teams using LiA to address issues
within their department; the Colo-rectal Specialist Nurses want to use LiA for a Patient Conversation
to ask how they can improve follow up treatment after surgery. The Oncology Team want to look at
the implementation of new standards and the Estates Department at Oldham have just asked to get
involved and a one to one meeting is planned for week commencing 25 June.
As LiA enters its second year at PAHT, the Sponsor Group is now planning how to extend and
sustain the improvements that have been made. Support from Senior Management levels in all
Divisions is vital to the success of this endeavour and the group is looking at ways this can be
achieved.
John Saxby
Chief Executive
Item 8
June 2013
Page 47 of 318
Item 9
Title of Report
The Corporate Performance Report
Executive
The report provides information about the Trust’s
Summary
performance against national and local indicators.
Actions
The Board is asked to review performance
requested
Corporate Objectives supported by this paper:
This paper supports corporate objectives – each KPI is mapped to the
corporate objectives in the scorecard.
Risks:
The Board Risk Register records 7 risks:
(1) Completing 90% of PDRs; (2) Delivery of 62 day cancer standards;
(3) Delivery of 4 hour emergency care standard; (4) Break even; (5)
Improvement in HSMR; (6) Delivery of RTT Standards; (7) HCAI
Public and/or patient involvement:
The key performance indicators within this report are derived from the
expectations of patients and the public.
Resource implications:
Failure to achieve some national indicators could result in loss of income.
Communication:
Through management structures
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
YES
X
X
X
X
X
X
X
X
X
X
NO
N/A
Hugh Mullen
Director of Operations
June 2013
[email protected]
1
Page 48 of 318
THE PENNINE ACUTE HOSPITALS NHS TRUST
The Corporate Performance Report
Introduction
1.
This report quantifies:
 The Trust’s performance against national indicators used by
regulatory agencies (identified in blue font throughout the report)
 The Trust’s performance against a range of local indicators
(identified in black font)
Strategic context
2.
The scorecard included in this report identifies the corporate objective
linked to each indicator.
Structure of the corporate performance report
3.
The structure of the report is outlined below:Section 1 – Performance overview
 Performance overview and performance framework ratings used by
regulators to assess whether trusts are meeting minimum standards
Section 2 – Performance scorecard
 A summary of key performance indicators showing current status,
historical trends, and forecasted future performance
Section 3 – The narrative to support the scorecard
 A summary of issues and actions for underperforming KPIs for each
section of the scorecard
Appendix 1 - Scorecard trends
Appendix 2 - RAG rating thresholds applied to the KPIs
2
Page 49 of 318
Regulatory performance assessment frameworks summary
5.
The performance assessment frameworks specify the minimum
standards expected of NHS organisations. The NHS Performance
Framework applies to trusts that have not attained Foundation status.
6.
The most recent Service performance ratings are summarised in the
table below:NHS Performance Framework 2012-13: Service Performance Rating
Estimated Performance
Summary
Actual Performance Summary
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
2.40
2.49
2.55
2.70
2.66
2.70
2.85
2.85
2.92
2.92
2.92
2.92
Performance
under review
Performing
7.
The performance rating for the Trust has improved during 2012-13 as
RTT, and C-Diff performance has improved. For March overall the
Trust is rated as “Performing.”
8.
Further details about individual indicators are provided in Sections 2
and 3 of this report.
Section 2 – The corporate performance scorecard
RAG rating thresholds used in the scorecard
9.
The Trust uses the following traffic light system
Table showing the three RAG rating thresholds:Performance
Green
Amber
Red
Black
10.
Performance threshold names and descriptions
Achieved - The indicator has been met
Underachieved - The indicator has been narrowly missed
Failed - The indicator has been missed by a significant margin
Unavailable - The indicator information is unavailable
Individual indicator thresholds are described in Appendix 2.
3
Page 50 of 318
Item 9
Section 1 – Performance overview
4.
Overall, the Trust’s performance is as follows: Reds include:- Hospital acquired infection, Financial forecast
outturn and performance against plan, Progress on delivery of QIPP
saving, and Bullying and harassment cases.
 Ambers include:- Attendance rate, Mandatory training, and Bank,
Agency and Locum spend.
Page 51 of 318
3
3
Financial performance score for Trusts
Progress on delivery of QIPP savings
£m Finance
No Finance
£m Finance
% Nursing
2
3
% Nursing
2
Financial forecast outturn & performance against plan
3. RESOURCES MANAGEMENT
Y/N HR - OD
% Nursing
% Operations
No Operations
2
2
Mixed Sex Accommodation rate per 1,000 FCEs
Self-certification against compliance with requirements
regarding access to healthcare for people with a
learning disability
How would you rate the overall standard of care
received?
Have you been informed of any dangers when you go
home?
2
2
Delayed transfers of care
2. PATIENT EXPERIENCE
Number of national RTT standards being achieved (best
possible = 4)
No Operations
% Operations
1
1
4 hour emergency access standard (Provider)
No Nursing
No Medical
No Operations
1
Hospital acquired Infection - Achieving of MRSA &
C-Diff reduction trajectories (Best =2)
No Medical
LEAD
EXEC
1
1
NPSA 'Never' Events
Stroke Care - Number of stroke care standards
achieved (best = 2)
Cancer - Number of national cancer standards being
achieved (best possible = 10)
1
Mortality Index (All Admissions 2011 CHKS Model)
1. CLINICAL QUALITY, EFFECTIVENESS, & SAFETY
PERFORMANCE INDICATOR
Corp % /
Obj No
C
Q
C
Q
Q
Q
M
C
Q
Q
Q
Q
C
M
Q
Cuml/
Monthly/
Quarterly
31.917
3
-0.431
82.6
82.6
Yes
0.5
3.5
4
10
2
95
2
0
95
Target
Profile
0
4
9.954
0
4
96.4
Yes
1.4
0
0
May-13 Jun-13
-1.37
10
95.2
0
Apr-13
Q1
Jul-13
Q3
Nov-13
PERFORMANCE
Aug-13 Sep-13 Oct-13
Q2
Section 2 – The Corporate Performance Scorecard
Dec-13
Jan-14
Feb-14 Mar-14
Q4
TRENDS UP TO
LAST 12 MONTHS
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
4
YEAR END
FORECAST
Page 52 of 318
4
4
4
4
4
4
Turnover Rate (rolling year)
PDR completion Rate 90% (rolling year)
Mandatory training compliance for patient handlers
(best=3)
Bank, Agency, and Locum spend
Bullying and harassment cases reduced by 10%
% of staff recruited within standard times
2
2
2
3
3
3
Trust telephone response times - external
Monthly cleaning scores
Patient satisfaction with food
Estates Help Desk calls attended within allocated
timeframe
Clinical waste (kilograms per patient)
Energy consumption per heated volume - GJ / 100m3
5. FACILITIES
4
Attendance Rate
4. WORKFORCE
PERFORMANCE INDICATOR
LEAD
EXEC
No Facilities
No Facilities
% Facilities
% Facilities
% Facilities
% Facilities
No Medical
No Medical
% Medical
% HR - OD
% HR - OD
% HR - OD
% HR - OD
Corp % /
Obj No
M
C
C
C
C
C
C
C
C
C
Q
M
M
Cuml/
Monthly/
Quarterly
74
1.2
80
75
88.5
70
70
5
8
3
90
7.0
95.2
Target
Profile
73
1.0
Feb-14 Mar-14
Item 9
G
G
G
G
G
G
96.0
96
G
G
G
G
72
72
Jan-14
5
YEAR END
FORECAST
G
Dec-13
TRENDS UP TO
LAST 12 MONTHS
94
Nov-13
Q4
G
Aug-13 Sep-13 Oct-13
Q3
6
Jul-13
PERFORMANCE
G
2
7.9
95.0
May-13 Jun-13
Q2
8.9
80.3
1
8.0
94.7
Apr-13
Q1
Section 3 – The narrative to support the scorecard
11.
This section of the report is divided into sub-sections mirroring those
used in the scorecard. Details are provided on underperforming
indicators.
Clinical Quality, Effectiveness, and Safety
12.
The following table summarises the underperforming indicators in this
section of the scorecard:Clinical Quality, Effectiveness, and Safety indicators not met
Hospital acquired Infection - Achieving of MRSA & C-Diff reduction
trajectories – Apr-13 to May-13 data
Rating
Red
Hospital acquired infection indicator
13.
This measure is made up from the following 2 sub-indicators: The number of hospital acquired C-Difficile cases against trajectory
(failed)
 The number of hospital acquired MRSA cases against trajectory
(failed)
14.
The Trust reported 8 C-Difficile cases in May, missing the monthly
trajectory of 5. The year to date performance trajectory of 10 was also
missed, with 18 cases reported in the period April to May. Work
continues, ensuring that the basics of care are priorities for all clinical
staff along with the implementation of infection control policies and
procedures.
15.
The Trust reported no cases in May and 1 case in April. The MRSA
threshold for 2013/14 was missed against a zero tolerance target. The
action plan to address issues identified from the Root Cause Analysis
is being implemented.
Patient Experience
16.
All of the indicators in the Patient Experience section were achieved.
Resources Management
17.
The following table summarises the underperforming indicators in this
section of the scorecard:Resources Management indicators not met
Financial forecast outturn and performance against plan – Apr-13 to
May-13 data
Progress on delivery of QIPP savings – Apr-13 to May-13 data
Rating
Red
Red
Financial forecast outturn and performance against plan
18.
The Trust deficit for May is £1.37m compared to a planned deficit of
£0.43m. The Trust is forecasting to achieve breakeven by the year
end.
6
Page 53 of 318
Workforce
20.
The following table summarises the underperforming indicators in this
section of the scorecard:-
Workforce indicators not met
Attendance rate – May-13 data
Mandatory training -12 month rolling compliance for patient handlers
(best = 3 standards' trajectories met) – Jun-12 to May-13 data
Bank, Agency and Locum spend – Apr-13 to May-13 data
Bullying and harassment cases – Apr-13 to May-13 data
Rating
Amber
Amber
Amber
Red
Attendance rate indicator
21.
May 2013 performance was 95.0%. The Trust action plan is being
implemented. Divisions are developing or have developed their own
plans to support the Trust wide plan. The bottom managers are to be
seen by Executive Directors regarding their own performance in
managing sickness absence.
Mandatory training for patient handlers indicator
22.
This indicator covers 3 types of mandatory training for staff who are
classified as patient handlers. The 3 types of training are: Fire Training (year end target = 90%)
 Hand Washing (year end target = 90%)
 Information Governance (year end target = 95%)
Performance against each type of training is measured on a 12 month
rolling basis and is summarised in the table below:Type of mandatory training
Target Trajectory Actual
Fire Training
>=82%
78%
Hand Washing
>=88%
81%
Information Governance
>=95%
94%
Total number of mandatory
3
2
training standards achieved
NB - Underachieved (Amber) <-5% and >=-15% of target, Failed (red) <-15%
23.
The Learning and Organisation Development department continue to
target the lowest 25 compliant areas with support to raise access to
training by supplying bespoke sessions, learning boards and
encouraging access to e-learning options. These areas are now being
supported to produce action plans to improve their compliance levels.
24.
A new PDR document has been launched which has priority for
mandatory training. The document indicates that the three KPI areas
must be green at all times. There are over 70 briefings planned from
13th June to end of July to deliver this message to all managers and
appraisers.
7
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Item 9
Progress on delivery of QIPP savings
19.
The Trust has identified CIPs with low or no risk of delivery with an
annual value of £9.954m. The CIP programme is currently under
review and the Trust expects to achieve £31.917m for the year.
25.
Managers are also pleased that they have a good source of information
regarding their staff compliance and are using this data to influence
decisions on access to study time. Staff are accepting more personal
responsibility to access their own training record and identify their own
compliance level and access training before compliance is reduced.
Bank, Agency and Locum spend
26.
The Trust missed the target of 8% with 8.9% reported YTD. Divisions
are implementing actions to provide a more joined up and coordinated
approach to address issues in managing our temporary workforce.
Bullying and harassment cases
27.
The Trust had 2 cases reported in February. The year to date target of
5 cases was missed with 6 reported for the period April to May. All
reported cases are being investigated under the Bullying and
Harassment policy.
Facilities
28.
All of the indicators in the Facilities section were achieved.
Summary
29.
This report has quantified:
 The Trust’s performance against national indicators used by
regulatory bodies (identified in blue font throughout the report)
 The Trust’s performance against a range of local indicators
(identified in black font)
30.
Where performance was below target, a summary of actions being
taken has been given.
31.
The appendices of the report show:
 The performance trends for every indicator
 The performance scorecard RAG ratings thresholds and details of
the sources of the thresholds
Recommendations
32.
The Board is asked to review the Trust’s performance
Hugh Mullen
Director of Operations
June 2013
8
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Page 56 of 318
Progress on delivery of QIPP savings
Financial performance score for Trusts
Financial forecast outturn & performance against plan
3. RESOURCES MANAGEMENT
Self-certification against compliance with requirements
regarding access to healthcare for people with a
learning disability
How would you rate the overall standard of care
received?
Have you been informed of any dangers when you go
home?
Mixed Sex Accommodation rate per 1,000 FCEs
Delayed transfers of care
2. PATIENT EXPERIENCE
Number of national RTT standards being achieved
(best possible = 4)
Stroke Care - Number of national stroke care
standards achieved (best = 2)
Cancer - Number of national cancer standards being
achieved (best possible = 10)
4 hour emergency access standard (Provider)
Hospital acquired Infection - Achieving of MRSA &
C-Diff reduction trajectories (Best =2)
NPSA 'Never' Events
Mortality Index (All Admissions 2011 CHKS Model)
1. CLINICAL QUALITY, EFFECTIVENESS, &
SAFETY
PERFORMANCE INDICATOR
Apr-12
May-12 Jun-12
Q1
Jul-12
Aug-12 Sep-12
Oct-12
Nov-12 Dec-12
PERFORMANCE TRENDS (2012-13)
Q2
Q3
Jan-13
Feb-13
Q4
Mar-13
Apr-13
PERFORMANCE SCORECARD TRENDS
May-13 Jun-13
Q1
Jul-13
Aug-13 Sep-13
Oct-13
Jan-14
Q4
Feb-14
Item 9
Nov-13 Dec-13
PERFORMANCE TRENDS (2013-14)
Q2
Q3
APPENDIX 1
9
Mar-14
Page 57 of 318
Energy consumption per heated volume - GJ / 100m3
Clinical waste (kilograms per patient)
Estates Help desk calls attended within allocated
timeframe
Patient satisfaction with food
Monthly cleaning scores
Trust telephone response times - external
5. FACILITIES
% of staff recruited within standard times
Bullying and harassment cases
Bank, Agency, and Locum spend
Mandatory training 12 month rolling compliance for
patient handlers (best =3 standards' trajectories met)
PDR completion Rate (Year To Date)
Turnover Rate (rolling year)
Attendance Rate
4. WORKFORCE
PERFORMANCE INDICATOR
Apr-12
May-12 Jun-12
Q1
Jul-12
Aug-12 Sep-12
Oct-12
Nov-12 Dec-12
PERFORMANCE TRENDS (2012-13)
Q2
Q3
Jan-13
Feb-13
Q4
Mar-13
Apr-13
May-13 Jun-13
Q1
Jul-13
Aug-13 Sep-13
Oct-13
Nov-13 Dec-13
PERFORMANCE TRENDS (2013-14)
Q2
Q3
Jan-14
Q4
Feb-14
10
Mar-14
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An improved rating >=0.25 AND <0.5 per quarter above
baseline of 81.0
An improved rating >= 0.5 per quarter achieved above
baseline of 81.0
2
between 60% and 90% of QIPP target identified as
deliverable and on target to deliver
>=3
90% of QIPP target identified as deliverable and on target to
deliver
Progress on delivery of QIPP savings
not achieving plan for year to date or planned outturn by less
than 1% of turnover
An improved rating >=0.25 AND <0.5 per quarter above
baseline of 81.0
An improved rating >= 0.5 per quarter achieved above
baseline of 81.0
achieving or exceeding plan for year to date and planned
outturn
n/a
>0% AND <=0.5%
>3.5% and <=5% cumulative
Compliant with standards
=0%
<=3.5% cumulative
n/a
Any of the national cancer standards not met during quarter
All 10 cancer standards met cumulative quarter
<95% And <=94% cumulative quarter
TIA>=60% cumulative YTD And time on stroke unit >=80%
All of the 3 bottom line standards achieved and the 1
supporting measures at least underachieved
>0 in month
>100% of the 2011-12 Q3 outturn
Worse than target (Failing)
Locally agreed
Locally agreed
Source of Thresholds
APPENDIX 2
Nationally specified
NHS Performance Framework thresholds
NHS Performance Framework thresholds
NHS Performance Framework thresholds
Less than 60% of QIPP target identified as deliverable and
on target to deliver
1
not achieving plan for year to date or planned outturn by
more than 1% of turnover
Local thresholds
Item 9
NHS Performance Framework thresholds used
NHS Performance Framework thresholds used
An improved rating <0.25 per quarter above baseline of 81.0 Locally agreed
11
NHS Performance Framework thresholds used &
Contract targets used
Contract target used
NHS Performance Framework thresholds used
An improved rating <0.25 per quarter above baseline of 81.0 Locally agreed
Not compliant with standards
>0.5%
>5% cumulative
Any of the standards failed
Any national cancer standards failed for the quarter
TIA <50% OR Time on stroke unit <60%
<94% cumulative quarter
<=cumulative profile for both standards OR current month >2 >cumulative profile for either standard OR current month >3 NHS Performance Framework thresholds used for
Std deviations
Std Deviations
trajectory & local within month peak indicator added
n/a
>95% of the 2011-12 Q3 outturn and <=100% of outturn
Below target (Underachieving)
PERFORMANCE THRESHOLDS
TIA<60% and >=50% OR Time on stroke unit <80% and
>=60% - Both Cumulative YTD
>=95% cumulative quarter
<=cumulative profile for both standards
0 in month
>=95% of the 2011-12 Q3 outturn
On target (Achieving)
Financial performance score for Trusts
Financial forecast outturn & performance against plan
3. RESOURCES MANAGEMENT
Self-certification against compliance with requirements
regarding access to healthcare for people with a
learning disability
How would you rate the overall standard of care
received?
Have you been informed of any dangers when you go
home?
Mixed Sex Accommodation rate per 1,000 FCEs
Delayed transfers of care
2. PATIENT EXPERIENCE
Number of national RTT standards being achieved
(best possible = 4)
Stroke Care - Number of stroke care standards
achieved (best = 2)
Cancer - Number of national cancer standards being
achieved (best possible = 10)
4 hour emergency access standard (Provider)
Hospital acquired Infection - Achieving of MRSA &
C-Diff reduction trajectories (Best =2)
NPSA 'Never' Events
1. CLINICAL QUALITY, EFFECTIVENESS, &
SAFETY
Mortality Index (All Admissions 2011 CHKS Model)
PERFORMANCE INDICATOR
SCORECARD RAG RATING PERFORMANCE THRESHOLDS
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Energy consumption per heated volume (2.5%
reduction in 2011-12) - GJ / 100m3
Clinical waste (kilograms per patient)
Estates Help Desk calls attended within allocated
timeframe
Patient satisfaction with food
Monthly cleaning scores
Trust telephone response times - external
5. FACILITIES
% of staff recruited within standard times
Bullying and harassment cases reduced by 10%
Bank, Agency, and Locum spend
Mandatory training compliance for patient handlers
(best=3)
PDR completion Rate 90% (rolling year)
Turnover Rate (rolling year)
Attendance Rate
4. WORKFORCE
PERFORMANCE INDICATOR
<74.32
<=1.2 Kg / Patient cumulative
>=80% cumulative
>=75% scored 3 from 5 cumulative
>=88.5% cumulative
>=70% within 20 seconds cumulative
>= 70% compliance with standards
<=last year's cumulative actual
<=8% cumulative
Mandatory training on trajectory for all 3 types
>=-5% of trajectory
>=7%
>= Monthly plan
On target (Achieving)
>74.32 AND <=75
>1.2 Kg per patient AND <=1.3 KG per patient cumulative
<80% and >=70% cumulative
<75% AND >=65% scored 3 from 5 cumulative
<88.5% AND >=80% cumulative
>=65% and <70% within 20 secs cumulative
<70% AND >=50% compliance with standards
n/a
>8% AND <=10% cumulative
<=1 mandatory training types rated as amber
<-5% of trajectory AND >=-15% of trajectory
>7% AND <=6.0%
< Monthly plan AND >=-0.5% of plan
Below target (Underachieving)
PERFORMANCE THRESHOLDS
>75
>1.3 Kg / Patient cumulative
<70% cumulative
<65% scored 3 from 5 cumulative
<80% cumulative
<65% within 20 seconds cumulative
<50% compliance with standards
> last year's cumulative actual
>10% cumulative
2 or more mandatory training types rated as red
<-15% of trajectory
<6.0%
<-0.5% of Month plan
Worse than target (Failing)
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Locally agreed
Source of Thresholds
12
Title of Report
Executive
Summary
Actions
requested
Information Management and Technology Strategy
This document sets out the Trust’s strategic direction for
Information Management and Technology for the period 20132017 superseding the IM&T strategy for the period 2010-2013
The Board are asked to:


Note the contents of the document which was reviewed
in detail at the Board Seminar Day on 1 June 2013, and
Approve the proposed IM&T Strategy for the period
2013-2017.
Item 10
Corporate Objectives supported by this paper:
The Strategy supports all corporate objectives.
Risks: Failure to support the delivery of the Trust’s corporate objectives.
Public and/or patient involvement: Communication of proposed IM&T objectives
included in stakeholder requirements workshops as part of the strategy’s development
Communication: as above
Have all implications been considered?
Yes
Assurance
√
Contract
√
Equality and Diversity
√
Financial/Efficiency
√
HR
√
IM&T
√
Local Delivery Plan/Trust Objectives
√
National policy/legislation
√
Sustainability
√
No
N/A
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Name
Brian Steven
Job Title
Deputy Chief Executive / Director of Finance
Date
27th June 2013
Email
[email protected]
Version
Date
Amendment
V1.0
5th May 2013
Created document
V1.1
21st May 2013
Amended after review with Brian Steven
V1.2
22nd May 2013
Updated section 9
V1.3
2nd June 2013
Amended after review with the Executive team
V1.4
16th June 2013
Amended after review with the Trust Board
Approvals:
Name
Title
Date
Version
John Jesky
Chairman
V1.4
John Saxby
Chief Executive
V1.4
Brian Steven
Deputy Chief Executive / Finance
Director
V1.4
2|Page
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Contents
1
EXECUTIVE SUMMARY ............................................................................................. 5
2
INTRODUCTION .......................................................................................................... 8
4
5
6
7
PURPOSE OF THIS DOCUMENT ........................................................................................ 8
2.2
PROCESS USED FOR THE DEVELOPMENT OF THIS STRATEGY...................................... 9
STRATEGIC CONTEXT .............................................................................................10
3.1
NATIONAL CONTEXT ....................................................................................................... 10
3.2
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) FRAMEWORK ................. 12
3.3
INFORMATION STRATEGY FOR THE NHS ...................................................................... 13
3.4
LOCAL CONTEXT ............................................................................................................ 14
3.5
STAKEHOLDER ANALYSIS .............................................................................................. 18
3.6
SUMMARY OF ACTIONS ARISING ................................................................................... 19
CURRENT STATE OF IM&T ......................................................................................20
4.1
PROGRESS AGAINST PREVIOUS IM&T STRATEGY ....................................................... 20
4.2
STATUS OF CURRENT IM&T INFRASTRUCTURE AND SERVICES PROVISION .............. 20
4.3
CURRENT STATE OF CLINICAL SYSTEMS ...................................................................... 22
4.4
SUMMARY OF ACTIONS ARISING ................................................................................... 24
VISION AND STRATEGIC OBJECTIVES .................................................................25
5.1
VISION ............................................................................................................................. 25
5.2
RELATIONSHIP BETWEEN VISION AND STRATEGIC OBJECTIVES ................................. 25
5.3
IM&T STRATEGIC OBJECTIVES ..................................................................................... 25
STRATEGIC CHOICES ..............................................................................................27
6.1
EPR STRATEGY ............................................................................................................. 27
6.2
END USER DEVICE STRATEGY ...................................................................................... 30
6.3
IT SERVICE MODELS ...................................................................................................... 31
6.4
TELEHEALTH AND TELEMEDICINE .................................................................................. 32
6.5
TRANSFORMING COMMUNITY SERVICES ...................................................................... 32
6.6
PROVISION OF INFORMATION ........................................................................................ 32
6.7
APPROVAL PROCESSES ................................................................................................. 32
ACTIONS AND IMPLEMENTATION PLAN ..............................................................33
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Item 10
3
2.1
8
GOVERNANCE ...........................................................................................................39
8.1
THE IM&T PROGRAMME COMMITTEE ........................................................................... 39
8.2
CLINICAL STRATEGY BOARD ......................................................................................... 39
8.3
METHODOLOGIES AND BEST PRACTICE ....................................................................... 40
8.4
IM&T CURRENT ORGANISATION STRUCTURE .............................................................. 42
9. COSTS ........................................................................................................................43
9.1
FINANCIAL LANDSCAPE .................................................................................................. 43
9.2
APPROACH TO FUNDING STRATEGIC IM&T DEVELOPMENTS ..................................... 43
10. RISKS ..........................................................................................................................43
11. LESSONS LEARNED FROM PREVIOUS STRATEGY ............................................45
12. CONCLUSION ............................................................................................................47
13. APPENDIX A: GLOSSARY ........................................................................................48
14. APPENDIX B: RECOMMENDATIONS FROM THE FRANCIS REPORT ................49
15. APPENDIX C: PROGRESS AGAINST PREVIOUS IM&T STRATEGY ...................51
16. APPENDIX D: LIST OF CLINICAL SYSTEMS..........................................................58
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The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
1 Executive Summary
The Information Management and Technology (IM&T) strategy supports and
underpins the strategic direction of the Trust. It will act as a catalyst to enable more
efficient processes and new and innovative ways of working.
The national strategic agenda focuses on involving patients in their own care and
providing them with information they need to make informed choices. There is an
emphasis on joining up health and care services and integrating information across
organisational boundaries. The competitive environment in which the Trust now
operates also requires it to become more business-like and to take a lead in the local
community. Together these challenges drive the Pennine Acute Hospitals NHS Trust
to improve efficiency and effectiveness of services at an ambitious rate. IM&T has a
critical role to play in enabling the Trust to overcome these challenges through
modernising business critical systems and transforming how information is shared
with its peers.
In summary, IM&T needs to support the Trust in responding to national strategic
initiatives by:





ensuring information is complete, accurate and available to enable the public
to become involved in decisions about how services are provided;
enabling patients to take control of their information, make informed choices
about their care and treatment options, and about how and whether to
participate in trials and research;
promoting and enabling the sharing of information and services to enable the
Trust and healthcare professionals to provide more integrated care within and
across organisational boundaries and to forge closer links with social services
applying IM&T in innovative and effective ways to support the Trust in making
quality and productivity gains in line with the national QIPP agenda;
providing information and systems to support the financial and planning
processes.
IM&T also needs to support the Trust in responding to local strategic initiatives by:



systems and solutions that enable real time data capture, feedback and
reporting underpinned by an infrastructure that enables the sharing of data
between departments, other Trusts and community healthcare providers;
development of intuitive systems with decision support;
infrastructure and interface development to enable data sharing and
collaboration opportunities with other Trusts and partners, including current
opportunities for collaboration on an electronic document management
solution procurement and for sharing disaster recovery arrangements;
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Item 10
This document examines the Trust’s business and strategic drivers and identifies
strategic objectives which will guide activities and prioritise investment in IM&T over
the next 3 years. It describes the current IM&T capabilities and assesses progress
against the previous strategy, identifying the key gaps that need to be addressed in
order to achieve the objectives. This is a strong, resilient and flexible strategy that
will future proof the organisation and aligns IM&T with the Trust’s strategic direction.
IM&T supports and underpins the major transformational change programmes in the
Trust, empowering the organisation to adopt a fresh approach to health care delivery
through new and innovative ways of working.





standardisation of software used by PCs and personal devices with a
consequent improvement in performance of hardware and infrastructure and
the ability to accommodate new technologies;
systems and connectivity to provide remote working from community
locations, and improvement in communications between hospital services and
community and social care;
support for achievement of Foundation Trust status;
being an active participant in the North East Transformation Board and
establishing the IM&T Sub Group in support of its agenda to integrate care
across the healthcare community;
making contributions to the Trust Cost Improvement Plan.
Since the last strategy was approved the IM&T Department has made great progress
in a number of areas. All clinical areas have wireless networking and a range of
mobile devices have been deployed. All ward areas have electronic whiteboards and
electronic prescribing has been successfully rolled out across the medical and
surgical wards at Oldham. However, in order to keep up with the accelerated pace of
change within the NHS the department has set itself ambitious goals for the future,
which will be challenging but achievable.
The strategic vision for IM&T is:
‘To empower the Trust through the deployment of business critical systems
and services which are scalable, flexible and agile.’
The strategic mission for IM&T is:
‘To become a more efficient and productive department.'
The following list identifies the principal objectives for IM&T to respond to in support
of the Trust’s efficiency and quality agenda:
A. to develop integrated IT systems to support integrated care. An electronic
patient record capable of being shared across acute and community services,
providing a single view of the patient record, available wherever and whenever it
is required, subject to confidentiality and security constraints. This includes
actions to implement an Electronic Document and Records Management
(EDRM) solution that will remove legacy paper and enable the creation of a
paper light environment;
B. to support flexible ways of working and improve working lives, providing
improved access to clinicians to the information and IT tools to support the safe
and effective care of patients, whenever and wherever it is required, including
across acute and community locations;
C. to deliver enhancements to the IT infrastructure which:





is service-orientated, flexible and responsive to users’ needs;
is efficient, ‘green’ and effective;
provides opportunities for generating income;
improves the user experience of IT;
reduces cost and risk related to IT services.
D. to provide efficient corporate and back office systems to support workflow
and efficiency through:

e-requisitioning;
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


e-procurement;
self-service HR;
e-rostering and leave management.
E. to deliver a high quality information service including the use of Business
Intelligence tools and dashboards to support the collection of income via Payment
by Results (PbR) and achievement of targets, standards and priorities;
F. to provide agile solutions which are flexible and able to grow to support the
corporate ambitions of the Trust in a rapidly changing environment, including:



support for the Foundation Trust application;
support for service reconfigurations, such as Healthier Together;
support for business initiatives, such as pathology service hosting.
This strategy is set apart from other strategies because of its emphasis on integrated
care. It highlights the need for integrated data to be shared with other healthcare
organisations across the community and the local community itself, for example by
the introduction of a patient portal and extranet which allows local authorities
appropriate access to Trust information. The strategy also considers how IT based
clinical services can be moved closer to the customer through self-service, greatly
reducing the time needed to provide applications and services. The strategy also
considers the infrastructure requirements needed to achieve this ambitious agenda.
The major strategic choices for achieving these objectives are also examined in more
detail for the key areas:





Integrated Systems for Integrated Care Strategy
End User Device Strategy
IT Service Models
Transforming Community Services
Provision of Information.
In conclusion, this strategy aims to maximise the benefit from investment in IM&T by
focusing on achieving the Trust’s strategic objectives and by using that investment in
the most efficient way.
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Item 10
G. to provide a more efficient and effective IM&T service.
The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
2 Introduction
In the current climate of change within the NHS, its ability to survive and grow rests
on how quickly it acts and responds to changing market forces. Technology updates
itself at lightning speed and the NHS must adequately plan and respond to leverage
such changes to its competitive advantage. The NHS is also changing its structure at
a pace never seen before as it learns to become more business-like. Achieving high
quality care whilst streamlining services to make them more efficient and effective is
a challenge but also an opportunity. The IM&T Department is responsible for
providing the best fit technology to support the services as they change.
There are several significant changes to note on a national and local level which
have a significant impact on IM&T since the previous strategy was published in 2010.
The main changes are:







The Francis Report was published earlier this year, with implications on the
way services are governed, the way the NHS interacts with the public and its
patients and statutory returns. There are underlying IM&T recommendations
put forward in support of this.
The establishment of the NHS Trust Development Authority (NTDA) in April
2013 to safeguard the core values of the NHS by developing and
implementing an accountability framework that is safe and unambiguous.
The speech given by the Health Secretary in January 2013, ‘From notepad to
iPAD; technology and the N HS’ outlines his intentions to make the NHS
paperless by 2018.
The Trust, along with many organisations in the NHS, is facing
unprecedented financial challenges as it focuses on delivering high quality
standards of care and maintaining performance. IM&T is a key enabler for
transforming the way information is recorded, viewed and reported.
The Trust is working hard to achieve financial balance and will submit its
application to become a foundation trust to the NTDA by March 2015.
There is greater emphasis on integrated care across the healthcare
community. To achieve this, he North East Sector Transformation Board
incorporating NHS Bury, Heywood, Middleton & Rochdale, Oldham and North
Manchester has been set up. Ann IM&T Sub-group reporting to this board has
also been established.
The Healthier Together Programme has been established to reform Health
and Care services to deliver better outcomes for Greater Manchester
residents. IT innovation forms a critical part of this programme.
This is a strong resilient strategy that will future proof the Trust. It is aligned with
strategic objectives as signed off by the Trust Board and underpins the major
transformational change programmes, acting as a catalyst to enable more efficient
and new and innovative ways of working.
2.1 Purpose of this Document
The Trust is committed to the effective use of IM&T to support the delivery of
excellent patient care, facilitate the work of its clinicians and deliver efficiency. This
strategy sets out the roadmap to achieving these aims. This document examines the
Trust’s business and strategic drivers and identifies strategic objectives which will
guide activities and prioritise investment in IM&T over the next 3 years. It describes
the current IM&T capabilities and assesses progress against the previous strategy,
identifying the key gaps that need to be addressed in order to achieve the objectives.
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The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
Finally, the strategy presents a challenging but significant programme of work
concentrating on improving the quality of information, efficiency of IM&T services and
integrating business critical systems to support a joined up approach to healthcare.
2.2 Process Used for the Development of this Strategy
The process used for the development of this strategy is summarised in the diagram
below:
Analysing
Stakeholder
Requirements
Future Vision
for IM&T
Determining the
Current IM&T
Environment
IM&T Current
Capability
Statement
Strategic Gap
Item 10
Determining
the Strategic
Environment
Strategic
Choices
Actions and Implementation Planning, Prioritisation, Costing
Staffing
Structures
Standards
Governance
Policies
The following Trust departments and individuals were interviewed and/or involved in
workshops during the creation of this strategy: the patient forum, medical staff,
nursing staff, allied health professionals (AHPs), GPs, senior management and IM&T
staff.
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The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
3 Strategic Context
IM&T strives to deliver modern, business-critical systems whilst maintaining the
security and integrity of the information recorded. It ensures that the infrastructure
backbone of hospital IT systems and services remain relevant to the organisation’s
needs. IM&T strives to achieve this in support of the Trust’s mission statement:
“To provide the very best care for each patient on every occasion.”
This section describes the context in which the Trust operates and identifies key
strategic drivers at a national and local level. Although technology should not lead
change, it must be capable of enabling it. This strategy has reviewed the strategic
and business drivers currently affecting the Trust and positioning the organisation for
success. Through collaboration with forums, such as the recently appointed North
East Sector Transformation Board, IM&T sub group and the Healthier Together
Programme, IM&T can review and update requirements to influence how integrated
care services across Greater Manchester will operate and develop.
3.1 National Context
In January 2011, the Government set out its plans to modernise the National Health
Service in the Health and Social Care Bill. It describes a health system in which
patients and the public have a stronger voice and more control:
“no decision about me without me.”
Effective technology is needed to enable this change to take place. High quality
information must be communicated efficiently and integrated successfully and safely
across organisational boundaries.
In November 2012, the NHS Mandate set out the ambitions for the health service for
the next two years. It reaffirmed the Government’s commitment to an NHS that
remains comprehensive and universal – available to all, based on clinical need and
not ability to pay – and able to meet patients’ needs and expectations, both now and
in the future.
The NHS Mandate is structured around five key areas where the Government
expects the NHS Commissioning Board to make improvements:

preventing people from dying prematurely;

enhancing quality of life for people with long-term conditions;

helping people to recover from episodes of ill health or following injury;

ensuring that people have a positive experience of care;

treating and caring for people in a safe environment and protecting them
from avoidable harm.
In December 2012, the NHS Commissioning Board released its new planning
framework ‘Everyone Counts: planning for patients’. This framework continues the
vision of a modern, patient-centred NHS, where improvements are driven by the
clinically-led, local commissioning system.
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This framework focuses on information in its broadest sense, including the support
people need to navigate and understand the information available. This is about
ensuring that information reduces inequalities and benefits all.
The principles behind the new approach to planning clinical led commissioning are:

empowered local clinicians delivering better outcomes;

increased information for patients to make choices;

greater accountability to the communities the NHS serves;

new incentives, awards and sanctions available to commissioners to drive
improvements in care quality.
Underpinning these principles is the expectation that IM&T will make accurate and
timely information available whenever and wherever it is required.

Quality – that agreed CQUIN schemes are delivered in full and basic
standards on quality are adhered to;

Delivery – that all the core standards set out in the planning guidance are
met and that all contracts are delivered in full;

Sustainability – that all NHS Trusts show an improvement trajectory for
surpluses and Financial Risk Ratings for 2013/14 linked to their overall
financial plans.
In a speech to the Policy Exchange in January 2013, Jeremy Hunt, the Health
Secretary, made it clear that one of the biggest challenges facing the NHS is the
Francis Report on the issues and causes of patient suffering at Stafford Hospital. He
emphasised that the NHS must respond by getting its culture and values right.
Although technology is not the answer to all these issues, it does have a key role to
play in allowing doctors and nurses time and space to deliver the standard of care
expected of them. To this end he announced that he wanted electronic records and
communications in place across health and social care by 2018. In order to achieve
the 2018 goal, the Health Secretary wants to see:
by March 2015

everyone who wishes will be able to get online access to their own health
records held by their GP;

adoption of paperless referrals – instead of sending a letter to the hospital
when referring a patient to hospital, the GP can send an email instead;

clear plans in place to enable secure linking of these electronic health and
care records wherever they are held, so there is as complete a record as
possible of the care someone receives;

clear plans in place for those records to be able to follow individuals, with
their consent, to any part of the NHS or social care system;
by April 2018

digital information to be fully available across NHS and social care services,
barring any individual opt outs.
Guidance on how this is to be achieved is expected shortly.
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Item 10
Also, in December 2012, the NHS Trust Development Authority published its
Planning Guidance 2013/14 which sets out clear expectations on:
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3.2 Commissioning for Quality and Innovation (CQUIN)
framework
The key aim of the Commissioning for Quality and Innovation (CQUIN) framework for
2013/14 is to achieve improvements in quality of services and better outcomes for
patients, whilst maintaining strong financial management.
‘Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS’
stated that, from April 2013, compliance with high impact innovations would become
a prequalification requirement for CQUIN. In order for the Trust to qualify for CQUIN
payments, it will need to satisfy at least 50% of the pre-qualification criteria. Relevant
criteria include:
1. 3 Million Lives: Set a trajectory for 2013/14 for increasing planned use of
telehealth/telecare technologies:

set a baseline for 2012/13;

base planning assumptions on the evidence available from the Whole
System Demonstrator programme (available on
www.3millionlives.co.uk ) or give evidence as to why this evidence
has not informed the planning process.
2. Digital First: Establish a 2012/13 baseline and a trajectory for improvement to
reduce inappropriate face-to-face contact:

identify which of the ten digital initiatives identified in the report
‘Digital First - the Delivery Choice for England's population’ apply to
the Trust;

identify any other local initiatives aimed at reducing inappropriate
face to face contact;

work with commissioners to establish ambitious trajectories for
2013/14 corresponding with the needs and priorities for the local
healthcare economy;

use the benchmarking tool to assess the initiatives that the Trust is
undertaking to reduce inappropriate face-to-face interactions and the
potential savings that could be attained.
The ten digital initiatives are:

minor ailments online assessment;

appointment booking online;

primary care pre-assessment;

appointment reminders;

mobile working in community nursing;

pre-operative screening online;

post-surgical remote follow up;

remote follow up in secondary care;

remote delivery of test results;

secondary care clinic letter.
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Locally agreed CQUINS include:

95% discharge summaries to GPs within 24 hours;

promoting self-care and inclusive care delivery;

integrated change and improvement;

reducing harm - Early Warning Scores (EWS);

vascular and children’s programmes.
3.3 Information Strategy for the NHS
Information strategy for Health and Social Care: ‘The Power of Information’
In May 2012, the Department of Health released its new information strategy ‘The
Power of Information’. This strategy set a ten-year framework for transforming
information for health and care. It aims to harness information and new technologies
to achieve higher quality care and improve outcomes for patients and service users.
The three main themes of the strategy are:

modern, convenient information access;

modern information and technology for professionals;

patient and citizen rights.
The strategy sets out a vision that includes:

there is a change in culture and mind-set, in which health and care
professionals, organisations and systems recognise that information in our
care records is fundamentally about us – so that it becomes normal for us to
access our own records easily;

information is recorded once, at first contact with professional staff, and
shared securely between those providing our care – supported by consistent
use of information standards that enable data to flow (interoperability)
between systems whilst keeping our confidential information safe and secure;

information is used to drive integrated care across the entire health and social
care sector, both within and between organisations;

electronic care records progressively become the source for core information
used to improve care, improve services and to inform research, etc, reducing
bureaucratic data collections and enabling us to measure quality;

modern technology is widespread to make health and care services more
convenient, accessible and efficient.
3.3.2
Review of the potential benefits from the better use of information and
technology in Health and Social Care
In January 2013, a review conducted by PricewaterhouseCooper on behalf of the
DoH was published which identified four additional actions to those set out in the
original strategy. These are:
1. driving the rollout and use of ePrescribing in secondary care and the
Electronic Prescription Service (EPS) in primary care;
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3.3.1
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2. driving the better use of information to aid the post-operative care of patients;
3. driving the use of acute operational performance information to enable
commissioners to achieve contractual savings; and
4. ensuring the widespread provision of complete and accurate clinical and
attendance information to clinicians and carers at the point of care via clinical
portals or other similar solutions.
The review also takes into account potential actions identified by other research
projects that could deliver significant benefits. Four further additional actions were
highlighted by this work:
1. driving the more sophisticated and widespread evaluation of cost and quality
information;
2. driving the broader use of patient-level treatment and outcomes data to
support the personalisation of services;
3. providing better and more targeted information to patients and carers to
facilitate choice of service or clinician; and
4. achieving a reduction in clinical negligence and litigation via the better use of
information.
3.3.3
The Francis Report
The Francis Report published in February 2013 reviewed the issues and causes of
patient suffering at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.
The report highlighted that, despite multiple checks early warning signs were not
picked up including:

“doing the system’s business” rather than focusing on patients;

more weight being given to positive news about the NHS than to information
that could cause concern;

compliance measures that failed to focus on the effect of a service on
patients;

tolerance of poor standards and risk to patients;

a failure of agencies to communicate and share concerns;

little appreciation of the loss of corporate memory due to reorganisation;
The report made 290 recommendations designed to ensure “self-interest and cost
control” were not put ahead of patients’ interests and singled out efficient and
effective record keeping as a major issue. IM&T has a significant role to play in
ensuring information is accurate, timely and available. This can only be achieved
effectively by moving away from paper-based systems which only give one staff
member or department a view of the patient at any one time. The report also
highlighted the potential of IM&T systems as enablers for quality control of
information and data, communications and the management of care pathways in
order to address the issues identified in the report. By opening up systems, IM&T can
help to remove silo working and provide a holistic view of the patient.
Details of the recommendations are included in Appendix B.
3.4 Local Context
The Pennine Acute Hospitals NHS Trust serves the communities of North
Manchester, Bury, Rochdale and Oldham, along with the surrounding towns and
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villages. This area is collectively known as the North-East Sector of Greater
Manchester and has a population of around 800,000. It is a large Trust with a total
operating budget of £560m. The main commissioners are NHS Bury CCG, NHS
Heywood, Middleton and Rochdale CCG, NHS Oldham CCG and NHS Manchester
CCG.
The Trust provides a range of elective, emergency, district general services, some
specialist services and operates from five sites.

Fairfield General Hospital, Bury;

North Manchester General Hospital;

Royal Oldham Hospital;

Rochdale Infirmary;

Birch Hill Hospital (Floyd Unit only).

Patient care is at the centre of everything we do. We work together to deliver
a high quality service to provide the best possible outcome for patients.

Accountability, honesty and integrity are keys to our success both individually
and across the Trust.

Treating everyone with respect and promoting good working relationships will
support individuals in reaching their full potential.
The Trust’s corporate objectives that align to our mission are:
1. Improving clinical effectiveness and safety. Our first responsibility is the
safety of our patients.
2. Improving the patient experience. We will measure and monitor patients’
experience of our care and act on the findings to improve services continually.
3. We will achieve national and local access standards.
4. Workforce. We believe that a diverse and inclusive workplace with a culture
of trust and respect is the most productive environment. We can best achieve
this when staff are empowered and engaged in decision-making.
5. Financial performance. We will meet our statutory financial duties and
manage delivery of our services within our allocated resources. We also have
an overriding obligation to deliver excellent value for money.
6. Maintaining our regulatory obligations. We will ensure that we meet or
exceed the requirements of the external NHS regulatory frameworks.
7. The Foundation Trust application. The Foundation Trust application and
subsequent authorisation is a benchmark of the Trust’s fitness for purpose.
8. Play our part in the wider community. The Trust will play a full and equal
part in improving the health and well-being of the community it serves
alongside other statutory and voluntary organisations.
9. Environment and sustainability. We aim to improve the physical and built
environment and invest in facilities that meet the best environmental and
sustainability standards. We are working to reduce carbon emissions from
our estate infrastructure and supply chain.
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The values that underpin the Trust’s mission statement are:
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10. Equality. Align all that we do with the new Public Sector Equality Duty to
develop a culture free of discrimination, harassment and victimisation that
promotes and advances patients, staff or visitors and ensures they are treated
with dignity and respect.
3.4.1
Foundation Trust Application
The NHS Trust Development Authority (NTDA) came into being in April 2013 to
support NHS Trusts to deliver high quality, sustainable services in the communities
they serve. The landscape includes NHS Trusts that deliver community, mental
health, acute and ambulance services and accounts for around £30 billion of the total
NHS budget. The NTDA is working with national partners, in particular Monitor, to
ensure that the systems and processes put in place complement those of the
Foundation Trust regime.
The Trust is planning to become an NHS Foundation Trust by December 2015, with
the application to be submitted to the NTDA by March 2015.
3.4.2
North East Sector
Greater emphasis is being placed on integrating care across the Trust’s local
healthcare community. To this end the North East Sector Transformation Board
incorporating NHS Bury CCG, NHS Heywood, Middleton and Rochdale CCG, NHS
Oldham CCG and NHS North Manchester CCG has been set up. In support of this
board the Trust has set up an IM&T sub group with local NHS and Council
representatives to address the IT requirements of this programme.
3.4.3
Healthier Together
Healthier Together is a review of health and care in Greater Manchester. The
Association of Greater Manchester Authorities (AGMA) Executive has challenged all
partners to work together to deliver new models of integrated care. This includes
primary, community and hospital services and the impact on social care. It is led by
NHS Greater Manchester on behalf of the area’s twelve Clinical Commissioning
Groups (CCGs).
The Healthier Together outline model of care is based on partnership working
between health and social care professionals across Greater Manchester. It aims to
develop integrated care services that will help the NHS and other care providers
provide quality services that are safe, accessible and sustainable. It will provide
enhanced levels of specialist, senior medical and nursing staffing creating
‘champions’ across organisations. The challenge for Greater Manchester will be to
ensure the model operates at the appropriate scale and pace to deliver the maximum
benefits to patients whilst supporting changes required to achieve an effective and
financially sustainable system of care.
The vision for the Healthier Together programme is for ‘Greater Manchester to have
the best health and care in the country’.
Working towards the vision, the programme aims to:

improve the health and wellbeing of people in Greater Manchester;

improve equality of access to high quality care;

improve people’s experience of healthcare service;

make better use of healthcare resources.
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Further information will be added as it becomes available, but one thing is clear,
excellent IM&T systems and services will be required to enable ‘joined up’ care
across Greater Manchester and the Trust’s IM&T capabilities will be key to delivering
successful outcomes from the programme.
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3.4.4
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Trust Strategic Drivers
The strategic drivers were analysed using a PESTLE analysis, looking at the political,
economic, social, technological, legal and environmental factors in the strategic
environment. The results are shown below:
Source: Business Development Team @ PAHNT
3.5 Stakeholder Analysis
A series of workshops and interviews were held which included a range of Trust
stakeholders including patients, clinicians, nursing staff, allied health professionals,
managers and IM&T staff.
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3.6 Summary of Actions Arising
In summary:





ensuring information is complete, accurate and available to enable the public to
become involved in decisions about how services are provided;
enabling patients to take control of their information, make informed choices
about their care and treatment options, and about how and whether to
participate in trials and research;
promoting and enabling the sharing of information and services to enable the
Trust and healthcare professionals to provide more integrated care and to forge
closer links with social services;
applying IM&T in innovative and effective ways to support the Trust in making
quality and productivity gains in line with the national QIPP agenda;
providing information and systems to support the financial and planning
processes.
IM&T needs to support the Trust in responding to local strategic initiatives through:








providing systems and solutions that enable real time data capture, feedback and
reporting underpinned by an infrastructure that enables the sharing of data
between departments, other Trusts and community healthcare providers;
developing intuitive systems with decision support;
putting infrastructure in place and developing interfaces to enable data sharing
and collaboration opportunities with other Trusts and partners, including current
opportunities for collaboration on an electronic document management solution
procurement and for sharing disaster recovery arrangements;
standardising on software used by PCs and personal devices with a consequent
improvement in performance of hardware and infrastructure and ability
accommodate new technologies;
providing systems and connectivity to provide remote working from community
locations, and improvement in communications between hospital services and
community and social care;
supporting the achievement of Foundation Trust status;
being an active participant in the North East Transformation Board and
establishing the IM&T Sub Group in support of its agenda to integrate care across
the healthcare community;
making contributions to the Trust Cost Improvement Plan.
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IM&T needs to support the Trust in responding to national strategic initiatives through:
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4 Current State of IM&T
This section describes progress made to date against the previous IM&T strategy
and describes the current status of IM&T capabilities.
4.1 Progress against Previous IM&T Strategy
The IM&T Department has made good progress against the previous strategy but is
still struggling to meet the needs of the organisation due to the low investment in
IM&T in previous years. In order to keep up with the accelerated pace of change the
Department has set itself ambitious goals. Progress has been made in a number of
key areas which are highlighted below. A more detailed description of what has been
achieved is included in Appendix C.
4.2 Status of Current IM&T Infrastructure and Services
Provision
Infrastructure
The Trust has developed its infrastructure significantly over the past three years.
Wireless networking is now in place in all clinical areas and suitable mobile
technology is made available on the wards including tablets and laptops-on-wheels.
Further work to understand what the right tools are for each environment is
continuing.
Data is one of the most valuable assets of the Trust. To facilitate the sharing of data,
the IM&T Department has consolidated its storage resources centrally using Storage
Area Network technology. This allows for an efficient use of storage. so servers can
access the same pool. This in turn removes waste by unused storage and
significantly reduces the operating costs compared with storing data on local drives.
To further secure the integrity of Trust data and improve its resilience, 134 servers
were moved to a new facility with minimum disruption to clinical services. As well as
improving the Trust’s ‘green’ footprint the programme has secured the capacity and
security necessary to support the Trust’s strategic direction.
The Trust has invested in a number of other infrastructure initiatives which support
the need for flexible and scalable technology, such as upgrading the remote area
network thus improving accessibility for clinicians working away from the Trust.
These initiatives have improved resilience, performance, and availability of
operational systems within the Trust and also helps to deliver the medium to longer
term strategic IM&T objectives.
Service Management
IT Service Management has been reviewed. The current state of the IT Department
has grown and developed as technology has been deployed throughout the Trust.
As the Trust has grown and harnessed the benefits of technology, the reliance on a
robust support function has also increased. Processes and procedures within the IT
Helpdesk function have been reconfigured and streamlined. Although great progress
has been made there is still room for improvement and service improvement is
ongoing.
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Integration
The Trust’s Integration Engine (TIE) is a critical system that provides the
interoperability to share information across systems. This sharing of information
extends beyond the Trust’s boundaries into areas such as GP practices, clinical
portals and remote-hosted systems such as Radiology.
A business case was recently approved for the replacement of the TIE to ensure
continued viability of its interoperability and to future-proof the Trust for at least
another five years.
InView is the Trust’s new management information system that provides a single
source of clinical, operational, financial and management information. In addition to
replacing the existing data content, InView includes support for further datasets such
as pathology, radiology, theatre, maternity, and pharmacy. It is the Trust’s chosen
solution to support all its information provision needs for the term of this strategy.
The Trust has been using the Qlikview dashboard development software for the last
two years to support the reporting of Trust financial, activity and performance
information. Additional Qlikview licences are needed to support the extended use of
dashboards and to guarantee that additional users will be able to access the
dashboard when they need to gain access. A business case has been approved.
Dashboards include:
Consultant Performance

Speciality Performance

Trust-wide Activity Monitoring

Surgical Division Performance

Medical Division Performance

Women & Children Division Performance

Diagnostics Division Performance

Service Line Reporting (SLR)

Patient Safety

Safety Thermometer

Unscheduled Care (A&E)

Cancer 2 Week Waits
Communications and Web Services
Comprehensive condition-specific information is available to patients via the Trust
website and the Trust is a certified member of The Information Standard. The Trust
hosts a dated intranet and public facing website, which have been developed over
time in-house. The Trust currently has a social media presence on Twitter, a social
networking site. It is used to share news, events and information about the Trust.
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Information Provision
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The Trust uses YouTube as a platform for hosting short promotional videos produced
by the Trust. This is an effective method of sharing video content internally and
externally which the Trust needs to invest in and expand.
A business case was recently approved for the replacement of the content
management system (CMS) to provide a new and modern Intranet, Internet and
Extranet (allows controlled access for non-Trust users such as GPs, Local Councils
etc).
4.3 Current state of Clinical Systems
Good progress has been made in a number of clinical areas which has greatly
improved the local environment.
Patient Administration System
PAS was upgraded in 2010 prior to clinical system implementations to make it more
resilient. A more modern look and feel has improved the quality and timeliness of
admission, discharge and transfer information and supplied enhanced bed
management functionality providing the capability to identify occupied or available
beds.
Upgrading PAS also enabled electronic whiteboards to be rolled out across the Trust
and phase one to provide length of stay information is complete. This has generated
a number of time-saving benefits to a diverse range of staff groups such as catering
and portering staff by providing an electronic means of finding where patients are and
their expected discharge.
Unified Communications
Digital dictation is now fully rolled out across the Trust enabling restructuring of
administrative support services.
Electronic Patient Record Programme
Electronic prescribing is now live in the whole of the Medical and Surgical Division at
The Royal Oldham Hospital critically improving patient safety, making the process of
prescribing and administering medicines on wards more efficient and contributing to
the Trust’s paper-light agenda by replacing paper. A roll out to all remaining wards at
The Royal Oldham Hospital and to the other Trust sites is planned in 2013.
There are a number of other specialist clinical systems in constant use across the
Trust’s wards and departments which do not communicate with each other causing a
huge amount of duplication of effort and frustration to Clinicians. IM&T has started to
make some in-roads to resolve this by integrating the electronic prescribing system
under Healthviews with the automated letters look up system and a replacement
electronic discharge summary which includes integrated clinical date from a variety of
sources. This is in the process of being rolled out with ePMA at The Royal Oldham
Hospital.
A programme of work to start replacing paper began last year as the Ophthalmology
Outpatient Clinic at The Royal Oldham Hospital went digital. This was followed by the
introduction of the electronic dementia assessment form. The programme has not
been without its problems as it was the first of type for the Trust, but IM&T has been
working closely with the Ophthalmology Department to achieve clinical sign off.
Radiology ordering and results went live in March 2013 and is also being rolled out
across the Royal Oldham Hospital.
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Other Clinical Systems
A new business critical theatre system was procured to help drive improvements in
theatre utilisation and improve productivity and efficiency within the Surgical Division.
The system is now live in all theatres across all four sites. Risks associated with the
support and maintenance of the previous system have also been mitigated. Reports
to assist with performance and efficiency are being developed and phase two to
implement the stock-taking module is being planned.
A number of other specialist clinical systems have been upgraded. A full list of what
has been achieved and is ongoing is available in Appendix C.
The IM&T Department has been successful in having a number of business cases
approved recently which enhance the clinical systems estate including:
Maternity Anaesthetic Module;

PathManager Replacement Server;

Dawn AC System Project;

MDT Video-conferencing;

Maternity;

Safeguard;

Community iPM to PatientCentre Migration;

Paediatric Diabetes;

Hicom Diabetes Upgrade;

A&E Symphony;

Order Communications and Results Reporting.
Item 10

The challenge for the IM&T Department is now to build on what has already been
achieved by ensuring these and other future systems meet the changing needs of the
organisation by being agile and timely in their development, flexible in their
capabilities and scalable as the Trust moves towards supporting integrated services
across the North East Sector and Greater Manchester.
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4.4 Summary of Actions Arising
In summary, IM&T needs to perform the follow actions:

Complete implementation of existing projects

Introduce new solutions where business cases have been approved

Continue to refresh and improve client services to achieve best practice

Improve the provision of information
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5 Vision and Strategic Objectives
This section aims to describe the vision for IM&T and how the implementation of this
strategy will impact on key stakeholders such as patients, healthcare professionals,
partner organisations, managers and researchers. It will also identify the key
strategic objectives for IM&T to achieve this vision.
5.1 Vision
The strategic vision for IM&T is:
‘To empower the Trust through the deployment of business critical systems
and services which are scalable, flexible and agile.’
‘To become a more efficient and productive department.’
5.2 Relationship between Vision and Strategic Objectives
The diagram below sets out the relationship between the vision, the mission and the
strategic objectives:
The action plan is included in section 7 of this document.
5.3 IM&T Strategic Objectives
The following list identifies the principal objectives for IM&T in support of the Trust’s
efficiency and quality agenda:
A. to develop integrated IT systems to support integrated care. An electronic
patient record (EPR) capable of being shared across acute and community
services, providing a single view of the patient record, available wherever and
whenever it is required, subject to confidentiality and security constraints. The IT
must be reliable for the future and flexible and agile to meet the challenges that
lie ahead. This includes actions to implement an Electronic Document and
Records Management (EDRM) solution that will remove legacy paper and
enable the creation of a paper light environment;
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The strategic mission for IM&T is:
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B. to support flexible ways of working and improve working lives, providing
improved access to clinicians to the information and IT tools to support the safe
and effective care of patients, whenever and wherever it is required, including
across acute and community locations;
C. to deliver enhancements to the IT infrastructure which:





is service-orientated, flexible and responsive to users’ needs;
is efficient, green and effective;
provides opportunities for generating income;
improves the user experience of IT;
reduces cost and risk related to IT services.
D. to provide efficient corporate and back office systems to support workflow
and efficiency through:




e-requisitioning;
e-procurement;
self-service HR;
e-rostering and leave management.
E. to deliver a high quality information service including the use of Business
Intelligence tools and dashboards to support the collection of income via Payment
by Results (PbR) and achievement of targets, standards and priorities;
F. to provide agile solutions which are flexible and able to grow to support the
corporate ambitions of the Trust in a rapidly changing environment, including:



support for the Foundation Trust application;
support for service reconfigurations, such as Healthier Together;
support for business initiatives, such as pathology service hosting.
G. to provide a more efficient and effective IM&T service, that can be used by all
Trust personnel through reviewing the structures and capabilities of the IM&T
Team;
 roll-out of up-to-date training to support new technology;
 achieving the ISO 27001 standard;
 implementing ITIL Best Practice;
 Undertaking a full options appraisal to examine IT Service Models.
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6 Strategic Choices
The main focus of this strategy which sets it apart from other strategies is its
integrated care focus. In this section, major strategic choices are considered about
how the end goals of the strategy can best be achieved.
6.1 EPR Strategy

A single, integrated point of care system covering the entire continuum of
care available whenever and wherever it is required.

A Patient Portal: an electronic window that will allow patients to actively
participate in their own care. It will allow patients to review and update their
health records, manage appointments and prescription renewals, access
personalised information or discharge materials, and communicate in
complete confidentiality with care providers.

The ability to share clinical information between health and social care
organisations ensuring joined up care for patients.
In the appraisal paper seven options were considered for the Trust to progress
towards a full EPR solution:
Option 1 - Do nothing: This option was not considered viable as the current
supplier (CSC) will not continue to support the existing HealthViews system beyond
April 2017 and the Trust would be exposed to an unacceptably high level of risk of
the clinical systems not meeting its organisational needs.
Option 2 - Continue to develop existing technology: This option was also not
considered viable as the current supplier (CSC) will not continue to develop the
existing HealthViews system beyond what is already in its development roadmap and
would like the Trust to migrate to Lorenzo.
Option 3 - Best of breed specialist systems co-ordinated through an interface
engine: This option consists of separate specialist systems which communicate with
each other through an interface engine. Specific data held against a patient would
be available to view through the different systems as required.
The main advantages of this option are that the Trust would be able to take
advantage of niche suppliers who have built up expertise in a particular area and
retain some of its existing systems such as A&E (about to be upgraded), Pharmacy
(about to be replaced), Maternity (about to be upgraded), Theatres and Pathology.
However, the Trust would not achieve all the benefits associated with a single patient
record and would not mitigate the risk that patient information might not be mirrored
correctly through all the systems consistently and in a satisfactory way. For this
reason, this option was not recommended.
Option 4 - Best of breed specialist systems coordinated through a clinical
portal: As for option 3, this option consists of separate specialist systems but with
the advantage of them being integrated through a clinical portal.
A clinical portal is an electronic window that will allow clinicians to view defined
information about individual patients in a ‘virtual’ electronic patient record drawn from
information held in different clinical systems. Easier access to this information will
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In February 2013, an EPR solution appraisal paper was developed. The three main
requirements arising from this paper were:
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support improved care delivery and decision making. Patients can be reassured that
clinical staff have their information prioritised for safe care.
This option gives the advantage of being able to take advantage of niche suppliers
who have built up expertise in a particular area and allows the Trust to retain some of
its existing systems. It also allows the organisation to take an incremental approach
to its delivery plan. This would allow areas which are forging ahead to continue whilst
supporting others to get going simultaneously.
Clinical portals have come a long way since the previous strategy was developed
and there are now portals available which allow the user to write back to different
clinical systems without having to log in separately. There will however, be significant
overheads in the IM&T Department associated with maintaining many complex
system interfaces.
This option was selected as the preferred approach.
Option 5 - Implement Lorenzo: Lorenzo is a clinical system which includes PAS,
A&E, clinical documentation, results and requesting, discharge and outpatient
prescribing and care plans. Maternity, advanced bed management and inpatient
medications administration functionality is still being developed.
Although Lorenzo will go some way to achieving a single patient record there is a
very real risk that it will not allow the Trust to fully achieve a single integrated patient
record and it would be an opportunity missed. Systems such as theatres, pathology
and pharmacy stock control and dispensing functions and offline working for
community are not part of the solution and would still need to be linked through an
interface engine. CSC has reported that they intend to fill these gaps with other
commercial products but at additional cost. Lorenzo cannot fully meet the Trust’s
needs in this challenging climate due to a lack of specialist software e.g. paediatrics
and inherent inflexibility. Although seven Trusts have now formally agreed to take the
system a large number of Trusts have not. Of those who have taken the system
some continue to experience issues well into its deployment. MedChart, the CSC
electronic prescribing system currently being implemented in the Trust is compatible
with Lorenzo and could be retained.
Lorenzo is adapted for working on tablet devices such as iPads and unlike many of
its American ‘one record, one patient’ counterparts it is already NHS compliant and
integrates with national systems, such as Choose and Book and the Summary Care
Record. This option would also allow the Trust to share records with any other local
Trusts using the system.
The Department of Health (DH) is offering the Trust additional funding to implement
Lorenzo. Although the DH subsidy makes this option appear attractive financially,
the PAS element of the system and limited clinical functionality has so far only been
implemented in one acute Trust. The more complex clinical functionality such as
medications administration is still under development. Because of the poor and slow
track record of delivery the Trust lacks confidence that the remaining functionality will
be “fit for purpose” or delivered in acceptable timescales. Even when all the planned
developments have been completed there will still be significant gaps in functionality
which will have to be plugged with other systems at additional cost.
By the end of March 2014, the Trust will have rolled out electronic prescribing,
eDischarge summaries with TTO information and order communications and results
reporting. This already puts the Trust further ahead than Lorenzo and on the road to
a full EPR.
For these reasons, this option was not recommended.
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Option 6 - Fully integrated single database. ‘One patient, one record’
In this option, a single database would hold all data relevant to each patient in a
single record. It would replace all the Trust’s clinical systems and its reporting
systems with a single, all-encompassing system. The clinician would only be
required to access one place to view as well as record information or perform
actions, such as placing a request.
A prerequisite for this option is to ensure the Trust has the appetite and commitment
to change its culture to suit an iterative way of working though once achieved the
Trust should be able to maximise on its investment. This option could future proof
the Trust for up to 20 years.
The Trust fully expects to reconfigure its services over the coming years. To commit
to an integrated EPR solution when the outcome of the reconfigurations is unknown
introduces too high a risk for the organisation. This option is also considered to be
too expensive and requires too great a level of transformation throughout the Trust to
be a viable option today. It would also involve the replacement of recent Trust
system investments well-before the end of their useful life.
For these reasons, this option was not recommended. However this is an option that
should be reconsidered in the future.
Option 7 - Build an EPR in house
The resource, technical expertise and technical experience required to develop,
implement, update and maintain an EPR in-house would be significant and would
expose the Trust to high risk. Commercial companies have spent over thirty years
developing and maturing their products. By taking commercially available products,
the Trust significantly reduces the risk to patients and staff. This was not considered
to be a feasible option for the Trust and was discounted.
Preferred Option
Option 4, the best of breed solution, integrated through a clinical portal, was selected
as the preferred option. This enables the Trust to exploit its existing system assets
and move towards an EPR more gradually over time.
The steps towards achieving this vision are as follows:




procure and implement a clinical portal;
procure and implement a patient portal;
procure and implement a replacement Patient Administration System;
over time, re-evaluate other business and clinical systems and replace as
required.
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These systems encourage standardisation of clinical practice and can be set up to
follow Trust policies, NICE guidance for best practice or any evidence-based best
practice. They are proactive in alerting and triggering next steps in a patient’s care,
responding to a change in the patient’s status. following strict protocols which use all
the information stored within the system to help the user inform their decision. Order
sets are not restricted to pathology or radiology requests on these systems but can
include everything required when a patient enters on a particular integrated care
pathway, including referrals, documents and assessments requiring completion,
ordering equipment, triggering alerts and monitoring timeliness of tasks such as the
frequency of VTE assessments.
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6.2 End User Device Strategy
The Trust has over 5,500 end user devices such as desktop PCs and laptops. The
Desktop Optimisation initiative was conceived in order to address the increasing
costs of ownership, administration, support and management arrangements of the
desktop estate across the Trust.
A business case for Desktop Optimisation has been approved to build a centralised
computing platform with greatly improved performance. This will be the strategic
solution for supporting end user device provision into the future. The diagram below
illustrates the key deliverables of the initiative:
Deploy initially to
2,200 PCs and
laptops
Gradually expand
this to the total
5,500 devices
Upgrade the
Windows XP
Operating
System to
Windows 7 on
remaining 3,300
devices
Deliver a solution
for deploying a
corporate
desktop for
remote users and
home users
Deliver a solution
for deploying a
corporate
desktop onto any
mobile device
Desktop optimisation initiative
Centralised client computing platform for PCs and laptops
Significantly
improve
customer
experience
through simpified
and intuitive
practices
Reduce power
consumption and
environmental
impact
Self-service “app
store” allowing
access to
applications
without speaking
to the IM&T
service desk.
Reduce
operational
overheads
The Windows 7 Upgrade Project provides a site wide Microsoft Licensing Software
Assurance agreement across the entire Trust client and is the most economical
method of allowing the Trust to migrate from Windows XP to Windows 7
Other benefits of Microsoft Software Assurance include:
-
Greatly improved methods of remote access.
Perpetual upgrades to Windows 7, Windows 8 and later.
Achieve the lowest cost of deploying and maintaining clients and applications.
There is an identified need to deliver care and support closer to the patient. IM&T
intends to make appropriate use of mobile technologies in order to support new
models of care, providing access to information wherever the patient and care
provider are situated.
The specific technology needs of Trust staff working in the community are being
analysed as part of a community online programme of work which has just been
initiated and forms a significant part of IM&T’s strategic objective to develop an
electronic patient record capable of being shared across acute and community
services.
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6.3 IT service Models

retaining services in-house;

merging with other Trust back office services, e.g. Helpdesk shared with
Facilities, HR, etc.;

developing shared service arrangements with other NHS or local authority IT
services;

full outsourcing of IT services to a commercial provider;

mixed economy or next generation models of IT outsourcing including:
o
Multisourcing - an approach to outsourcing in which IT operations
and technology infrastructure are contracted to a number of vendors,
usually in combination with some internally provided elements of
information technology. The purpose is to maximise the
effectiveness of the Trust’s IT by ensuring that various elements are
sourced to the best possible providers, while allowing the Trust to
maintain its focus on core competencies. Multisourcing can aid risk
management programmes by diversifying risk in vendor operations.
The practice can also promote competition among various providers;
cut costs related to repetitive service contracts and improve quality,
collaboration and innovation among a group of IT providers;
o
IT Resourcing – in which, the commercial supplier provides specialist
skills available from their talent pool to backfill the Trust’s teams,
relieving the pressure of staff shortages, IT projects or major roll-outs.
In addition to the main onsite teams, a flexible resource solution can
be utilised effectively to support with ad hoc tasks, on either a
proactive or reactive basis;
o
IT Co-sourcing - a hybrid model integrating both in-house and
outsourcing services. It is a partnership and collaborative approach
with shared objectives, shared risks and shared rewards between
both parties. This model helps in rationalising headcount, whilst
focusing on cost efficiencies within the Trust’s existing ways of
working;
o
Ethical IT Outsourcing Services – in this model, existing staff can be
retained, either on or off site, but transferred into a more flexible and
focused commercial environment. This model plans for and aims to
prevent the loss of local knowledge which once gone, takes time to
rebuild and re-learn.
o
IT Offshoring Services – unlikely to be suitable for the Trust, as the
purest evolution of IT outsourcing, offshoring takes advantage of a
cost-effective business model, whereby the more simple functions
and queries can be resolved remotely by an offshore facility.
A full options appraisal examining IT service models will be undertaken during the
lifetime of this strategy.
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The Trust is currently consolidating and improving its IT infrastructure and services.
This is an essential first step in understanding what is required from its IT service
delivery model. During the lifetime of this strategy, options for IT service models will
be evaluated. These could include:
The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
6.4 Telehealth and Telemedicine
Telemedicine is the use of communication and information technologies to deliver
clinical care where the individuals involved are not at the same location. They can
either be two health care professionals or a health care professional and a patient.
Telehealth includes this definition, and also covers telecommunication to deliver nonclinical services such as research and health education promotion.
Telemedicine can be split into three main categories: store-and-forward, remote
monitoring, and interactive telemedicine. Store and forward telemedicine involves
transmitting medical data from a patient to a doctor for assessment at a later time;
remote monitoring uses devices to monitor patients in a non-medical setting; and
interactive telemedicine uses technology such as videoconferencing and telephones
for real-time remote communication.
There is little appetite in the Trust to commence a telehealth or telemedicine pilot
immediately. However, it is recognised that these innovative technologies provide
immense opportunities for enhancing the delivery of integrated care services.
Therefore a study will be undertaken, during the second year of this strategy, to
evaluate options for taking this forward and the relevance to the delivery of patient
care in the future.
6.5 Transforming Community Services
A tactical solution has been implemented to migrate Community PAS users from iPM
to the acute PatientCentre PAS to provide an integrated solution across the
community and acute services. However, a solution is required to support the work
of District Nurses, Health Visitors, Community Midwives and other community-based
staff. This solution needs to support mobile and disconnected working. It must also
interoperate with Trust systems and share information with GP systems.
An options appraisal to determine the optimal approach for community systems will
be undertaken during the lifetime of this strategy.
6.6 Provision of Information
The Trust is planning to move towards a self-service model with an information portal
to facilitate the sharing and viewing of information across the Trust including hospital
and community systems.
The approach will be to standardise onto the Trust’s InView data warehouse and a
single set of reporting and analysis tools such as QlikView and Business Objects.
A comprehensive set of dashboards has been developed and work is in progress to
extend this to cover external benchmarking information such as Dr Foster.
The Trust is currently establishing a new team of information analysts, based within
the Divisions. Their aim will be to help the Trust achieve the top quartile for
outcomes (e.g. mortality rates, lengths of stay, readmissions) and tariffs.
6.7 Approval processes
The IM&T Department will work with the Executive Directors, Divisional Directors,
Clinical Directors and the Clinical Strategy Board in order to prioritise actions arising
from this strategy.
Governance arrangements and the approval process are included in section 8
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7 Actions and Implementation Plan
The action plan looks at just the first three years because of the challenges and
pressures facing the Trust. As plans for national and local initiatives, such as
Healthier Together appear, this strategy will be reviewed and if necessary updated.
The actions required to achieve the IM&T strategic objectives are identified below:
A. To Develop integrated IT systems to support integrated care
Action
Year
1
Year
2
Year
3
A1. Bed Management Project with Real Time Reporting
of Bed States
Item 10
A2. Phase 2 of the Electronic Whiteboards Project
(Clinical Indicators) to Include Testing And Roll Out
A3. Order Communications and Results Reporting
A4. Replacement Discharge Summaries
A5. Paper-Light in HealthViews
A6. Evaluation and Implementation of Clinical Portal
Software
A7. Full Rollout of E-Prescribing and Medicines
Administration
A8. Upgrade of Maternity System
A9. Theatres Stock-taking / Reporting
A10. Roll Out of the Dawn Anti-Coagulant System
A11. Community Staff Migration from iPM To
PatientCentre
A12. Roll Out of Electronic GP Radiology Ordering
A13. Greater Manchester Electronic Clinical
Correspondence
A14. Christie Clinical Portal
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A15. Replacement Pharmacy System
A16. Climate HIV System
A17. E-rostering System
A18. Doctors’ Leave Management System
A19. Upgrade of Diabetes System
A20. Upgrade of A&E System
A21. Evaluation of Input Options Such As Voice
Recognition and Data Pens
A22. Procure and Implement a Replacement Patient
Administration System
A23. Over Time, Re-evaluate Other Clinical Systems and
Replace As Required
A24. Evaluate and Implement Options for Community
Systems and Mobile Working;
A25. Procure EDRMS and Scanning Solution
A26. Implement EDRMS
A27. Evaluate and Implement Order Scheduling Software
A28. Evalution and Implement a Solution to Support
Intergrated Patient Care in the NE Sector of GM
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B. To Support Flexible Ways of Working and Improve Working Lives
Action
Year
1
Year
2
Year
3
B1. Evaluate Voice over IP (VoIP) to unify
communications across a range of media e.g. email,
text messages and voicemails.
B2. Evaluate options for telehealth and telemedicine;
B3. Improved home access/ hot desking for staff
Item 10
B4. Extend rollout of BOYD (Bring Your Own Device)
B5. Implement additional Video Conferencing facilities /
virtual meetings capabilities from the desktop
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C. To Deliver Enhancements to the IT Infrastructure
Action
Year
1
Year
2
Year
3
C1. Implement Replacement Integration Engine
C2. Replace the Trust Intranet and Implement SharePoint
C3. Complete the Data Centre Virtualisation Project
C4. Complete the Hardware Asset Management Project
C5. Complete the Virtual Desktop Project
C6. Upgrade from N3 To N4 Network
C7. Implement Network Access Controls (real time alerts
to security breaches)
C8. Continue Implementation of Wireless Networking
C9. Upgrade MS Exchange Email Servers
C10. Expand Uninterruptible Power Supply (UPS) Provision
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D. To Provide Efficient Corporate and Back Office Systems
Action
Year
1
Year
2
Year
3
Year
1
Year
2
Year
3
D1. Implementation of e-requisitioning
D2. Implementation of e- procurement
D3. Implementation of self – service HR
Item 10
D4. Implementation of e-rostering and leave management
E. To Deliver a High Quality Information Service
Action
E1. Implementation of Single Data Warehouse
E2. Implementation of Reporting & Business Intelligence
Tools
E3. Establishment of Directorate-based Information Teams
E4. Complete Implementation of Dr Foster Benchmarking
Tools
E5. Develop the Information Portal
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F. To Provide Agile Solutions Which Are Flexible and Able To Grow
Action
Year
1
Year
2
Year
3
Year
1
Year
2
Year
3
F1. Develop an IM&T infrastructure that is robust and can
easier accommodate growth and retraction of services
F2. Engage with health care workers to determine the
need for solutions and how the directorates see the
technological growth of solutions over time
G. To Provide a More Efficient and Effective IM&T Service
Action
G1. Review Structures and Capabilities of the IM&T Team
G2. Roll Out of Up-To-Date Training to Support New
Technology
G3. Achievement of ISO 27001
G4. Implementation of ITIL Best Practice
G5. Undertake Full Options Appraisal Examining IT
Service Models
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8 Governance
This section sets out the governance arrangements for the implementation of this
strategy.
8.1 The IM&T Programme Committee
The IM&T Programme Committee have been established to oversee the
implementation of the Trust’s IM&T Strategy including those deployments provide
through the National Programme for IT (NPfIT).
Additionally it will support the management of IM&T within the Trust.









to develop/agree and recommend IM&T strategy in line with the Trust’s business
objectives;
to monitor performance of the Trust against its IM&T strategy;
to develop, agree and recommend plans and deployment under NPfIT that
contribute to the agreed IM&T strategy;
to identify resource requirements to deliver deployment plans, identify financial
resources and highlight funding gaps;
to monitor progress of plans and allocation and use of resources;
to recommend change management activities prior, during and post deployment
facilitating change through executive leadership;
to ensure the Trust’s IM&T Service is managed and delivered in the most
effective and economic manner to support the Trust’s overall strategic aims;
to develop, agree and approve IM&T policy;
to ensure progress of plans and allocation of resources of the Trust’s IM&T
capital schemes.
8.2 Clinical Strategy Board
The Clinical Strategy Board is accountable to the IM&T Programme Committee. It
consists of clinical directors and senior managers of the Trust and has corporate
responsibility for overseeing the implementation of the Trust’s Clinical IM&T strategy,
service aims and objectives as approved by the Trust Board.
Its terms of reference are:




to develop and contribute to the Trust’s clinical IM&T strategy development,
including consideration of all underpinning strategies e.g. Clinical Services
Strategy, Workforce Planning etc;
to provide a forum by which the IM&T Programme Committee can be
advised of issues/decisions that impact on clinical IM&T services;
to ensure the Clinical IM&T Strategy complies with all relevant legal and
statutory requirements e.g. Caldecott guidelines, data protection act,
statutory reporting etc;
to identify, consider and recommend services and systems that the EPR
should interoperate with whether they are institutional or community-wide
within or external to the Trust;
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Its terms of reference are:
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






IM&T Strategy 2013-2017
to establish and sustain an effective and inclusive partnership with clinical
user focus groups drawn from stakeholders’ representative of the Trust at all
levels where appropriate for the development of the Clinical IM&T Strategy;
to consider any support requirements (staff, infrastructure etc) for achieving
the above and sustaining an EPR that allows the archiving of and persistent
access to potentially all patient information recorded within the Trust;
to influence prioritisation of clinical requirements based on clinical need and
impact on the Trust;
to promote to external organisations the value in using the EPR as the
primary source of information e.g. GP practices;
to encourage assimilation of currently segregated and non-centralised
systems and mini-databases into the centralised electronic patient record;
to advocate adoption of an EPR across the Trust as the preferred method for
recording and viewing patient information; and,
to instigate, quality-assure and take decisions and monitor the necessary
works required to achieve the above.
8.3 Methodologies and Best Practice
The IM&T Department will adopt best practice and methodologies in order to manage
this ambitious programme of work effectively. This section sets out the standard
methodologies to be adopted by IM&T.
8.3.1
Programme Management
Managing Successful Programmes (MSP) is a structured, flexible framework that
allows the management and control of all activities involved in managing a
programme. MSP is the de facto standard used for managing programmes in the
NHS. Senior Staff within the IM&T Department responsible for managing
programmes are expected to follow the MSP methodology as part of the IM&T
Department’s drive to improve its services.
8.3.2
Project Management
PRINCE 2 is the de facto standard used for managing projects in the NHS. It is a
generic, tailorable project management methodology, covering how to organise,
manage and control projects. PRINCE 2 has been adopted as the in-house standard
for project management and key staff have received training and mentoring in project
management techniques. All projects have a Project Board with a sponsor and
clinical engagement. A recent audit confirmed that this implementation is robust.
8.3.3
Service Management
ITIL is the most widely accepted approach to IT service management in the world.
ITIL provides a cohesive set of best practice, drawn from the public and private
sectors internationally.
As part of the IM&T Department’s structure review a capability and training review
scheme will be introduced to ensure ITIL best practice is fully implemented and
adhered to.
8.3.4
Security Management
The ISO/IEC 27000 series consists of information security standards published by
the International Standards Organisation (ISO) and the International Electrotechnical
Commission (IEC). The series is designed to give best practice recommendations on
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information security management including risks and controls within the context of an
overall Information Security Management System (ISMS).
The Trust intends to gain certification to the ISO/IEC 27001 standard in order to
achieve:
better management of information security risks, now and in the future;

increased access to new customers and business partners;

demonstration of legal and regulatory compliance;

potential for reduced public liability insurance costs;

enhanced status and competitive advantage;

overall cost savings (reduced errors and re-work).
Item 10

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8.4 IM&T Current Organisation Structure
Clinical Coding
Project Team
Head of Projects
Electronic Patient
Record Team
IT Manager
Datacentre
Associate Director
for IM&T
Deputy Associate
Director for IM&T
Datacentre
team
Technical Support
IT Manager
Service Delivery
Service Desk
Network Team
Central Systems
Contracting Team
Head of
Information
Information
Manager
Divisional Support
Team
Interfacing Team
Business
Intelligence Team
Data Quality Team
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9. Costs
9.1
Financial Landscape
The current economic downturn will impact negatively on public sector spending and in this
environment the Trust must plan to address inevitable cost reductions. In short, the Trust
needs to eliminate waste, increase efficiency and maintain quality.
Against this backdrop, and in line with the QIPP agenda, IM&T must now be positioned as a
service improvement tool to drive up quality, drive out inefficiency and drive down cost.
Approach to Funding Strategic IM&T Developments
As with all major schemes, the IM&T developments will follow the Trust’s normal planning
procedures.
10.
Risks
The IM&T programme is large and complex and there is significant risk of delay and over
spend which would constitute a threat to the delivery of benefits and achievement of the
Trust’s objectives. Additionally, failure to support the complex configuration of live systems
would have a serious effect upon the ability to achieve organisational goals.
The main areas of risk are summarised below:
No
1
Risk
Sufficient project funds cannot be
secured leading to delayed or
abandoned projects.
Probability
(H/M/L)
Severity
(H/M/L)
H
H
Mitigation
Agree PAHT funding through this
strategy.
Agree external funding with
Commissioners.
Prepare contingency plans for
funding shortfalls.
2
Project run late or over-budget,
delaying delivery of benefits.
M
H
Use ‘best practice’ project
management methods (PRINCE 2).
Adopt a development methodology
to ensure projects and
developments are managed in a
quality controlled and consistent
manner.
3
Projects completed, but Benefits
not fully realised.
M
M
Prepare and monitor Benefits
Realisation plans for all major
projects.
Appoint Business Change Managers
to ensure benefits realised.
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Item 10
9.2
The Pennine Acute Hospitals NHS Trust
No
4
Risk
Loss of efficiencies and disruption
to organisation arising from
unreliable systems
IM&T Strategy 2013-2017
Probability
(H/M/L)
Severity
(H/M/L)
M
H
Mitigation
Implement ‘best practice’ support
structures (based on ITIL).
Create highly resilient Data Centre.
Strengthen Disaster Recovery
capabilities as part of corporate
Business Continuity plan.
5
Failure to attract and retain high
quality staff leads to project failures
and unreliable systems.
M
H
Develop IM&T managers with strong
focus on leadership and people
management skills.
Ensure effective communications
with all IM&T staff.
6
7
8.
Failure to identify project and
programme risks.
IM&T are not involved earlier
enough in hospital projects.
Trust culture does not change to
one of “IT is not optional, it is part
of the day job”
M
H
H
H
H
H
Ensure MSP & PRINCE 2
methodologies are followed.
Continually educate or reinforce that
the business MUST involve IM&T at
the outset.
Secure Senior Clinical leadership.
Switch off old ways of working.
Appoint Business Change Managers
to ensure IT is fully utilised and
business processes are changed
9.
10.
Clinicians see IT as purely
administration
Lack of flexibility and response to
change
H
H
Secure Senior Clinical leadership.
Enforce new ways of working by
changing JDs, judge as part of PDR
process.
H
H
Secure Senior Management
Support.
Switch off old ways of working.
Enforce new ways of working by
changing JDs, judge as part of PDR
process.
Appoint Business Change Managers
to ensure IT is fully utilised and
business processes are changed
These risks, and associated action plans, will be managed and monitored through a
combination of project risk logs, a programme risk log and the corporate risk register.
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11.
IM&T Strategy 2013-2017
Lessons learned from previous strategy
This section sets out lessons learned from the previous strategy:
ID
Type
Event
Recommendations
Clinical
systems
Issues regarding collecting data for
reporting are sometimes identified
late in the project
Involvement of the Information
Department in producing any
statistics / reports from the
beginning of the project
Take up rate of new systems can be
slow with staff reluctant to change
current working practises
Ensure responsibility for making
implementations effective is a
clear responsibility of the Project
Board with support from the
Executive Directors, Divisional
Directors and Clinical Directors
Responsibility for attendance at
training should be the
responsibility of the Senior Users
on the Project Board to oversee
with support from the Executive
Directors, Divisional Directors and
Clinical Directors.
1
2
Clinical /
Business
Critical
systems
3
Training can be poorly attended
despite being offered a range of
means for training being offered
Clinical
systems
Use eLearning where
appropriate.
Ensure training is incorporated
into induction and locum
programmes
4
All IT Systems
5
Efficiency and productivity
capabilities delivered through the IT
systems are not being utilised to
their fullest extent
Benefits from IM&T investments
are not being fully realised
All IT Systems
The Board, Clinical Directors ,
Clinical Leads and Divisional
Directors are responsible for
ensuring that IM&T capabilities
delivered through this strategy
are utilised to their fullest extent
within their areas of
responsibility
The Board, Clinical Directors,
Clinical Leads and Divisional
Directors are responsible for
ensuring that benefits identified
through this strategy are
delivered in a timely manner
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Item 10
Lessons Log
The Pennine Acute Hospitals NHS Trust
6
Clinical
systems /
Business
Critical
Systems
Business process changes not
thought through in enough detail
by the business prior to
implementation
IM&T Strategy 2013-2017
Ensure this is given sufficient
priority at the Project Board and
made the responsibility of the
Senior Users
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12.
IM&T Strategy 2013-2017
Conclusion
Item 10
In conclusion, this strategy aims to maximise the benefit from investment in IM&T to
focus on achieving the Trust’s strategic objectives and to use that investment in the
most efficient way. Business cases will be presented for each of the major projects
to ensure that value for money is demonstrated. The major strategic choices for
achieving the Trust’s objectives are: Electronic Patient Records (EPR) Strategy; End
User Device Strategy; IT Service Models; Transforming Community Services;
Integrated Patient Care and Provision of Information.
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13.
IM&T Strategy 2013-2017
Appendix A: Glossary
ALS
Automatic Letter System
DoH
Department of Health
EPR
Electronic Patient Record
IM&T
Information Management and Technology
IT
Information Technology
NE
North East
NPfIT
National Programme for IT
PACS
Picture Archive and Communication Systems
PAS
Patient Administration System
PbR
Payment by Results
QIPP
Quality, Innovation, Productivity and Prevention
SAN
Storage Area Network
SLA
Service Level Agreement
TTO
To Take Out
VOIP
Voice Over Internet Protocol
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14.
Appendix B: Recommendations from the
Francis Report




















performance information should be stored in shared databases for monitoring;
patient should have the ability to real-time and retrospective access to their
records and a facility to enter comments, In a form usable by them if they
wish, including the summary care record;
IM&T systems should provide prompts and defaults where these will
contribute to safe and effective care, and to accurate recording of information
on first entry;
Systems should have the ability to produce alerts to overdue/due tasks or
where likely inaccuracies have occurred;
systems should be capable of collective performance and audit information
automatically. This information should be appropriately anonymised direct
from entries to avoid unnecessary duplication of input;
systems should be designed by healthcare professionals in partnership with
patient groups to secure maximum professional and patient engagement in
ensuring accuracy, utility and relevance;
systems and processes should be capable of reflecting changing needs and
local requirements over and above nationally required minimum standards;
provider organisations should have a board level member with responsibility
for information;
quality accounts information should be presented in a common output for
easy comparison between providers by DoH and NHS Commissioning Board;
system formats should allow the ability to lodge the Trust’s quality accounts
with all organisations commissioning services;
system processes should allow for all necessary directors to sign off quality
accounts;
ensure data is properly anonymised when used for managerial or regulatory
purposes;
a quality and risk profile should be placed in the public domain as far as is
consistent with maintaining any legitimate confidentiality of such information,
together with appropriate explanations to enable the public to understand the
limitations of this tool;
systems should create the ability to capture patient and public comments and
a means of publishing the outputs;
results and analysis of patient feedback, including qualitative information,
need to be made available to all stakeholders as near “real time” as possible;
proactive system should be put in place for following up patients shortly
following discharge to capture issues, feedback and additional advice;
provide information to the ‘NHS Information Centre’ for analysis, publication
and oversight of healthcare information in England;
systems and processes should have the ability to provide breakdowns of
clinically related complaints for the Information Centre to collate and publish
in more detail;
greater transparency and accessibility should be given to serious untoward
incident statistical information;
systems and processes which give:
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Item 10
The Francis Report highlighted areas of IM&T Strategies that should be addressed in
response to the findings at Mid Staffordshire NHS Foundation Trust. These are listed
in Appendix A.
The Pennine Acute Hospitals NHS Trust
•
•
•









IM&T Strategy 2013-2017
effective, real-time information on the performance of each of their
services against patient safety and minimum quality standards;
effective real-time information of the performance of each of their
consultants and specialist teams in relation to mortality, morbidity,
outcome and patient satisfaction;
information on the above should be made available upon request
by commissioners and regulators and to the extent that it is
relevant to individual patients to assist in choice of treatment.
more information should be collected on efficacy of treatment in specialties by
healthcare professionals;
statistics on the efficacy of treatment should be prepared and published
through DoH, Info Centre, CQC or specialty organisations, and subject to
regular review;
DoH, Information Centre, CQC and specialty organisations should seek and
have regard to the views of patient groups and the public about the
information needed by them;
all statistics should be made available online and accessible through provider
websites as well as other gateways;
resources to collect and forward data to the relevant central registry must be
allocated;
vigilant auditing of data to ensure consistent and reasonable accuracy;
review of patient outcome statistics, including hospital mortality and other
outcome indicators;
hospital-level mortality indicators are not yet recognised as national or official
statistics. The DoH, Health and Social Care IC should work to establishing
this status;
an accreditation system for healthcare relevant statistical methodologies.
This power has already been created within the Health and Social Care Act
2012 and should be used as soon as possible.
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IM&T Strategy 2013-2017
15.
Appendix C: Progress against previous IM&T
Strategy
Action
Progress
A&E system upgrade
The business case has been approved and
completion is expected by July 2013.
Admission, discharge and
transfer improvement
programme
Completed in 2011
ALS discharge summary
replacement
Clinical sign off has been achieved for this
project and the pilot ward went live in March
2013. Full roll out at ROH is underway. Roll
out beyond ROH is on hold, subject to approval
of the business case. A review will be carried
out to consider the replacement of clinic letters
in ALS in parallel to the roll out of discharge
summaries.
This action will be carried forward into the new
strategy.
Bed management project
The implementation of PatientCentre and
electronic whiteboards has been completed and
mobile devices have been provided for mobile
working.
The replacement of paper within the
departments is near completion and this action
will be carried forward in the new strategy to
finalise the project.
Real-time reporting on bed states is in progress
and will be carried forward into the new
strategy.
Cardiology Enterprise Archive
(Additional storage)
The solution went live in August 2012. The
validation of results is in progress and
completion is expected by the end of June
2013.
Christie Clinical Portal
The system is ready to go live subject to
governance approval by The Christie.
Implementation will be carried forward into the
new strategy.
Climate HIV system
The business case has been approved and
implementation is in progress.
The completion of this action will be carried
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Item 10
The completion of this action will be carried
forward into the new strategy.
The Pennine Acute Hospitals NHS Trust
Action
IM&T Strategy 2013-2017
Progress
forward into the new strategy.
Clinical portal
This functionality is ready for deployment by the
supplier, CSC. An initial evaluation of whether
the deliverable is clinically fit for purpose will
proceed. Testing of the portal is due in June
2013.
This action will be carried forward into the new
strategy.
Community staff migration from
iPM to PatientCentre
The business case was approved in February
2013 and the migration is anticipated to be
complete by the end of 2013.
This action will be carried forward into the new
strategy.
Data centre move
Completed in June 2012.
Data centre virtualisation
The consolidation of physical servers to save
space and energy consumption is around 40%
complete at the time this document was created
and is still ongoing.
The completion of this action will be carried
forward into the new strategy.
Data leakage solution
Order placed in March 2013 for a solution to
help prevent loss of patient identifiable data by
means of web and email communication.
This action will be carried forward into the new
strategy.
Data warehouse/Dashboards/
Information provision
Data has been migrated from the current data
warehouse to the Trust’s new data warehouse,
InView. Validation of all data outputs from the
new data warehouse are complete.
The new data warehouse will now operate in a
parallel running mode with existing data
systems for the next six months. The intention
is that all other internal information sources will
be decommissioned by then end of 2013.
Good progress has been made on the
dashboard front and dashboards now exist to
support the monitoring of performance,
efficiency and quality of care at all levels of the
organisation.
Phase 1 of the consultant and speciality
dashboards are in development and expected
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Action
IM&T Strategy 2013-2017
Progress
to be complete by June 2013.
Theatre and Radiology data routines are to be
developed to provide data to support 18 week
reporting. To be completed by summer 2013.
A Trust Balanced Scorecard is under
development and will become available in the
summer of 2013.
The completion of this action will be carried
forward into the new strategy.
Dawn anti-coagulant system
The business case has been approved and the
roll out is underway and is expected to be
completed by the end of July 2013.
This action will be carried forward into the new
strategy.
Diabetes system upgrade
The business case has been approved and
completion is expected by July 2013.
The completion of this action will be carried
forward into the new strategy.
Digital dictation project
This was fully implemented in 2012.
Digital pens pilot
This action will be carried forward into the new
strategy.
Digitalspark stroke system
This went live in March 2013.
DNA appointment reminder
This went live in February 2013.
Doctors’ leave management
system
The initial requirements documentation has
been completed and further requirements
analysis is in progress.
The completion of this action will be carried
forward into the new strategy.
Doctors’ revalidation system
This system went live in February 2013.
Electronic GP radiology
ordering
This is now live in all Bury GP practices and the
roll out to Oldham and HMR is imminent.
This action will be carried forward into the new
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Item 10
A number of modules have been procured from
Dr Foster Business Intelligence and are in the
process of being rolled out across the
organisation
The Pennine Acute Hospitals NHS Trust
Action
IM&T Strategy 2013-2017
Progress
strategy.
Electronic Prescribing and
Medications Administration
This functionality is now live on all medical
wards including MAU at ROH. Full roll out to
Surgery, Maternity and Gynaecology us
underway at ROH to be completed in June
2013. The Trust is an early adopter for a new
version which includes medicines reconciliation
and infusions which will enable roll out of more
complex prescribing. Following approval of the
business case roll out beyond ROH will
commence and is expected to be completed by
April 2014.
This action will be carried forward into the new
strategy.
Electronic whiteboards
Phase 1 of the project is complete and all
general wards have active white boards. The
rollout to DSUs is planned and will be carried
forward in the new strategy.
The next phase (clinical indicators and drag
and drop) is currently in the pre-implementation
phase and will be carried forward into the new
strategy.
eRostering phase 1
Deployment is in progress with full nursing
deployment expected to complete by Dec 2014.
The completion of this action will be carried
forward into the new strategy.
Greater Manchester Electronic
Clinical Correspondence
Three pilot GP Practices went live in February
2013.
Further implementation will be carried forward
into the new strategy
Hardware asset management
The business case has been approved and the
processes have been agreed.
The completion of this action will be carried
forward into the new strategy.
Maternity system upgrade
The business case was approved in February
2013 and orders have been raised for
additional equipment. Go live is expected to be
completed by late summer 2013.
This action will be carried forward into the new
strategy.
Network Access Control (real
time alerts to security breaches)
This project is in ‘learning’ mode with
completion expected by July 2013.
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Action
IM&T Strategy 2013-2017
Progress
Order communications and
results reporting
The roll out of radiology to pilot wards is
underway and the roll out of pathology blood
sciences to pilot wards will follow shortly. This
will be carried forward to the new strategy.
PACs/RIS procurement –
Greater Manchester Consortium
This project went live in April 2013.
Paper Light project in
HealthViews
The ophthalmology outpatient clinic (ROH)
went live in Nov 2012, the acute oncology
service went live in December 2012 and the
dementia assessment form went live in
December 2012. A programme of work to start
replacing paper forms with electronic forms is
underway subject to the re-establishment of the
substantive EPR team.
This action will be carried forward into the new
strategy.
PAS/iTanium hardware upgrade
Completed in 2010, prior to all other EPR work,
to upgrade PAS hardware and render it more
resilient
PAS upgrade to Patient Centre
Completed in 2011
Pathology system – new
hardware
This project is complete.
Pharmacy system replacement
The procurement of a new solution is
underway.
This action will be carried forward into the new
strategy.
Remote access network
The network has been upgraded locally and the
N3 network is being upgraded to N4.
The completion of this action will be carried
forward into the new strategy
Replacement integration engine
The tender for this has been completed and the
business case was approved in March 2013.
Implementation will be carried forward into the
new strategy.
Replacement theatre system
A new theatre system has been procured and
implemented at all four sites. Reports to assist
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Item 10
The completion of this action will be carried
forward into the new strategy.
The Pennine Acute Hospitals NHS Trust
Action
IM&T Strategy 2013-2017
Progress
with performance and efficiency are currently
being developed and the next phase of the
project which is to implement the stock-taking
module is due to be completed by autumn
2013.
This action will be carried forward into the new
strategy.
SharePoint project
The requirements have been reviewed and the
scope of work agreed. A Project Manager has
been recruited to take this forward.
Summary care project
This project is complete.
Telecoms voice over IP
This solution will provide unified
communications for video linking, telephone
calls, supporting MDT meetings and
collaborative working across geographical
areas.
This action will be carried forward into the new
strategy.
Trust internet / intranet
replacement
The business case has been approved and an
order was placed in March 2013. Project at
detailed planning stage.
This action will be carried forward into the new
strategy.
Virtual desktop project
The aim of this project is to deliver remote
access for users. The solution works with
systems that have offline functionality and with
single sign-on (SSO). The procurement of the
solution is complete with the roll out planned
over the following 12 months.
The completion of this action will be carried
forward into the new strategy.
Voice recognition project
This project was put on hold however a project
manager is about to be appointed to take this
forward during 2013/2014.
The completion of this action will be carried
forward into the new strategy.
Web filtering system
An order was placed in March 2013 to upgrade
the current web filtering solution to the latest
version. This will be deployed by May 2013
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Action
Progress
Wireless network
This is upgraded and reviewed annually.
This action will be carried forward into the new
strategy.
This was introduced as part of EPR programme
and is an ongoing programme.
This action will be carried forward into the new
strategy.
Item 10
Wireless working on wards
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16.
IM&T Strategy 2013-2017
Appendix D: List of Clinical Systems
System name
ALS Create
ALS Lookup
Anti coagulant - Dawn AC
Badgerlite
Bronchoscopy LCMS
CARDDAS
Description
System is used to create clinical correspondence, discharge summaries and OPD letters.
These letters are sent electronically to GP practices to assist in meeting Trust targets.
This facility allows the viewing of patient’s clinical documents which have been created in the
ALS Create system. This is to enhance continuity of care and promote communication
between disciplines.
This is an anticoagulation therapy management system which doses patients and records all
their previous results and doses. It also provides appt dates and clinic lists.
Neonatal patient data management system - web based.
Used to record the procedures of Bronchoscope, pleural aspiration, pleural biopsy etc. The
system generates histology and microbiology request cards and copies of the report for the
case notes and GP. Used to support audit. Its functionality is different from Somerset
database. Used on all 4 sites.
The system is used for cardiology appointments, holding patient information, recording clinical
information during invasive procedures, reporting, audits, inventory and stock control.
Cardiology CALM
This is a standalone system. It is used to score the risk to a patient of coronary disease for
helping to educate them to a better life style.
CD View
Use for scanning referrals. Integral part of the management of waiting list. Scanning carried
out at RI & FGH but all sites can view images held on server in data centre.
Centricity EA Archive
The system stores all images from the Catheter Lab at Rochdale, echo images from Rochdale
and some echo's from NMGH
Choose & Book (CAB)
This is a booking system that allows patients to select the date and time of their first O/P
appointment. The appointment is electronically booked into a slot on PAS.
Clinical Audit databases
These are a set of Access databases which have been developed to enable the Trust to
facility clinical audit information requirements.
Compuscope
This system is used to record the colposcopy procedures and provides examination and
management information. Uses mini PAS. Letters are printed and sent to GP and Patient.
CRIS
Dendrite - ARAS
Dendrite - Infectious
diseases
Dendrite - Thora Re-ops
Dendrite - Vascular
Diamond
Download 2001
Dr Fosters
Encore Pro
G2 (Digital dictation)
GECKO
Management system providing all radiology reports, reception and appointments data and
departmental statistics. Links to Miami server to provide PTL data.
Provides point of care data capture (incorporating NSF minimum datasets), data analysis and
reporting, outcome tracking and risk modelling. The following registries are within the Dendrite
system
Provides point of care data capture (incorporating NSF minimum datasets), data analysis and
reporting, outcome tracking and risk modelling.
Provides point of care data capture (incorporating NSF minimum datasets), data analysis and
reporting, outcome tracking and risk modelling.
Provides point of care data capture (incorporating NSF minimum datasets), data analysis and
reporting, outcome tracking and risk modelling. The following registries are within the Dendrite
system
Infectious diseases, Vascular surgery with ARAS to go live in the new year.
Occupational Lung Disease and Thoracoscopy registries currently being developed and due to
go live around April/May 2011. This is a small company but widely used throughout the NHS.
System used in diabetes clinics to record information used as a clinical record and to produce
standard format GP letters. Information from the system is used for audit and research
purposes. The system has a PAS and Pathology interface.
Download 2001 is a sleep investigation and analysis system for oximetry tests.
3rd party system used for reporting on performance indicators to compare such things as
mortality rates against other Trust.
Encore Pro 2 is a sleep investigation system that is used to download and analyse data from
CPAP machines.
Electronic transcription service. Digital dictation system which replaces the Trusts analogue
system.
This is a centralised data repository for the Trust’s historic information reporting and
requirements.
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HealthViews
This is a database of patients who have undergone or awaiting endoscopy. It is used to
produce reports for GP’s and consultants. It also contains an audit tool for producing quarterly
reports.
Clinical Information System including e-forms and documentation and order communications
and results reporting.
HiPPO
Used by information department for monthly reporting. Currently moving to new data
warehouse after which Hippo will no longer be used.
HIV Research
This database stores information about patients with HIV for information and surveillance.
ICBIS
Infection Control
Inflammatory Bowel
Disease System
INVIEW
Keystone
Lilie
Maternity
MedChart
Mela Pain
MUSE
Novocer
Occupational Health
Order Communications
PACS
PacsSCAN
Access database which is used to keep a record of Intensive care beds and critical care
transfers in the NW. The database is kept on a central server.
ICnet collects patient information from microbiology and is used to provide reports on
infections and looks at trends over a period of time. ICnet is used to record clinical data by the
infection prevention team.
Partial electronic clinical record system for patients with IBD: holds information about
diagnosis, treatment etc.
Information dashboards
The application’s main task is to receive, translate and transmit electronic patient detail reports
in standard formatted structures to various recipients as below:
Pathology report to GP practices, Trust GUM system and the RUCLEAR service. Radiology
and discharge summary results to GP practices, Cytology reports to PCTs & CDS to
secondary uses service (SUS)
Lillie is a standalone system for the GUM clinics. It operates as an appt diary, patient data
registration system. It produces standard letters, records coded activity and produces reports
for audit and includes statistical returns for DoH.
A system which records all maternity activity and provides clinical data required by the
Maternity services.
Electronic Prescribing and Medicines Administration (ePMA) solution.
System used by Anaesthetics, Critical Care and Pain Service to collect acute and chronic pain
data in the operational setting and provide clinical audit information to the National Institute of
Pain Survey (NIPS) for benchmarking purposes.
The MUSE system stores ECG’s across the Trust.
Muse-web is a view only system which allows users to view images without being able to
make any changes.
On upgrade will be able to view Carddas & Muse through Web browser.
Novacor is an analysis system for event recorders, 24 & 48hr ECG and BP.
A system which records all Occupational health activity and provides clinical data required by
the services.
This is a secure system for the electronic transmission of Pathology and Radiology orders and
results. It forms the beginnings of EPR.
This is a picture archiving and communication system. It stores the majority of radiographic
images for retrieval on workstations and web-browsers throughout the Trust. Integrates with
RIS to allow viewing of reports and referral information.
Pathology - Co Surve
PacsSCAN is used to upload Medical illustration images onto PACS
This is the Trust’s Patient Administration System and is used to collect inpatient, day care,
ward attenders and outpatient activity across the Trust and is also used for case note tracking
& coding.
Disease management & reporting.
Pathology - Comark
Refrigerator temperature monitoring.
Pathology - Conworx
Point of care testing.
Pathology - Instrument
Manager
Analyser management.
Pathology - LabCentre
Laboratory Management (Due for review March 2014)
Pathology - PathManager
Data Warehouse.
Pathology - Pathosys
Cancer reporting
Pathology - PMIP
GP Ordering.
Pathology - QC Lite
Document scanning archive. Simple scanning only.
PAS
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GI Reporting Tool
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The Pennine Acute Hospitals NHS Trust
IM&T Strategy 2013-2017
Pathology - Q-Pulse
Document Management.
Pathology - Review
Result data warehouse.
Pathology - T-Quest
GP ordering and GP.
Pathology - Winscribe
(Digital Dictation)
Stand-alone system for Pathology.
PatientCentre
PatientCentre provides clinical activity support, underpinned by a core administrative
component designed to improve business processes within the Trust. The software is
accessed through a single, user-friendly graphical interface.
Pharmacy
Pharmacy Stock Management System including support for dispensing, stock control, ward
supply, procurement, clinical information & financial reporting.
Practice Navigator
PN is a fifteen-user LAN based Audiology system used for attendance recording, clinical
information, stock control, reporting (inc 18 weeks) and appt booking.
Prescription Tracking
The system tracks prescriptions through Pharmacy. It enables wards to view their own
prescriptions and their progress through the Pharmacy department.
Prism - Cardo resp
Prism - Neuro Physiology
Pulmolink
ResScan
RIS Viewer
Rochdale PACS
Used for Physiological measurement in respiratory and cardiology including sleep. Prism is a
data management system including appointments data, demographics and reports. Reports
are viewed Trust wide via Prism.net.
Used for Physiological measurement in neurophysiology. Prism is a data management
system including appointments data, demographics and reports. Reports are viewed Trust
wide using Prism.net.
This is an integrated Diagnostic Respiratory information system which stores respiratory test
results and exports reports to Prism-net to be viewed by clinicians across the Trust. The
system has a PAS link.
Res-Scan is a sleep investigation system used to download and analyse data from the
ResMed machine.
Holds historical radiology information prior to the new CRIS system which became operational
in Nov 2007.
Legacy PACS system at Rochdale. Archive system containing Rochdale images from 2001
until LSP PACS in November 2007.Access limited to some Rochdale users.
SeeBeyond
System that handles messaging/file mediation between Pennine Acute systems. It is the link
that enables all the different systems to pass information to each other.
Sentinel
Sentinel is an integrated Cardiology Information management system for downloading and
analysing 24hr Holter tests and BP’s.
SMED
Somerset Cancer Registry
SSDMan Trisoft - HSDU
SMED is a sleep investigation and analysis system used for more in-depth tests.
Database of all cancer performance and activity for the Trust. Enables submission of all
mandatory cancer performance data to the national cancer database, clinical information to
the national cancer registry and clinical information to the national cancer clinical audit
databases (NCASP.)
Used to track instruments used in the operating theatres.
Symphony
A system for tracking A&E attendances and monitoring patient 4 hour targets. This system is
also used to generate income via PBR.
TA Monitor
Rheumatology
TheatreMan
Theatre information & management system
TIMS
This is a Theatre information & management system to record all aspects of theatre activity
across the Trust. It is used to schedule patients onto elective & emergency theatre lists and
record each stage of the patient’s journey
Vector Diabeta3
Database containing approx 32,000 records of all patients with diabetes with the PCT’s HMR,
Oldham and Bury. It has an admin function to recall various types of appointments sent out
and a clinical function that controls the image capture of patient’s retina in the community and
allows the viewing of the images and grading into disease levels.
Ward Watcher
Used to produce high quality data detailing a patient’s pathway through Critical care areas.
Provides the Trust & Intensive care national audit with high quality / trustworthy information on
subjects such as mortality rates.
60 | P a g e
Page 119 of 318
Title of Report
Risk Management Strategy
Executive
Summary
It is a requirement under the NHSLA Risk Management Standards
that the Risk Management Strategy is reviewed on an annual
basis by the Board. The Strategy has been reviewed and no
changes made. A further review will be necessary in year to
ensure that the Strategy reflects proposed changes to the Quality
Governance structure. At that point the Strategy will need to be
resubmitted to the Board for approval.
Actions
The Board is asked to approve the Risk Management Strategy
Requested:
Corporate objectives supported by this paper:
As the Strategy describes the corporate process associated with the management of
risk across the organisation it supports all corporate objectives.
Public and/or Patient Involvement:
Not relevant for this paper
Resource Implications:
Not relevant for this paper
Communication:
Not relevant for this paper
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Month and Year
Email
Mr J Saxby
Chief Executive
June 2013
[email protected]
Page 120 of 318
YES
X
X
X
X
X
X
X
X
X
NO
N/A
Item 11
Risks:
Failure to comply with the NHSLA Risk Management Standards and a consequent
increase in the premium paid. Failure to manage risk appropriately across the Trust.
Risk Management Strategy
for The Pennine Acute Hospitals NHS Trust.
Item 11
Keywords: risk management, risk identification, risk assessment, governance
Document Number:
Version:
Developed in Consultation with:
Ratified by:
Date Ratified:
Next review date:
Expiry Date:
Document Author:
EDQ011
Version 7
Governance, Risk Management
Committee
Trust Board
31st May
July 2013
26th May 2014
Helen Curtis – Governance Director
Page 121 of 318
Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
Pennine Acute Hospitals NHS Trust
Risk Management Strategy
Main Revisions from previous issue
Name of Previous Document:
Risk Management Strategy
Previous Document Number:
EDQ011
Previous Version Number:
Version 5.1
Reason for Revision:
Annual review as required under the
NHSLA Risk Management Standards
for Acute Trusts. No amendments
made.
Expiry date: 26/05/14
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Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
Contents
Page
1. Introduction, Aims & Scope
4
2. Definitions
4
3. Governance Arrangements
4-5
4. Accountability and Responsibility
6-7
5. Strategic Objectives
7
6. Staff Involvement
7
7. Audit and Financial Controls
8
8. Complaints
8
9. Claims
8
10. Implementation, Training and Education
8
12. Policies and Procedures
9
13. Assessments
9
14. Monitoring and Review
10
15. Associated Trust Documents & Supporting References
10
Item 11
8-9
11. Incident Reporting
10
Associated Trust Documents
10
Supporting References
11-17
16. Appendices
Appendix A – Risk Management Committee – Terms of
Reference
Appendix B – Clinical Governance Committee – Terms of
Reference
Appendix C – Committee Structure Chart
Appendix D – Arrangements for Monitoring Compliance
Appendix E – Equality Impact Assessment
11-13
14-17
18
19
20-22
Expiry date: 26/05/14
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Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
1.
Introduction, Aims & Scope
1.1
This document sets out a risk management strategy for The Pennine Acute
Hospitals NHS Trust. The Trust is committed to effective governance and will
establish an infrastructure that ensures that the elements of governance are
established and integrated into the management and operational processes of
the organisation. Risk identification, assessment and management is a
fundamental part of effective governance in both clinical and non-clinical
activities as is the health, safety and welfare of all people affected by the
Trust’s activities. Effective management in these areas will enhance the
quality of care, improve safety, minimise loss of resources and protect the
reputation of the Trust. It is applicable to all staff groups within the Trust.
2.
Definitions

Risk – “The probability or threat of a change, injury liability, loss or other
negative occurrence, caused by internal and external vulnerabilities, and
which may be neutralised through premeditated actions”. (Governance in
the New NHS. HSC 1999/123).

Risk management is defined as “the culture, processes and structure that
are directed towards the effective management of potential opportunities
and adverse effects” (Governance in the New NHS. HSC 1999/123).
2.1
Risk management is concerned with generating information regarding risk,
harnessing individual and corporate expertise in an integrated system that
highlights risk factors and ensuring that action is taken to minimise loss of life,
financial loss, loss of staff availability, loss of plant and equipment and loss of
reputation.
2.2
By its very nature, health care is a risky activity. Risks will always be a part of
the NHS whilst clinicians treat patients and seek to develop more effective
care and treatment. Risks should only be taken because of a positive decision
to do so, based on good information and a sound understanding of the
possible consequences and outcomes. This same principle applies to all
areas of the organisation such as the buildings, equipment, people and
systems of management within the Trust.
3.
Governance Arrangements
3.1
The Chief Executive is the accountable officer for all aspects of governance.
3.2
There is a Risk Management Committee, chaired by the Chief Executive, to
ensure the effective implementation of this strategy and to receive reports on
the incidence of risk and the steps taken to manage it. The Membership of the
Risk Management Committee is included in the Terms of Reference at
Appendix A. The Trust Board is committed to providing the resources and
support systems for the risk management strategy in order to promote quality
Expiry date: 26/05/14
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Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
3.3
There is a Clinical Governance and Quality Committee chaired by the Chief
Executive. The membership is included in the Terms of Reference at
Appendix B. Attached at Appendix C is a committee structure organisation
chart.
3.4
The Trust’s Audit Committee is responsible for assessing the establishment
and maintenance of an effective system of internal control and risk
management.
In particular the Audit Committee is responsible for
independently assuring the Trust Board of the adequacy of the structures,
processes and responsibilities for identifying and managing key risks facing
the organisation.
The Risk Management Committee and the Clinical
Governance & Quality Committee will submit assurance statements annually
to the Audit Committee detailing how the Committees have fulfilled their terms
of reference.
3.5
Individual Divisions, Directorates and Departments will, if required, have risk
management policies and strategies which comply with the Trust risk
management strategy and policy. The Governance Director will oversee these
arrangements with the Divisional Directors who will be responsible for
facilitating and disseminating identified risks throughout the Trust in order to
prevent recurrence and aim to reduce loss through claims and absence.
3.6
Each Division has established a Divisional Governance Committee with Terms
of Reference that reflect those of the Risk Management Committee and the
Clinical Governance & Quality Committee. Representatives from the Divisions
are present at both the Risk Management Committee and the Clinical
Governance Committee.
3.7
Health and Safety Committees are established with a Central Committee
under the chairmanship of the Governance Director with managerial
representation from each site and Division on equal level of staff
representation. Trust Safety Advisors will be in attendance at this meeting as
will Risk co-ordinators as the agenda dictates. Local Health and Safety
Committees chaired by a senior member of the site management team, will be
set up to expedite across from the Trust’s Health and Safety Committee,
receive reports from the Governance Department and deal with Health and
Safety issues capable of local resolution.
3.8
The Executive Management Team is responsible collectively and individually
for the regular review of the Board Risk Register.
Expiry date: 26/05/14
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Item 11
health care and provide a safe environment for patients, visitors, staff and
others affected by the work of the Trust. The Board will review quarterly the
Assurance Framework which is supported by the Board Risk Register. In
addition the Board receives the minutes of the Risk Management Committee.
The minutes are received for review, follow up and identification of further
action as necessary.
Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
4.
Accountability and Responsibility
4.1
The nature of health care determines that risk management covers both
clinical and non-clinical events.
Clinical risks are those arising from
professional healthcare practice and decisions. Non clinical risks are those
arising from all other processes. Financial risks are a combination of both
clinical and non-clinical risks affecting the financial status of the Trust. In
order to address clinical and non-clinical risk issues, the Trust has identified
the following essential roles: -
4.2

The Chief Executive has overall responsibility for the management of risk.

The Medical Director has responsibility for clinical risk through the Clinical
Governance & Quality Committee

The Director of Finance is responsible for establishing mechanisms for
appropriate financial control

The Operations Director is responsible for operational risk through the Risk
Management Committee

The Governance Director is responsible for whole systems governance in
the Trust, for co-ordinating external governance assessment under the
NHSLA Risk Management Standards and for maintaining effective links
between incidents, complaints, claims and the risk register.
The
Governance Director will liaise closely with Executive and Divisional
Directors.

The Assistant Chief Executive is responsible for maintaining a strategic
overview of complaints and claims management

The Risk Co-ordinators will be responsible for providing advice on clinical
risk issues and in conjunction with Clinical Directors be responsible for the
day to day monitoring of clinical risk management within the Trust. They
will liaise closely with Infection Control teams and other professional teams
responsible for safety and quality of clinical care.

The Trust Safety Advisers/Officers will be responsible for co-ordinating the
health and safety management programmes and with other managers will
be responsible for the monitoring of physical risk throughout the Trust.

The Fire Safety Advisers/Officers will be responsible for co-ordinating fire
safety programmes.

The Security Advisers/Officers will be responsible for monitoring, training
and advising on security issues.

Back Care Training Co-ordinator/Manual Handling Advisors who advise
and educate on risk and management issues relating to moving and
handling.
All employees have a responsibility to:
Work in accordance with all Trust Policies and Procedures
Expiry date: 26/05/14
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Risk Management Strategy EDQ011 Version 6

Attend induction and regular mandatory training on risk management
policies and procedures

Identify through risk assessment, any risks they feel exist within their
department or during the delivery of their services and report these to their
line managers for action

Provide incident reports and supporting documentation for any unexpected
event or incident they are involved in
5.
Strategic Objectives
5.1
The Risk Management Strategy will be underpinned by specific policies for all
the key elements of risk and which incorporate, as a minimum, the
requirements of the NHSLA Risk Management Standards for Acute Trusts.
5.2
Policies should describe procedures :

To understand the risks the Trust faces, their causes and control, and the
cost of risk to the trust.

To prevent wherever possible the exposure of the Trust to a risk which has
not been identified

To monitor the management of risk within the Trust

To identify, control and eliminate or reduce to an acceptable level all risks
which may adversely affect:

The quality of care to patients

The ability of the Trust to provide services

The health, safety and welfare of patients, visitors and staff

The ability of the Trust to meet its contractual commitments

The capacity to reduce risk to patients, employees and others, manage
and control risk where acceptable and to transfer risk where it is
unacceptable or unavoidable

The maximisation of resources available for patient services and care

To identify the resources required to manage risk and to build the
resources into business plans.
6.
Staff Involvement
6.1
Joint training initiatives will be provided for all staff representatives and
managers involved in developing this strategy. Through its established
consultation and communication forums the Trust will seek to engage the
whole workforce. The Trust will also seek to address the requirements of the
HR Performance Framework of relevance to the risk agenda including the
reduction of accidents, violent incidents and workplace injuries.
Expiry date: 26/05/14
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Item 11
Pennine Acute Hospitals NHS Trust
Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
7.
Audit and Financial Controls
7.1
The Trust will specify Standing Financial Instructions and all staff will work
within the agreed financial procedures. The Director of Finance will establish
and monitor mechanisms for financial control including the use of the Internal
Audit function.
8.
Complaints
8.1
All complaints will be recorded, reported and managed in accordance with the
requirements of the NHS complaints procedure. The Trust will have
designated complaints co-ordinators who are easily accessible to the public
and Trust employees. There will be on each hospital site a designated Patient
Advice Liaison Service (PALS) who co-ordinates any immediate concerns and
enquiries that may effect patient care.
8.2
There will be a well-publicised complaints procedure, with clearly visible
information displayed throughout all wards and departments detailing the
contact person for complaints and the processes involved.
9.
Claims
9.1
All reported claims will be systematically managed, by designated claims
managers who work closely with the NHSLA. Claims managers will have
experience and expertise in health care law and civil litigation practices and
procedures.
10.
Implementation, Training and Education
10.1
This document will be made available via the ‘Documents’ page of the intranet
which all staff are encouraged to use. Risk management training will be
provided across the Trust and will include the following:




Induction (for all staff) – reference to the Trust’s arrangements for handling
risk, especially for all newly appointed clinicians and those staff involved in
health and safety, control of infection, claims and complaints
Awareness – general appreciation by all staff of the importance of
managing risk and the Trust’s strategy for dealing with it.
Risk identification – techniques for risk assessment, education and training
in incident reporting systems.
Fire, security and moving and handling education and training.
11. Incident Reporting
11.1
There will be a system in place to ensure all incidents and near misses are
identified, recorded and reported to the appropriate manager at the earliest
Expiry date: 26/05/14
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11.2
Reports will also be disseminated to the Trust and Divisional Governance
Committees. Lessons learned from incident and near miss reporting will be
shared appropriately and widely throughout the Trust. The Trust will report all
patient safety incidents to the National Reporting and Learning System
(NRLS).
12.
Policies and Procedures
12.1
The Trust will ensure that all risk management policies and procedures are in
place to meet national and local requirements. These will be stored in each
ward and department area in a designated folder and will increasingly also be
made available on the Trust intranet. All areas in the Trust will have free
access to this information. Risk management policies relating to infection
control will be stored in the infection control folders.
13.
Assessments
13.1
The principles of risk management require staff to identify hazards and why
and carry out risk assessments within the working environment and to take
reasonable measures to control risk. The Trust will assess and control risk
using the principles of risk management. This will include clinical and nonclinical work practices, not necessarily covered by the Health & Safety at Work
Regulations.
13.2
All Divisions will be required to undertake formal risk assessments within their
areas and maintain a Divisional Risk Register. Divisions will also be required
to develop local action plans to address the risks identified. The Trust
Executive Management Team will be responsible for reviewing the Board risk
register. The resource implications of identified risk need to be incorporated
into local and Trust business planning.
13.3
The Trust will actively participate in external accreditation and assessments
and implement any recommendations arising from these assessments.
13.4
The Trust risk management programme will be structured to ensure that risk
management and the verification of risk management practice are conducted
in a focused and effective fashion. This will ultimately reduce the cost of
claims that need to be settled, and make a positive contribution towards
improving the quality of patient care and the safety of patients, staff and
visitors within the Trust.
Expiry date: 26/05/14
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Item 11
opportunity, in accordance with the agreed policy of positive, non-punitive
reporting. Analysis of these reports will be disseminated monthly and reported
quarterly to all key stakeholders.
Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
14.
Monitoring and Review
14.1
The Risk Management Committee will conduct an annual review of the risk
management strategy and policy against the minimum requirements of the
current NHSLA Risk Management Standards for Acute Trusts, Primary Care
Trusts and Independent Sector Providers of NHS Care, Criterion 1.1 ‘Risk
Management Strategy’. The Trust’s Internal Audit Department conducts an
annual review of the Trust’s risk management processes including the
application of the Risk Management Strategy and Policy. The Trust is also
required to monitor progress in the management of risk in order to complete
the Annual Governance Statement.
14.2
Further details regarding monitoring in relation to the NHSLA’s Risk
Management standard can be found in Appendix D.
15.
Associated Trust Documents & Supporting References
15.1
Associated Trust Documents:
15.2

Risk Management Policy (EDQ012)

Standing Orders Incorporating Standing Financial Instructions & Detailed
Scheme of Delegation (EDF006)

Accident & Incident Reporting Policy (EDQ008)

Complaints Handling Policy (EDG004)

Induction & Mandatory Training Policy (EDH024)

this is not an exhaustive list, please check on the ‘Documents’ pages of the
Trust intranet.
Supporting References:
Department of Health (1999). Governance in the New NHS. Heath Service
Circular HSC1999/123.
NHS Litigation Authority (2010). NHSLA Risk management Standards for
Acute Trusts Primary Care Trusts & Independent Sector Providers of NHS
Care 2010/11, Version 1 NHS Litigation Authority January 2010.
Expiry date: 26/05/14
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Risk Management Strategy EDQ011 Version 6
Appendix A - Risk Management Committee Terms of Reference
RISK MANAGEMENT COMMITTEE
TERMS OF REFERENCE
1
CONSTITUTION
The Board hereby resolves to establish a Committee of the Board to be known as the
Risk Management Committee (The Committee),
2
AUTHORITY
The Committee has no executive powers other than those specified in these Terms
of Reference or otherwise by the Trust Board in its Scheme of Delegation.
The Risk Management Committee is authorised to investigate any activity within its
Terms of Reference. It is authorised to seek any information it requires from any
employee and all employees are directed to co-operate with any request made by the
Committee.
The Committee is authorised to obtain independent professional advice as it
considers necessary in accordance with these Terms.
MEMBERSHIP, QUORUM AND ATTENDANCE.
Item 11
3
The Committee shall comprise












Two Non Executive Directors
Chief Executive (Chair)
Governance Director
Director of Finance & IM&T
Director of Operations
Director of Estates and Facilities
Chair of Health & Safety Committee
Divisional Director – Medicine
Divisional Director – Surgery
Divisional Director – Diagnostics
Divisional Director – Women & Children
Associate Director of IM&T
Additionally the Board Secretary should attend the meeting but will not hold full
membership rights.
Expiry date: 26/05/14
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To be quorate at least half the total number of the members of the Committee must
be present, including at least one of the Executive Directors and one of the Non
Executive Directors.
As meetings are bi monthly a minimum of four attendance out of six attendances is
required.
4
FREQUENCY
Meetings will be held bi monthly. Additional meetings of the Committee may be held
on an exceptional basis at the request of the Chairman or any three members of the
Committee.
5
RESPONSIBILITIES
To continuously and systematically identify and evaluate internal and external risks
that could adversely affect the achievement of the organisation’s objectives. To seek
ways to prevent occurrence or minimise these risks and advise the Trust board on
the magnitude of risk and identify the consequences if the risk is not prevented or
minimised.
The specific responsibilities of the Committee are as follows:(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
(ix)
To assure itself that the Risk Management processes of the Trust are
robust and compliant with Risk Management Standards.
To assure itself that the Board Assurance Framework process is robust
and compliant with the requirements of Monitor.
To protect the Health and Safety of employees and all others to whom the
Trust owes a duty of care.
To satisfy itself and the Board that the structures, processes and
responsibilities for identifying and managing risks to patients, staff and the
organisation are adequate.
To receive, review and approve risk assessments and the resultant action
plans, where appropriate.
To develop, agree on behalf of the Board and continually review a Risk
Management Strategy and Policy, Health and Safety Strategy and Policy.
To ensure that all requirements are met for the Chief Executive to sign the
Statement of Internal Control in the Trust Annual Report.
To ensure that all requirements for reporting to the Strategic Health
Authority and the Department of Health are met.
To work closely with the Clinical Governance & Quality Committee and the
Audit Committee.
6
REPORTING
6.1
The minutes or a report from the Chair of the Risk Management Committee
meetings shall be formally recorded and submitted to the Board and provided
for information to the Audit Committee and the Clinical Governance & Quality
Committee.
Expiry date: 26/05/14
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6.2
The Committee will provide an annual assurance statement on its activities to
the Trust Audit Committee.
7
OTHER MATTERS
The following sub committees will report to the Risk Management Committee:
Health and Safety Committee
Fire Safety Committee
Trust Security Committee
Medical & Scientific Committee
Radiological Protection Committee
IM&T Programme Committee
Laser Protection Committee
Information Governance Committee
Resilience Forum
Non Clinical Records Management Committee
Clinical Governance & Quality Committee (for information)
Item 11
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
Expiry date: 26/05/14
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Appendix B - Clinical Governance & Quality Committee Terms of
Reference
CLINICAL GOVERNANCE AND QUALITY COMMITTEE
TERMS OF REFERENCE
1
CONSTITUTION
By resolution of the Trust Board, a Committee of the Trust is established to be known
as the Clinical Governance and Quality Committee (“the Committee”).
2
AUTHORITY
The Committee has no executive powers other than those specified in these Terms
of Reference or otherwise by the Trust Board in its Scheme of Delegation. The
Clinical Governance and Quality Committee is authorised to investigate any activity
within its Terms of Reference. It is authorised to seek any information it requires
from any employee and all employees are directed to co-operate with any request
made by the Committee. The Committee is authorised to obtain independent
professional advice as it considers necessary in accordance with these Terms of
Reference.
3
MEMBERSHIP
Membership of the Committee shall comprise:












Two Non Executive Directors
Chief Executive (Chairman)
Executive Medical Director
Executive Director of Nursing/Director of Infection, Prevention and Control
Executive Director of Human Resources & Organisational Development
Deputy Medical Director
Divisional Directors
Clinical Representatives (6)
Head of Pharmacy Services
Governance Director
Head of Midwifery
Head of Safeguarding
The Executive Team will review the membership of the Committee annually to
ensure that it meets the clinical governance and quality requirements of the Trust.
Members will be required to attend 75% of the committee meetings in any one year.
The Committee holds a key role in the governance of the Trust. For the avoidance of
doubt Trust employees who serve as members of the Committee do not do so to
represent or advocate for their Division or service area but to act in the interests of
the Trust as a whole and as part of the trust wide governance structure.
Expiry date: 26/05/14
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4
Risk Management Strategy EDQ011 Version 6
MEETINGS AND QUORUM
Meetings will be held monthly. Additional meetings of the Committee may be held on
an exceptional basis at the request of the Chairman or any three members of the
Committee. To be quorate, at least half the total number of the members of the
Committee must be present, including one of the Executive Directors and one of the
Non Executive Directors.
5
ATTENDANCE
Only members of the Committee are entitled to be present at its meetings. The
Committee may however invite non-members to attend its meeting as it considers
necessary.
6
AIM
The aim of the Clinical Governance and Quality Committee is to oversee the
development; implementation and progression against the Quality Improvement
Strategy ensuring that the Strategy achieves its stated goals within the agreed
timescales. The Committee will assume responsibility for ensuring the timely
production of the Quality Accounts in accordance with national guidance. The
Committee will be responsible for overseeing the Trust’s performance against the
relevant CQUINs and other care quality indicators.
7
DUTIES
The duties of the Committee are as follows:
a) promote quality and excellence in patient care;
b) identify, priorities and manage risk arising from clinical care on a continuing
basis;
The Committee will further
7.2 Co-ordinate the work of its sub-committees ensuring that improvement activity
spreads, is complementary and maximises the impact on patient safety,
effectiveness and patient experience.
7.3 Monitor the performance of the Trust in relation to the quality and patient safety
objectives agreed annually identifying improvement measures, comparing both the
Trust’s performance over time and that of its peers.
7.4 Agree Trust wide clinical governance and quality priorities and give direction to
the clinical governance and quality activities of the Trust’s Divisions, including review
of Divisional objectives.
Expiry date: 26/05/14
Page 15 of 22
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Page 135 of 318
Item 11
7.1 The Committee will ensure that adequate and appropriate governance structures,
processes and controls are in place across the Trust and in each of its Divisions to:
Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
7.5 Approve the Terms of Reference and membership of its Reporting SubCommittees (as listed at 10.2 below and as may be varied from time to time at the
discretion of the Committee), and oversee the work of those sub committees,
receiving monthly exception reports from them for consideration and action as
necessary.
7.6 Promote within the Trust a culture of open and honest reporting of any situation
that may threaten the quality of patient care.
7.7 Ensure that there is an appropriate process in place to monitor and promote
compliance across the Trust with mandatory clinical standards and guidelines such
as NICE guidance and the NHSLA Risk Management Standards.
7.8 Oversee the processes within the Trust to ensure that appropriate action is taken
in response to adverse clinical incidents, complaints and litigation and that examples
of good practice are disseminated within the Trust and beyond if appropriate..
7.9 Consider matters referred to the Committee by its sub committees or any of the
Divisions.
7.10 Review and approve relevant policies and procedures.
8
REPORTING ARRANGEMENTS
8.1 Minutes are to be taken of meetings of the Committee and are to be presented to
the Executive Team and Trust Board. The Chair of the Committee shall draw to the
attention of the Trust Board any issues that require its particular attention, or require
it to take action.
8.2 Reporting Committees
The following Sub Committees will report to the Clinical Governance
Committee:












Patient Safety Committee
Infection Prevention and Control Committee
Clinical Audit & Effectiveness Committee
Pennine Acute Drugs And Therapeutics Committee
Safeguarding Vulnerable People Forum
Patient Experience and Equality and Diversity Committee
Pennine Acute Cancer Committee
Critical Care Steering Group
Research and Development Committee
Divisional Governance Committees
Risk Management Committee (for information)
Information Governance Minutes (for information)
Expiry date: 26/05/14
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Pennine Acute Hospitals NHS Trust
Risk Management Strategy EDQ011 Version 6
8.3 The Committee will provide an annual assurance statement on its activities to the
Trust Audit Committee.
9 INFORMATION SOURCES
9.1 To receive exception reports from its reporting committees.
9.2 To receive mortality data on a monthly basis from CHKS
9.3 To receive a CQUIN report on a monthly basis
9.4 To receive the minutes of the reporting sub committees.
10
MONITORING
Item 11
On an annual basis the Committee must review its own effectiveness against the
above terms of reference.
Expiry date: 26/05/14
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Page 138 of 318
Expiry date: 26/05/14
Clinical
Director
ates
Infection
Preventi
on
NHSLA RISK MANAGEMENT STANDARDS
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Safeguarding vulnerable
people
Clinical Audit
Pennine Drugs &
Therapeutic
Patient and Public
Involvement
Nutrition Steering Group
Pennine Acute Cancer
Information Governance
Critical Care
Organ Donation
Research & Development
Clinical
Governance
Committee*
Learning
From
Experience
Blood
Transfusion
Clinical Care
Clinical
Director
ates
Divisional
Governance
Committee –
Diagnostics &
Clinical Support
Safe
Environment
Clinical
Director
ates
Divisional
Governance
Committee –
Women &
Children
Competent &
Capable
Workforce
Resuscit
ation
Divisional
Governance
Committee Medicine
Governance
Clinical
Director
ates
Divisional
Governance
Committee Surgery
Trust Board
Committee Structure
*Common membership of Risk Management Committee and Clinical Governance Committee
-Chief Executive
-Governance Director
-Divisional Directors
Trust Health &
Safety
Fire Safety
Trust Security
Medical &
Scientific
Radiation
Protection
Laser
NPfIT
Health Records
Forum
Risk Committee*
Risk Management Strategy EDQ011 Version 6
PENNINE ACUTE HOSPITALS NHS TRUST
Appendix C - Trust Committee Structure
Pennine Acute Hospitals NHS Trust
Page 18 of 22
Page 139 of 318
Risk Management Strategy EDQ011 Version 6
Minimum requirement to be
monitored
Process for
Monitoring
Responsible
Individual/
Group/Committee
for Monitoring
Frequency
of
Monitoring
Responsible
Individual/Group
/Committee for
Development of
Action Plan
Risk
Management
Committee
Responsible
Individual/Group.
Committee for
Development of
Action Plan
Governance
Director
Responsible
Individual/Group/
Committee for
Monitoring of Action
Plan
Risk Management
Committee
Expiry date: 26/05/14
Item 11
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The organisation has an
Policy review
Governance
Annual
approved risk management process
Director
strategy that is
implemented and monitored
As a minimum, it must include a description of the following requirements and a description of the process for monitoring compliance with them
1.1a
Organisational risk
Policy Review
Governance
Annual
Risk
Governance
Risk Management
management structure
process
Director
Management
Director
Committee
detailing all those
Committee
committees/sub committees
/groups which have some
responsibility for risk
1.1b
Process for Board or high
Review process
Internal Audit
Annual
Risk
Governance
Risk Management
level committee review of
Management
Director
Committee
the organisation wide risk
Committee
register
1.1c
Process for the
Review process
Internal Audit
Annual
Risk
Governance
Risk Management
management of risk locally,
Management
Director
Committee
which reflects the
Committee
organisation wide risk
management strategy
1.1d
Duties of the key
Review process
Internal Audit
Annual
Risk
Governance
Risk Management
individual(s) for risk
Management
Director
Committee
management activities
Committee
1.1e
Process for monitoring
Review process
Internal Audit
Annual
Risk
Governance
Risk Management
compliance with all of the
Management
Director
Committee
above
Committee
1.1.1
NHSLA
Standard/
Criterion
The arrangements for monitoring compliance of this strategy in relation to the NHSLA minimum standards are summarised in the following
table:
Appendix D - Arrangements for Monitoring Compliance with this Strategy
Pennine Acute Hospitals NHS Trust
Page 140 of 318
Risk management Strategy
Is the policy
new or for
review?
Expiry date: 26/05/14
Objective:
To have robust risk management processes in the Trust
NHSLA
X
Service Users
Governance Director
Staff
Adherence to the Strategy
X
Public
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1.6 Who implements and is responsible for
the policy?
1.5 Who are the main stakeholders in
relation to the policy
1.4 What factors could influence the
intended outcomes either positively or
negatively?
Review
Other
Name of Author(s)
Helen Curtis
Aim: Sets out how the Risk Management Policy will be implemented
Date of assessment 8. 9.10
Page 20 of 22
Risk Management Strategy EDQ011 Version 6
1.3 Who is the policy intended to benefit, and Patients, relatives, visitors, staff and other stakeholders.
what are the expected outcomes?
Reduction in risk
1.2 Are there any associated objectives or
directives of the policy? i.e. Care Quality
Commission (CQC), NHS Litigation
Authority (NHSLA)
Area
1.1 Briefly describe the aims and objectives
and the purpose of the policy
Name of
Policy
Part One
Equality Impact Assessment Pro-forma (Policy)
Appendix E - Completed Equality Impact Assessment
Pennine Acute Hospitals NHS Trust
Page 141 of 318
N
1.10 Is there any doubt about answers to any of the questions?
Age
N
N
N
N
Disability
N
N
N
N
Ethnicity
(Race)
N
N
N
N
Religion
N
N
N
N
Gender
N
N
N
N
N
N
N
N
N
N
N
N
Carers
N
N
N
N
Expiry date: 26/05/14
Item 11
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2.1 In what way does the policy impact on any particular group listed above? Include here what evidence you have collated,
whether there are any gaps and what further information is required.
It does not. The Policy applies universally.
2.2 Adverse Impact - if you have identified potential or real direct or indirect discrimination ? If so, can it be justified (e.g.,
legislation, clinical or social evidence)?
N/A
2.3 Positive Impact - does the policy actively promote equality of opportunity and/or good relations between different groups of
people? Promotes good risk management practice. In doing so it would positively identify as a risk any discriminatory practice
Part Two
N
N
1.8 Is there potential for, or evidence that, the proposed policy will
promote equality of opportunity for all and promote good relations
with different groups?
1.9 Is there public concern (including media, academic, voluntary or
sector specific interest) in the policy area about actual, perceived or
potential discrimination about a particular community?
N
Human
Rights
1.7 From the evidence, does the policy affect or have the potential to
affect individuals or communities differently or disproportionately,
either positively or negatively (including discrimination)?
For each of the Nine Equality Categories ask the question below:
Part One (cont)
Risk Management Strategy EDQ011 Version 6
Sexual
orientation
Pennine Acute Hospitals NHS Trust
Social
Deprivation
Page 142 of 318
EDQ011
Risk Management Strategy EDQ011 Version 6
Date sent to Committee: May 2011
Policy Number:
Directorate
Corporate Nursing
Equality Champion
Vic Crumbleholme
Expiry date: 26/05/14
6 June 2011
Page 22 of 22
Please scan or insert electronic signature
Signed*
Signed*
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Governance Director
Helen Curtis
Date
Designation
Assessors Name
This policy has been assessed as having medium to high impact. Parts 1 and 2 have been completed.
Full impact assessment is necessary.
This policy has been assessed as having low to medium impact. Parts 1 and 2 have been completed.
Full impact assessment is unnecessary.
This policy has been assessed as having no or low equality impact. Part 1 is completed.
Trust Board
Risk Management Strategy
Ratifying Committee:
System):
Policy Title (as it appears on the Document Management
Part Three
Pennine Acute Hospitals NHS Trust
Title of Report
Register of Seals
Executive
Summary
The report details documents sealed between 20 December 2012
and 20 June 2013.
Actions
The Board is asked to note this report
Requested:
Corporate objectives supported by this paper:
All corporate objectives are supported by sound corporate governance
Risks:
None
Public and/or Patient Involvement:
None
Resource Implications:
None
Communication:
None
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
NO
N/A
√
√
√
√
√
√
√
√
√
Gavin Barclay
Assistant Chief Executive
June 2013
[email protected]
Item 12
Name
Job Title
Month and Year
Email
YES
√
Page 143 of 318
THE PENNINE ACUTE HOSPITALS NHS TRUST
Register of Seals
Introduction
The previous report to the Board presented in December 2012 covered the period between
20 June 2012 and 20 December 2012.
Listed below are details of The Pennine Acute Hospitals NHS Trust documents sealed
between 20 December 2012 and 20 June 2013. These documents have been sealed in
accordance with the requirements of section 11 of the Trust’s Standing Orders.
SEAL NO.
227
228
229
230
231
232
DOCUMENT DETAILS
Renewal of Lease for Telecomms mast at North
Manchester General Hospital
Contract documents re refurbishment of existing
Maternity ward to create new Ophthalmology department
at Rochdale Infirmary
Contract document re proposed Rheumatology hub –
Level C at Rochdale Infirmary
Contract document re alterations to Ultrasound
department at The Royal Oldham Hospital
Legal Charge relating to land has been cancelled
regarding Birch Hill Hospital
Employee reference to McKesson
DATE SEALED
10/01/13
10/01/13
10/01/13
10/01/13
21/01/13
07/06/13
Recommendations
The Board is asked to note this report.
Gavin Barclay
Assistant Chief Executive
June 2013
2
Page 144 of 318
Executive
Summary
Actions requested
Annual Trust Security Report 2012/2013
This report provides the Trust Board with an overview of the
current security related projects and achievements for the
year 2012/2013
The Board is asked to note the report.
Corporate Objectives supported by this paper:
1
Improve clinical effectiveness and patient safety
2
Improve the patient experience
4
Workforce
6
Maintain our regulatory obligations
Risks:
Violence and Aggression towards patients and staff. Damage to property. Loss of
Trust assets. Claims against the Trust. Damage to Trust reputation.
Public and/or patient involvement:
Not Applicable
Resource implications:
Staff Training
CCTV improvements
Security Contract
Lone Worker Devices
Communication:
Currently success is communicated in local press, Pennine News, weekly bulletins,
Trust intranet, Trust security awareness week and at variety of meetings throughout
the Trust.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
YES








NO
N/A

John Wilkes
Director of Facilities
June 2013
[email protected]
1
Page 145 of 318
Item 13
Title of Report
Facilities Directorate
Trust Annual Security Report
May 2013
Glynis Jones
Local Security Management Specialist
May 2013
2
Page 146 of 318
Page
1.
Introduction
3
2.
Security Contract
3
3.
Security / Fraud Awareness
3
4.
Incidents
4
5.
Conflict Resolution
5
6.
Prevent
5
7.
Lone Workers
6
8.
CCTV
6
10.
Security Standards
7
11.
Police
7
13.
Summary
8
3
Page 147 of 318
Item 13
Contents
1. Introduction
1.1
This report provides the Trust Board with an overview of security activities at The
Pennine Acute Hospitals NHS Trust in 2012/2013.
1.2
Day to day operational provision of security to the Trust is currently via the Trust
Security Contract with MITIE. This contract is monitored by the Facilities Directorate
and Local Security Management Specialist.
2. Security Contract
2.1
On Sunday 29th April 2012 the Security Contract changed from Securitas, who had
held the contract for seven years to MITIE. The contract is for more hours and with
a lower cost to the Trust than the previous contract. The change over went very
smoothly without any disruption to any services. Managers from MITIE and
Facilities Staff were present on all sites during this critical time.
2.2
Throughout the past 12 months the security contract has continued to run very
smoothly and the set monthly targets have always been met.
2.3
Working with the MITIE over the past 12 months has been very rewarding for the
Trust. As well as providing an excellent man guarding service on all our sites, their
management team both regionally and site based have been helpful, professional
and innovative as well as helping the Trust to make further financial savings.
3. Security/Fraud Awareness
3.1
In October 2012 a joint Security and Fraud Awareness Month was held within the
Trust. Glynis Jones, Local Security Management Specialist (LSMS), and Sue
Smith, Local Counter Fraud Specialist (LCFS), visited each site together, handing
out leaflets, posters and other literature and chatting to staff about security and
fraud issues.
3.2
A total of 286 staff from 162 departments came to the sessions. As this was such a
successful event the LSMS and the LCFS will continue to do joint awareness
sessions during 2013.
3.3
Also over the past 12 months the LSMS and the LCFS have worked closely
together on numerous cases of Fraud, and will continue to do so for the benefit of
the Trust.
4
Page 148 of 318
4.1
Last year a target of 5% was set to reduce physical assaults on staff; this would
have equated to a reduction of approximately 9 assaults. Unfortunately there was
an increase in assaults from 184 in 2011/12 to 255 in 2012/13. This increase is
believed to be the result of an easier to use reporting system and by staff being
encouraged to report everything and not just accept violence as “part of the job”
Below are the recorded physical assaults going back to 2005.
2005 / 2006 – 115 Reported Physical Assaults
2006 / 2007 – 143 Reported Physical Assaults
2007 / 2008 – 186 Reported Physical Assaults
2008 / 2009 – 196 Reported Physical Assaults
2009 / 2010 – 262 Reported Physical Assaults
2010 / 2011 – 211 Reported Physical Assaults
2011 / 2012 – 184 Reported Physical Assaults (135 clinical)
2012 / 2013 – 256 Reported Physical Assaults (175 clinical)
300
250
200
Clinical
150
Non Clinical
100
50
20
05
/2
00
6
20
06
/2
00
7
20
07
/2
00
8
20
08
/2
00
9
20
09
/2
01
0
20
10
/2
01
1
20
11
/2
01
2
20
12
/2
01
3
0
Prior to 2011 assault were no split in to Clinical and non clinical for NHS Protect
4.2
Because of this increase a group has been set up via Listening In Action to look at
how we can reduce assaults, both clinical and non clinical. Along with members of
our own staff, Greater Manchester Police are part of this group.
4.3
Some work has already been completed by the LSMS and statistics have been
broken down to look at the types of incidents, age and sex of perpetrators, times
and dates of when assaults have occurred.
5. Conflict Resolution Training
5.1
Conflict Resolution Training continues to be mandatory for frontline staff, during the
period April 2012 – March 2013 a total of 951 staff received this trainings. The
sessions are currently 5.5 hours long. The training is well received by staff and
there is also an on-line version for staff who are not frontline.
5
Page 149 of 318
Item 13
4. Physical Assaults
5.2
To compliment the Conflict Resolution Physical Intervention training has now recommenced. This training is offered to frontline staff and targets the departments
who are most at risk of violence. This training is not mandatory.
6. Prevent
6.1
PREVENT is a core part of CONTEST which is the national counter terrorism
strategy. The aim of CONTEST is to reduce the risk to the United
Kingdom and its interests overseas from international terrorism, so that
people can go about their lives freely and with confidence.
 The aim of Prevent is to stop people becoming terrorists, or supporting
terrorism, by identifying vulnerable people through the Health Safe Guarding
route, that are being groomed to support terrorist activity or perpetrate
terrorist acts.
 Identified persons will be referred to the appropriate agencies to ensure they
are given appropriate advice and support to mitigate their radicalisation.
.
6.2
There are no specific targets of staff numbers to be trained but the DH and
Home Office has intimated that it is desirable all NHS staff undertake the
Health WRAP Training as part of their safeguarding requirements.
6.3
An online referral system has been developed to assist in a seamless assessment
and referral process of any identified vulnerable person being potentially
radicalised.
6.4
All staff who under take the 1 hour WRAP training will have the session recorded on
ESR by the Education & Training Department.
6.5
Monthly returns are completed by Emergency Planning and sent to Department of
Health. There may be some form of audit next year.
6.6
The models of PAHT training and strategy delivery have been commended by
the Department of Health
7. Lone Workers
7.1
Lone Worker Devices continue to be issued to Trust Staff as needed and we
currently have 234 devises, with approximately 18 months left of the contract.
7.2
The devices, although very good and technically work well, staff are not using them
correctly. Reminders have been sent out as to how they should be used and some
extra training offered.
7.3
The problems seem to be that the devices need to be charged daily and the
majority of staff are not doing this. Further work will be carried out with
staff to make sure they are used correctly.
7.4
Over the next 12 months the LSMS will look at alternative devises that may be
better suited to the needs of our staff.
6
Page 150 of 318
Workshops have been held for staff working out in the community about dealing
with unacceptable behaviour. The LSMS, H & S Advisor and Neighbourhood
police have been involved and the session have been favourably received by staff.
8. CCTV
8.1
The wireless camera system that was purchased and used at Westhulme worked
very well and several people were arrested after breaking into the building. The
police were immediately contacted via the alarm company attached to the wireless
system. Now that Westhulme has been demolished the cameras will be used in
places as and when they are needed. Some training has been complete by Estates
Staff so that the camera’s can be installed by the Trust.
8.2
A pilot scheme using body cameras, worn by the security officers in the A & E
Departments at NMGH and TROH was proving to be very effective, but has had to
be suspended due to some problems between the Trusts wireless system and the
actual body cameras. Once the problem is resolved the pilot will re-commence.
8.3
MITIE have audited all of our security control rooms to look at the feasibility of
centralising them, a business plan is currently being formulated. If this project
should go ahead the four control rooms will be reduced to one and run on a similar
basis to that of the police and local councils. It would lead to a more effective
surveillance system in the Trust and eventually could be used as a finance
generation scheme with other local healthcare providers.
9. Security Standards
9.1
As part of the NHS Standard Contract new Standards for Security Management
comprising of 31 standards across the four strategic areas of work have been
produced:




Strategic Governance (standards 1.1 – 1.5)
Inform and Involve
(standards 2.1 – 2.7)
Prevent and Deter
(standards 3.1 – 3.15)
Hold to Account
(standards 4.1 – 4.4)
9.2
In addition to these standards an Organisational Crime Profile must be completed in
conjunction with the LCFS as well as a Standards Self Review. These documents
form the basis of decision whether the organisation will be assessed in
conjunction with information from Area Security Management Specialist (ASMS) and
other bodies such as the Care Quality Commission and the Health & Safety
Executive.
9.3
NHS Protect are currently delivering some awareness session to Trusts with
regards to these standards and how Trusts will comply them.
7
Page 151 of 318
Item 13
7.4
10. Police
10.1
Working with the police has improved greatly over the past 12 months, especially
with the North Manchester and Oldham Neighbourhood Teams. The LSMS and the
Neighbourhood Police now work together on a regular basis, this is not only useful
to both parties,but also to the community surrounding our hospital sites.
10.2
North Manchester has a dedicated officer who holds a surgery in the restaurant at
NMGH every 2 weeks and is accompanied by the LSMS, the surgeries are open to
staff, visitors and local residents. This visible presence has given staff and public
the opportunity to discuss and issues they may have. There are also regular visits
to make sure that there is a visible police presence when needed to help to deter
crime. Regular meetings also occur with the local Inspector.
10.3
At the Royal Oldham there are regular patrols around the site by PCSOs, who call
on to wards and departments. There are numerous surgeries in the Link Corridor
and monthly meetings with the local Inspector.
11. Summary
11.1
It has been disappointing that physical assaults on staff have risen this year, but
systems are already in place to look at this problem and make improvements for the
coming year. Although there has been a rise in violence this also shows that staff
are now reporting more of what is happening on our wards and departments.
11.2
Standards of security on our sites continues to improve by better use of security
staff, training, awareness and the dedication of staff involved in the safety and
security of the Trust.
8
Page 152 of 318
Emergency Preparedness, Resilience and Response
(EPRR) - Annual Report 2012/13
Executive
Summary
The 2012/13 Annual Report for Pennine Acute Hospitals
NHS Trust Emergency Preparedness, Resilience and
Response marks a successful year for the unit and looks
forward to a new set of objectives for 2013/14 which are
based on the Trust’s corporate objectives and risks
identified nationally and regionally.
Actions
requested
The Trust Board is asked to receive the Annual Report
which has been approved by the Risk Committee.
Corporate Objectives supported by this paper:
Corporate Objective – Patient Safety
To ensure the Trust is sufficiently prepared to deliver services in an
emergency.
Risks:
That the Trust suffers economic and reputational loss in a poor recovery from
a major incident; that the Trust is in breach of DH requirements for EPRR or
that the Trust does not comply with its duties as a category one provider in
statute – the Civil Contingencies Act 2004.
Public and/or patient involvement:
With other category one providers for joint planning for preparedness,
resilience and response.
Resource implications:
none
Communication:
The annual report will be placed on the Trust intranet.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
1
Page 153 of 318
YES
X
X
X
X
X
X
X
X
NO
N/A
X
Item 13
Title of Report
Name
Job Title
Date
Email
John Wilkes
Facilities Executive Director/ Accountable Emergency
Officer
1 June 2013
[email protected]
2
Page 154 of 318
Item 13
Pennine Acute Hospitals NHS Trust
Emergency Preparedness,
Resilience and Response.
Annual Report 2012/13
Page 155 of 318
Emergency Preparedness, Resilience and Response
Annual Report for 2012/13
CONTENTS
Page
Executive Summary……………………………………………………………………3
1. Introduction………………………………………………………………….… …. …..4
2. Organisation…………………………………………………………………….... …...5
3. Emergency Planning……………………………………………………..…...............5
3.1 Major Incident Exercises………………………………………………………....5
3.2 Training…………………………………………………………………………….6
3.3 Telecommunications Exercises (Exercise Poppy)…………………………….7
3.4 Chemical, Biological, Radiological, Nuclear & Explosives (CBRNE)….. ......7
3.5 Lockdown…………………………………………………………………….. …..9
3.6 PREVENT………………………………………………………… ..………… …9
3.7 EPRR Service Development…………………………………………………...10
4. Winter Planning…................................................................................................ .11
5. H1N1 Seasonal Flu…………………………………………………………….….……11
6. Business (Service Continuity)……………………………………………….… ……12
7. Review of Objectives for 2012 / 2013………………………………..……………… 13
8. Objectives for 2013 / 14………………………………………………………………..14
9. Incidents during 2012/13…………………………………………………………........16
Glossary………………………………………………………………………………….17
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Item 13
Emergency Preparedness, Resilience and Response
Executive Summary.
The 2012/13 Annual Report for Pennine Acute Hospitals NHS Trust Emergency
Preparedness, Resilience and Response marks a successful year for the unit and looks
forward to a new set of objectives for 2013/14 which are based on the Trust’s annual
business Plan and risks identified Nationally and regionally.
The Report details the objectives for the unit for 2012/13 – which were all met, including:
•
Having up to date, tested, Major Incident plans and Major Incident burns plans
•
Has trained, competent managers provided with command and control centres
available round the clock to effectively manage a major incident or emergency
•
Has audited, up to date business continuity plans when faced with disruption from
identified risks including: severe weather, pandemic flu, fuel shortage and
industrial action.
The report sets out the key requirements in 2013/14 for the Trust as a category one
provider under the Civil Contingencies Act to ensure that arrangements are in place to
manage incidents and events while maintaining services to patients. NHS England has
placed particular emphasis on the following areas:
•
Comply with category one provider status as described in statute (Civil
Contingencies Act 2004)
•
Comply with EPRR NHS England requirements as detailed in the Emergency
Preparedness Framework 2013.
•
Comply with the NHS England business continuity framework 2013
•
Align with the 2012 International Standard for Business Continuity (ISO 22301)
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1.
INTRODUCTION
1.1
As a category one responder under the Civil Contingencies Act 2004 (CCA 2004)
Pennine Acute Hospitals NHS Trust has a responsibility to ensure local
arrangements are in place for civil protection should an emergency occur. With
other category one responders (i.e. the Ambulance Service, other NHS Acute
Trusts, other emergency services and local authorities) the Trust is required to
provide Emergency Preparedness, Resilience and Response (EPRR), i.e;
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
1.2
Assess the risks of emergencies occurring to inform contingency planning.
Put in place emergency plans.
Put in place service continuity management arrangements.
Put in place arrangements to make information available to the public about
civil protection matters and maintain arrangements to warn inform and
advise the public in the event of an emergency.
Share information with other local responders to enhance co-ordination.
Co-operate with other local responders to enhance co-ordination and
efficiency.
The Trust duties under the act are encompassed within the NHS England
Emergency Preparedness Framework (2013) which states that:
“The NHS needs to be able to plan for and respond to a wide range of
incidents and emergencies that could affect health or patient care. These
could be anything from extreme weather conditions to an infectious disease
outbreak or a major transport accident. This work is referred to in the health
service as ‘emergency preparedness resilience and response’ (EPRR).
Under the Civil Contingencies Act (2004), ‘category one’ responders, must show
that they are working with other responders to assess risks, develop and maintain
plans, share information and co-operate on civil contingency response, and can
manage incidents and events while maintaining services to patients.
NHS organisations must also be able to maintain continuous levels in
key services when faced with disruption from identified local risks such as
severe weather, fuel or supply shortages or industrial action. This is known
as business continuity management.”
1.3
The NHS Resilience and Business Continuity Management requires organisations
implement a process that will ensure effective business continuity and expects all
NHS organisations to prepare, maintain and review service continuity plans to
enable them to maintain critical services for a least seven days.
1.4
NHS England requires all NHS organisations to align themselves with the new
(2012) International Standard for Business Continuity (ISO) 22301 and a recently
issued core standards for business continuity management, to which the Trust
should adhere.
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2.
ORGANISATION
2.1
Emergency Preparedness, Resilience and Response (EPRR) is led by the
Executive Director of Facilities, who Chairs the Trust Resilience Forum. The Trust
Accountable Emergency Officer is responsible for Emergency planning and
business continuity management and is a required appointment by NHS England
in every NHS Trust. The Resilience Forum reports to the Risk Management
Committee of the Trust Board.
2.2
EPRR is made effective through line managers and clinicians participating in the
production of plans for emergencies and regular reviews through a programme of
extensive training, testing and exercising. This process is planned and facilitated
by the Emergency Preparedness Officers
2.3
EPRR has recently been restructured across Greater Manchester. It is expected
that the clinical commissioning groups will monitor compliance with EPRR
standards in the Trust as part of the contracting and standard setting process and
that NHS England will ensure that, through the Greater Manchester Area Team,
Trust compliance with EPRR arrangements.
3.0
EMERGENCY PLANNING
3.1
MAJOR INCIDENT EXERCISES
3.1.1 During 2012 Pennine Acute Hospitals NHS Trust conducted major incident table
top exercises at all four sites as required by the Civil Contingencies Act 2004
(C.C.A.)
(The Royal Oldham Hospital Major Incident Table Top Exercise ‘Whirlwind II’ 2012)
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3.1.2 The new interactive style of delivery of the table top exercises continues to be well
received and has generated significant engagement. This has resulted in good
attendance levels at exercises. The outcomes are recorded and this information is
utilised to update and improve the major incident plans. The Royal Oldham
Hospital and North Manchester General Hospital table top exercises were tested
against a scenario of a Chemical attack by terrorists on an Olympic event day in
Central Manchester
3.1.3 The table top exercises that were conducted at the Rochdale Infirmary and
Fairfield General Hospital used scenarios that highlighted the changes in services,
and the roles of those sites during a major incident, in relation to the Trust service
reconfiguration programme. The table top exercises of 2012 tested the new Burns
Major Incident Plan, Surge (high volumes of casualties) and revised radio channel
management.
3.1.4 All of the PAHT major incident plans were revised in 2012 to take into account
reconfiguration, the revised roles in emergency capacity at Rochdale Infirmary and
Fairfield General Hospital and the adoption of a phased, proportional response in
activating the Major Incident Plan.
3.1.5 All Acute NHS trusts are mandated under the C.C.A. 2004 with conducting a ‘Live’
exercise every three years. Work has begun relative to planning the next live
exercise in 2014
3.1.6 All exercises are subject to a post event debrief and analysis following which the
emergency planning officer compiles a report which is then held on the C.Q.C.
emergency preparedness evidence file. The exercise is an opportunity to review,
revise and amend the MIP and develop future training.
3.2
TRAINING
3.2.1 Support for the Hospital Control Teams has been facilitated by the provision of
dedicated Emergency planning and Service continuity web pages on the Trust
intranet to enable rapid access in the event of an emergency for all teams.
3.2.2 Training for hospital ‘Silver’ level managers has been provided by the Trust EPOs
carrying out Silver Control Room training. These events are intended to orientate
and train managers in their roles during a major incident.
3.2.3 Training session are carried out for the Trust Executive team tasked with running
Trust ‘Gold Control’ and a ‘Gold’ team action card has now been placed on the
Emergency Planning and Service Continuity Web Pages.
3.2.4 Selected PAHT personnel will have training as major incident loggists during 12 /
13.
3.2.5 Emergency Planning and Service Continuity is also covered on the Trust induction
programme. This has been very well received with excellent feedback.
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3.2.6 Specific and auditable training in relation to major incident management and Call
out teams for the A&E departments has begun to be facilitated by the E.P.O.
3.3
TELECOMMUNICATION EXERCISES (EXERCISE POPPY)
3.3.1 The C.C.A. (2004) requires the Trust to test the telecommunications call out
system bi annually for each site. The eight exercises for 2012 were successfully
completed.. The issues and actions were highlighted in post event reports
completed by the Emergency planning Officer (E.P.O.)
3.3.2 These exercises are known as exercise ‘Poppy’. They are normally run 2-3 days
prior to a corresponding sites major incident table top exercise and are facilitated
by the telecommunications team. All on call rota contact numbers and major
incident numbers are tested for that corresponding site.
3.4
Chemical, Biological, Radiological, Nuclear & Explosives / Hazardous
Materials (C.B.R.N.E / HAZMAT)
Members of PAHT Emergency
Departments undertaking
decontamination Training on the
PAHT CBRNE / Hazmat Course
3.4.1 The Trust is obligated under the C.C.A. (2004) to provide a C.B.R.N.E. response
in relation to either an accidental or deliberate release of hazardous substances.
3.4.2 The PAHT C.B.R.N.E. / HAZMAT Faculty has continues to develop and has
proved to be an ideal forum to facilitate a generic response across the Trust. The
departmental C.B.R.N.E. leads are fully aware of their responsibilities and their
departmental managers have provided clinically free time to enable the leads to
execute their duties relative to equipment maintenance and staff training.
3.4.3 To date 82% of A&E staff have completed the two day course. A training manual
has been produced by the EPO to support the course which has been adopted
regionally, nationally and internationally. A new A1 sized aid memoire poster
relative to donning the gas tight Personal Respiratory Protective Suits has also
been produced for the A&E departments..
3.4.4 The training of A&E reception staff continues in relation to being the first point of
contact by a contaminated self presenting patient as does the training of Security
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Emergency Preparedness, Resilience and Response
Annual Report for 2012/13
staff in relation to security management of a CBRNE / Hazmat incident (Project
Shield) These will be ongoing during 2013.
3.4.5 There were three Hazmat incidents in the Trust in 2012.These actual events
reinforced the 2 day training provided to A&E staff. These events replaced “live”
incident training during the year as sanctioned by the GM Resilience Associate
Director.
3.4.6 Although Rochdale Urgenct Care Centre (RUCC) no longer provides a full
C.B.R.N.E. / Hazmat response , the staff continue to be trained via the Trust
course so that they may utilised on other sites during a protracted incident and
facilitate any recognition phase within the RUCC
3.4.7 The first new generation fixed decontamination unit was installed at NMGH
Emergency Department which has dramatically enhanced the decontamination
capability of the hospital. This is the first unit in the North of England of its type
and the bespoke design is based on our organisations operational experiential
responses to incidents and challenges encountered during training exercises.
The unit is specifically designed to enhance the speed of response and also
support daily operational activity by means of facilitating the showering of soiled
patients prior to entering the E.D. (If patient condition allows). Other internal
enhancements mitigate all equality and diversity requirements attached to the
complexities of patient decontamination. The unit has been activated a number of
times since instillation and performed beyond expectations facilitating
departmental continuity and rapid incident recovery
(New generation decontamination system at NMGH E.D)
3.4.8 The inflatable decontamination units, pumps, compressors and mobile lighting etc
currently in use at the Oldham and Bury sites continue to deteriorate as a result of
reaching the end of its life span and a number of risks remain.
3.4.9 It is also noted that the current stock of PRPS suits are due to expire in 2014. The
manufacturers may extend the life of the units by another three years, although
confirmation has not yet been received.
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3.5
Annual Report for 2012/13
LOCKDOWN
3.5.1 Work on the lockdown process continues. Locks have now been installed at all
Trust A&E departments and other access routes will be selected in 2013.
3.6
PREVENT
3.6.1 PREVENT is a core part of CONTEST which is the national counter terrorism
strategy. The aim of CONTEST is to reduce the risk to the United
Kingdom and its interests overseas from international terrorism, so that
people can go about their lives freely and with confidence.
3.6.2
The aim of Prevent is to stop people becoming terrorists, or supporting terrorism,
by identifying vulnerable people through the Health Safe Guarding route, that are
being groomed to support terrorist activity or perpetrate terrorist acts.
Identified persons will be referred to the appropriate agencies to ensure they are
given appropriate advice and support to mitigate their radicalisation.
3.6.3
At the end of November 2012, the Trust Emergency Planning Resilience &
Response Unit was tasked to lead and develop the PAHT PREVENT Strategy.
This process involves training a core of Trust staff to deliver training sessions
known as ‘Health WRAP’s’ (Workshop to Raise Awareness around PREVENT’)
and then ultimately to disseminate to all staff.
(Department of Health representatives Peter Walmersley & Julie Smith with NHS England North PREVENT
representative Jen Yousef pictured with PAHT PREVENT Team Allan Cordwell, David Clements and Glynis Jones)
3.6.4
Compliance in delivering Prevent will be a requirement relative to PAHT securing
future NHS contracts, however, there are no specific targets of staff numbers to
be trained but the DH and Home Office has intimated that it is desirable all NHS
staff undertake the Health WRAP Training as part of their safeguarding
requirements
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Emergency Preparedness, Resilience and Response
3.7
Annual Report for 2012/13
EPRR Service Development
3.7.1 The development of the Trust Emergency management models have been
enhanced by their presentation, and sharing of, at various national and
international conferences during 2012 /2013. These include International
Conference on Preparedness to Emergencies & Disasters in Tel Aviv, Union of
Risk Management for Preventative Medicine (URMPM) World Congress in London
and the National Dutch CBRN Conference in ‘s-Hertogenbosh which included a
tour of the Jereon Bosch Hospital and the Dutch CBRN Academy in Eindhoven
3.7.3 E.P.O. Allan Cordwell attended and critiqued an Israeli national nuclear response
exercise named ‘Operation Black Cloud’ in Hyfa
PAHT EPRRU team member Allan Cordwell with
the Director of the All India Medicine and
Informatics Institute Delhi at IPRED (International
Conference on Preparedness & Response to
Disasters in Tel Aviv
Mr John Saxby welcoming Major W.Broers, Mr
D.Devirers (Dutch Government Operative), Stn
Officer G.O’Neil GMF&RS, Mr S.Dunn Rolls Royce
Nuclear Submarines to PAHT. Pictured with Allan
Cordwell EPO, M.Lock HCA, T.Norman C.N.
(PAHT CBRNE / Hazmat Tactical Training Unit)
3.7.4 Representatives of the Dutch Government and Military, along with representatives
from Rolls Royce Nuclear Submarines attended the PAHT two day CBRNE /
Hazmat Course and also toured various PAHT Emergency Departments with a
view to adopting elements of PAHT emergency management models.
3.7.5 The team has recently added CBRNE / Hazmat video training footage that was
professionally filmed at FGH by Brickwall Films Ltd to the web pages to enhance
training.
3.7.6 The team continues to support requests for assistance and advice relative to
CBRNE / Hazmat from other acute hospitals across the U.K. and Europe. Some
mutual cross working with the United States Centre for Disease Control (CDC)
has also been undertaken.
3.7.9 The team continues to lead and represent the Greater Manchester Acutes Group
relative to CBRNE / Hazmat regionally, nationally and internationally and they
won the ‘Frontline Team of the Award’ in the Facilities Division in 2012
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Annual Report for 2012/13
Mr John Wilkes, Director of
Facilities, Presenting
‘Front Line Team of the
Year Award’ for the
Facilities Division to PAHT
E.P.R.R.U. members Mr
David Clements & Mr Allan
Cordwell
4.0
WINTER PLANNING
4.1
The winter of 2012/13 was initially mild but from January through to February
there were a number of episodes of heavy snowfall requiring emergency
preparedness and March was particularly cold – the second coldest since 1910 –
but without precipitation.
4.2
A key lesson from the winter was the value in telephone conferencing of on call
managers to prepare and communicate in advance of and during severe weather
as well as using the normal communication channels. Close coordination with
PCTs and Local Authorities were a feature of planning for adverse weather.
4.3
The Trust has had a very successful winter operationally with the key targets for
service capacity for the emergency admission of patients being met. The Trust
arrangements for managing surges in patient admissions whether it be through
winter weather, Bank Holiday contractions of primary and community services or
any other reason are now integrated in capacity plans, emergency planning and
training for on call managers.
5.0
SEASONAL FLU
5.1
The seasonal flu staff vaccination campaign was the best ever for the Trust at
60% of staff being vaccinated. The Trust flu fighter team were shortlisted to the
top five in the National award for the best flu fighter team. Extensive publicity, a
wide range of opportunities for vaccination for staff - particularly visits to wards
and departments helped in reaching staff and obtaining a high uptake.
5.2
Detailed and regular information on the progress of influenza and the Trust
response was provided to Trust Executive Directors and to NHS North. The
pattern of admission of patients this winter was 91 hospital admissions with
confirmed influenza across the Trust but with only 6 requiring intensive care.
Unlike the previous three years the Trust did not have young patients dying of
influenza. There was no national flu epidemic this year but it does remain both
Nationally and for Greater Manchester the single greatest risk the community
faces in terms of likelihood and impact and so extensive preparations continue to
made in anticipation of a possible flu pandemic.
11
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Emergency Preparedness, Resilience and Response
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6.0
BUSINESS (SERVICE) CONTINUITY
6.1
Business continuity is about ensuring Trust services are maintained when faced
with a disruption from identified local risks. The Trust had its business continuity
(previously known as service continuity) planning externally audited this year and
passed. Some minor modifications to documents were suggested by the
Resilience Team auditors from NHS Greater Manchester and these have been
approved by the Resilience Forum and adopted.
6.2
Continuity planning methodology has been revised leading to a simplified
approach which is being rolled out across wards and departments. The aim is to
have a smaller number of documents on the EPRR website and to rely on the
training of managers to achieve business continuity in an emergency as the nature
and extent of individual incidents cannot be planned for in detail. Key areas for
Trust wide plans remain the business continuity strategy and specific plans for
pandemic flu, severe weather, and impact analysis of loss of buildings, systems,
staff or suppliers in maintaining services.
6.3
NHS England has required Trusts for 2013 to align their business continuity
planning with the new International Standard ISO 22301. Associated with this
NHS England issued in March 2013, a set of core standards in EPRR with which
the Trust must conform. A number of other changes have been required including
the appointment of an Executive lead in Emergency Preparedness who will
provide quarterly reports to the Trust Board on the subject.
6.4
The reforms in Business Continuity required by NHS England require the Trust to
produce a Risk Register of possible local emergencies that could severely impact
services which should reflect national and Greater Manchester priorities. These
will be developed during 2013 and are likely to include the following risks:
•
•
•
•
•
•
•
•
•
6.5
Pandemic flu/infectious disease
Severe weather
IT failure
Fuel shortage
Industrial action
Loss of workplace
Staff shortage
Terrorist attack
Chemical contamination
The viability of the business continuity programme can only be determined through
testing, training and improvements. There is an annual programme of business
continuity tests at departmental level with revisions to plans to give assurance. In
addition to the testing there were live incidents in 2012/13 in relation to severe
weather, industrial action, threatened fuel shortage, chemical contamination and
surge planning for winter and Bank holidays.
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7.0
REVIEW OF OBJECTIVES FOR 2012/13
No.
SMART ( Specific, Measurable,
Achievable, Realistic, Time)
Objectives
Implement training programme for
loggists, poppy exercises, major
incident plan table tops, CBRNE
training, induction and students.
Indicator ( how the objective
will be measured) and by
when
Programme implemented on
time as scheduled
Training for night managers in
command and control and use of
control rooms using web site
guidance - SCARS
Training for Silver and Gold
commanders in control rooms
settings.
Programme implemented on
times scheduled
Review and modify major incident
plans at each Trust hospital to
accommodate a proportional
response to emergencies.
Continue table top exercises for
continuity plans
MIPs to be modified and
completed by March 2013
6
Complete surge planning for mass
causalities and mass fatalities before
the Olympics 2012
Complete by June 2012 and
testing thereafter as
programmed.
7
Work with the local resilience for a at
PCT, LA and NHS Greater
Manchester Resilience team l
8
Update plans for the five highest
emergency risks for Greater
Manchester as identified in the
community risk assessment being
the Olympics, Fuel Shortage, Flu,
Flood and Terrorism
Update continuity plans and prepare
the Trust for Easter extended break,
summer heat wave and winter.
Meet targets in areas of joint
interest. Ensure integrated
emergency planning and meet
new DH guidance.
Plans updated by 2012
1
2
3
4
5
9
10
Comply with 2012/13 operating
framework for emergency planning
which stipulates the following areas.
a. Testing and review of emergency
preparedness, readiness and
Programme implemented on
times scheduled
As programmed
Updated plans agreed with line
managers one month in
advance of these events
Meet the requirements of the
operating framework 2012/13
13
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RAG Status
/ Comments
Green
Engagement &
uptake
increasing year
on year
Green
Support for
OOH staff
Green
Key role for
Command &
Control
Managers
Green
Now on Trust
Intranet
Green
Best Year to
date for
departmental
engagement
Green
M.I.P. table
Tops included
Olympic
scenario
Green
Major
restructuring
post April 2013
Green
Plans updated
Green
Trust
operational
targets met
Green
Response
required for all
risks listed in
10b during the
Item 13
Emergency Preparedness, Resilience and Response
Emergency Preparedness, Resilience and Response
11
12
14
15
response as required by the Civil
Contingencies Act 2004
b. Be prepared to respond safely
and effectively to full spectrum of
threats, hazards and disruptive
events including.
• Pandemic flu
• Mass casualties
• Potential terrorist incidents
• Severe weather
• Chemical, Biological,
Radiological and Nuclear
incidents
• Fuel supply and disruption
• Public health incidents
• The 2012 Olympic and Para
Olympic games.
Install a first fixed decontamination
unit at NMGH and commission and
train clinical staff in its application.
Develop detailed plans for phase 2
at TROH.
Following revision of continuity
planning methodology rolling out
simplified approach across key
services
Complete whole hospital evacuation
strategy and train silver control
managers in its application
Continuing development of the
PERF (Pennine Emergency
Response Faculty) Consolidate and
formalise Merit (clinical flying squad)
response and further develop
CBRNE and Hazmat auditable
training.
Annual Report for 2012/13
year
NMGH unit commissioned and
training completed by June
2012
Green
First in North of
England
March 2013
Green
Methodology
adopted in table
top exercises
Green
Adopted in MIP
scenarios
Green
Continues to
develop
March 2013
Ongoing
Legend: Green = Objective met to date, Amber = objective not yet met but
expected to meet target, Red = objective not met
8.0
No.
1.
OBJECTIVES FOR 2013 / 14
SMART ( Specific,
Measurable,
Achievable,
Realistic, Time)
Objectives
Implement training
programme for
loggists, poppy
exercises, major
incident plan table
tops, CBRNE training,
induction and
students.
Indicator ( how the
objective will be
measured) and by
when
Programme
implemented on time as
scheduled – see
appendix 3.
Adopt new table top
scenarios in evacuation
and include business
continuity testing.
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RAG
Status
Annual Report for 2012/13
2
Training managers
in and out of hours
in command and
control
Programme
implemented on time
as scheduled – see
appendix 3
3
Review and modify
major incident plans at
each Trust hospital
following table top
exercises.
Continuing
development of the
PERF (Pennine
Emergency Response
Faculty) Consolidate
and formalise Merit
(clinical flying squad)
response and further
develop CBRNE and
Hazmat auditable
training.
MIPs to be modified
and completed by
March 2014 following
review of exercise
outcomes.
Ongoing
5
Enhance PAHT
corporate reputation
at Regional, national
and International
EPRR events
6
Develop &
implement the
PAHT PREVENT
project as tasked by
DH & Home Office
Develop and update
surge plans and
preparedness to
support operational
response at periods
of high demand
Attending meetings
& conferences to
promote the PAHT
EPRRU integrated
models of
emergency
management
Delivery of Health
WRAP (Workshop
to Raise Awareness
around PREVENT)
4
7
8
9
Through the
application of the
EPRR cycle deliver
Trust corporate
objectives for:
Quality improvement
Support corporate
objective for
strategy
development to
In conjunction with
divisions provide
plans for Winter
preparedness, BH
preparedness and
other periods of
pressure beyond
normal escalation
levels
Patient safety is
enhanced through
effective EPRRU
activity – see 1- 4
above
Compliance with
Civil Contingencies
Act 2004 & NHS
England EPRR
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Annual Report for 2012/13
create a self
determining and
autonomous trust
10
11
12
13
14
Framework 2013.
Demonstrated as
audited by
commissioners
Support corporate
Demonstrable rapid
objective in
recovery from
productivity through incidents and
assuring business
emergencies to
continuity
deliver patient care
and Trust income
stream
Develop and
Respond to local
respond to a Trust
challenges and risks
risk register for
and national and
EPRR by July 2013 regional perceived
priorities
Align Trust with new Implement NHS
ISO 22301 Business England framework
Continuity standard during 2013
Implement EPRR
Provide programme
core standards
of work through LRF
issued by NHS
to achieve full
England in March
compliance by
2013
March 2014
Meet NHS England
Report progress
EPRR framework as through the
issued in March
Accountable
2013
Emergency Officer –
Executive Director
of Facilities –
quarterly report
9.0.
SIGNIFICANT INCIDENTS IN 2012/13
1.
Severe weather in the winter 2012/13– see section 4 above
2.
The Major Incident Plans and/or the Business Continuity Plans of the Trust were
activated on 6 occasions in 2012. (other than for severe weather)
1. March 2012
2. June 2012
3. August 2012
4. November 2012
5. December 2012
6. February 2013
3.
fuel tanker drivers threatened industrial action.
BMA industrial day of action.
Lime contaminated self presenter at Rochdale Infirmary
Oldham gas explosion
NMGH A&E chemical contamination - chlorine
TROH A&E chemical contamination - toluene
2012 was the Olympic Year with Manchester fielding some of the football matches
and the Trust was involved with the extensive preparedness for a potential
terrorist incident.
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GLOSSARY
Fallen Shield: The deliberate or accidental ingress of a hazardous
Substance / agent into the Emergency Department/Hospital.
Accountable Emergency Officer: also known as Director of EPRR. Leads on EPRR
and provides assurance to the Trust Board on EPRR strategies, systems, training,
policies and procedures.
BS NHS 25999: the British Standards Institute, in conjunction with the NHS, has tailored
their Business Continuity Standard to include specific reference to how NHS
organizations should achieve resilience. Released in November 2009. Replaced in 2012
with ISO 22301.
Business Continuity: also known within the NHS as Service Continuity. A method of
improving service resilience to ensure continuous delivery of healthcare when a service
is faced with disruption. Key method is to draw up plans to maintain critical services for at
least 7 days following a range of potential disruptive events and testing and reviewing the
plans. Arranging plans to provide rapid recovery from a disruptive incident.
Business impact tool: The process of analysing key functions in a ward or department
and the effect that a service disruption might have on them. Leads to developing plans
and resources to maintain key services through an incident.
Care Quality Commission (CQC): The NHS independent regulator. Responsible for the
registration of NHS Trusts, inspecting services and the attribution of performance ratings
for essential standards of quality and patient safety.
- Core Standard C24. One of the standards set by the CQC – which sets standards for
Emergency Preparedness.
CBRNE: An incident involving either an accidental or deliberate release of a hazardous
substance whether, Chemical, Biological, Radioactive, Nuclear or Explosive.
Category One Responder: The Civil Contingencies Act identifies category one
responders as having a primary role in response to an incident and this category includes
the Emergency Services, NHS Trusts and Local Authorities.
Civil contingencies Act 2004: A new framework for civil protection at local level (part 1)
which also sets out emergency powers the government may grant to facilitate the
response to an emergency. (part 2)
Core Standards for EPRR: NHS England released core standards for EPRR in 2013, to
which the Trust must comply. Listed as appendix 2.
EPO: Emergency Preparedness Officer. Responsible for anticipating, planning,
exercising and facilitating the Trust’s response to and recovery from an emergency.
17
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Item 13
Emergency Preparedness, Resilience and Response
Emergency Preparedness, Resilience and Response
Annual Report for 2012/13
EPRR: Emergency Preparedness, Resilience and Response. – the process for planning
and responding to a wide range of incidents and emergencies that could impact on the
Trust and patient care.
Exercise Poppy: Regular unannounced exercise of switchboard and response times
from key staff in a test of the major incident call out sequence.
Gold control: The central command and control in an incident – based at Trust HQ. Has
a strategic overview. The tactical coordination and control centre is at Hospital level known as silver control and the operational forward control is usually the casualty
receiving area in a major incident - Accident and Emergency – known as bronze control.
HERG: Health Economy Resilience Group
HAZMAT : Hazardous Materials – usually the management of patients accidentally
contaminated by these as opposed to a deliberate act of terrorism.
ISO 2301: 2012 Standard for Business Continuity
LSMS: Local Security Manager Specialist. Responsible for the operational management
of Trust security.
LHRP: Local Health Resilience Partnership - a strategic forum for health organisations.
Supports LRF- chaired by Area Team director and nominated Director of Public Health.
LRF: Local Resilience Forum – covers the police area – Greater Manchester Police in
our case and includes representatives from all category 1 emergency providers. Usually
chaired by the police and responsible for integrated multi agency emergency planning for
the area.
Major Incident: Any emergency that requires the implementation of special
arrangements by one or more of the Emergency Services and/or the NHS. Usually for an
Acute Trust a response to the Ambulance Service of notification of casualties following
an external major incident or a response to a major incident either on Trust premises or
impacting on Trust staff or systems.
MERIT: The medical emergency response incident team (MERIT)
This team usually consists of a doctor and a nurse or two of each. Ideally, they should
not come from the hospital that will be receiving casualties. They will arrive at the scene
of the emergency and provide medical care for patients requiring at the scene They will
arrive equipped with kit bags, containing limited airway and surgical equipment.
MIP: – Major Incident Plan.
Required for each Trust hospital site. Provides guidance and instruction to staff
responding to an activation of the major incident plan for the hospital site in an
emergency situation.
National resilience extranet: A recently developed but not yet fully implemented
National alert and comms system.
18
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Annual Report for 2012/13
PPE: Personal Protective Equipment
PERF: Pennine Emergency Response Faculty
Project Argus: The National Counter Terrorism Security Office is a police unit which
provides a three hour free training course on raising awareness and giving advice on the
terrorism threat. The course is known as project Argus and includes the training of NHS
staff.
Resilience: ability of an organization to resist the effects of an incident
Resilience Forum and Committees: The formal committees both within the Trust and
across the public sector bodies in each Borough set up to manage the emergency
planning and business continuity processes.
Risk register: Log of the risks that threaten the organization’s success in achieving its
goals. These are quantified, ranked and where possible, mitigated.
Service Continuity: See Business Continuity
Service impact assessment: See Business impact tool
Silver Control: See Gold Control
Table top exercise: To exercise and rehearse key staff on an incident scenario.
Required to be carried out annually in each hospital. The exercises are recorded and
reviewed.
19
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Item 13
Emergency Preparedness, Resilience and Response
Title of Report
Research & Development Annual Report 2012/13
Executive
The report outlines the performance of Research &
Summary
Development between April 2012 – March 2013
Actions
The Board is asked to note the report
requested
Corporate Objectives supported by this paper:
This report does not directly support the corporate objectives
Risks: Not Applicable to this report
Public and/or patient involvement:
Public and patients have not been involved in the production of this report
Resource implications:
There are no resource implications as a direct consequence of this report
Communication:
The R&D committee communicates its work through the Clinical Governance
and Quality Committee
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
YES
√
√
√
√
√
√
√
√
√
√
Dr. Steve Woby
Head of Research and Development
4 June 2013
[email protected]
Page 174 of 318
NO
N/A
Item 13
Agenda Item:
Research & Development
Annual Report
April 2012-March 2013
Dr. Steve Woby
Head of Research & Development
01 June 2013
1
Page 175 of 318
Page Number
Section 1
Introduction
3
Section 2
Structure of the Research & Development Department
3
Research & Development Committee
4
Section 3
Principal Research & Development Objectives for 2012/13
5
Section 4
Recruitment into NIHR CRN Studies
7
Section 5
Cancer Research
11
Section 6
NIHR CRN Commercially funded trials
12
Section 7
Other Research & Development Achievements
14
Section 8
Funding Allocation from the GMCLRN
15
Section 9
Objectives for 2013/14
16
Section 10
Conclusion
16
Section 11
Appendix
17
2.2
List of Figures
Fig. 1 Organisational Structure of the Research & Development Department
4
Fig. 2 Recruitment into NIHR CRN Studies by Trust (2012/13)
8
Fig. 3 Number of Patients recruited to studies by Speciality Group (2012/13)
9
Fig. 4 Total number of NIHR studies by Speciality Group (2012/13)
10
Fig. 5 PAHNT’s NIHR CRN Activity by Study Design Type (2012/13)
11
Fig. 6 Breakdown of Actively Recruiting Studies at PAHNT (2012/13)
12
Fig. 7 Commercial Research Activity during 2012/13
13
List of Tables
Table 1
Research & Development Objectives for 2012/13
6
Table 2
Breakdown of PAHNT’s Funding Allocation from the GMCLRN
15
Table 3
PAHNT’s Recruitment per Specific NIHR CRN Study
17
2
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Item 13
CONTENTS
1.0 SECTION 1:
INTRODUCTION
1.1 This annual report provides details of the Research and Development (R&D)
activity that has occurred within The Pennine Acute Hospitals NHS Trust
(PAHNT) between 1st April 2012 and 31st March 2013.
1.2 The Trust is a partner in the National Institute for Health Clinical Research
Network (NIHR CRN) via its contract with the Greater Manchester
Comprehensive Local Research Network (GMCLRN) and supports the seven
National Institute for Health Research (NIHR) Clinical Research Networks. The
Trust supports a range of research projects including NIHR CRN commercial,
NIHR CRN non-commercial, “own account” and student projects. This report
focuses on the Trust’s NIHR CRN research activity.
1.3 The NIHR Clinical Research Networks are:
•
•
•
•
•
•
National Cancer Research Network (NCRN)
Stroke Research Network (SRN)
Mental Health Research Network (MHRN)
Diabetes Research Network (DRN)
Medicines for Children Research Network (MCRN)
Dementias and Neurodegenerative Diseases Research Network (DeNDRoN)
A Primary Care Research Network focuses on health areas for which primary
care has particular responsibility, including disease prevention, health
promotion, screening, early diagnosis, and the clinical management of long
term conditions.
2.0 SECTION 2:
2.1
STRUCTURE OF THE RESEARCH & DEVELOPMENT
DEPARTMENT
The current organisation structure of the R&D Department is summarised in
Figure 1 (Page 4).
3
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Organisation Structure of the Research & Development
Department
Dr. Tina Kenny
(Trust R&D Lead)
Dr .Steve Woby
(Head of R&D)
Katie Doyle
(R&D Facilitator)
Charlotte Lever
(R&D Monitor)
6 x Senior
Research Nurse
Kataryna Moklak
12 x Research
Nurses
(R&D Co-ordinator)
Margaret Tyrrell
(R&D
Administrator)
2.2
3 Research
Administrators
Pennine Acute Research & Development Committee
2.2.1 The PAHNT R&D Committee meets quarterly and is chaired by Dr. Tina
Kenny (Trust R&D Lead).
2.2.2 The R&D Committee reports to the Clinical Governance and Quality
Committee, which in turn reports to the Trust Board. The aim of the R&D
Committee is to increase the number of high quality NIHR CRN studies being
undertaken within the Trust and ensure that all research being conducted
complies with professional and ethical standards, as specified in the
Department of Health Research Governance Framework for Health and Social
Care, The Medicines for Human Use (Clinical Trials) Regulations and other
current guidelines. Membership of the Committee includes representatives
from R&D, Infectious Diseases, Diabetes, Stroke, Dementia and
Neurodegenerative Diseases, Paediatrics, Pharmacy, Finance and Library
Services.
4
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Item 13
Figure 1.
3.0 SECTION 3:
PRINCIPAL RESEARCH & DEVELOPMENTS OBJECTIVES
FOR 2012-2013
3.1 The R&D Department had a number of objectives for 2012-13. These objectives
are detailed below:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
Exceed GMCCRN target of recruiting 10% of new cancer patients into a
research study (primary recruitment).
Proactively liaise with the Greater Manchester Comprehensive Local
Research Network to ensure that the Trust maintains existing levels of
R&D infrastructure support.
Increase recruitment into paediatric NIHR CRN studies by 50%
Recruit at least 1 patient into a respiratory NIHR CRN study
Increase recruitment into cardiology NIHR CRN studies by 50%
Increase by 10% the number of NIHR CRN portfolio studies being hosted
by the Trust.
Develop and implement a system for recording NIHR CRN recruitment
metrics (e.g., 70 day target, recruitment to time and target)
Increase by 10% the number of NIHR CRN commercial trials actively
recruiting across the Trust.
Ensure that the Trust achieves its NIHR CRN recruitment target set by the
GMCLRN.
Seek to achieve the GMCCRN target of recruiting 7.5% of new cancer
patients into a RCT.
Table 1 (page 6) clearly highlights whether the above objectives were achieved.
However, a more detailed account of the Trusts R&D performance in relation to
each of the above objectives is provided in Sections 4-7.
5
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6
Objective for 2012/13
i.
Exceed GMCCRN target of recruiting 10% of new cancer patients into a research
study (primary recruitment).
ii.
Proactively liaise with the Greater Manchester Comprehensive Local Research
Network to ensure that the Trust maintains existing levels of R&D infrastructure
support.
iii.
Increase recruitment into paediatric NIHR CRN studies by 50%
iv.
Recruitment at least 1 patient into a respiratory NIHR CRN study
v.
Increase recruitment into cardiology NIHR CRN studies by 50%
vi.
Increase by 10% the number of NIHR CRN portfolio studies being hosted by the
Trust.
vii.
Develop and implement a system for recording NIHR CRN recruitment metrics (e.g.,
70 day target, recruitment to time and target)
viii.
Increase by 10% the number of NIHR CRN commercial trials actively recruiting
across the Trust.
ix.
Ensure that the Trust achieves its NIHR CRN recruitment target set by the
GMCLRN.
x.
Seek to achieve the GMCCRN target of recruiting 7.5% of new cancer patients into a
RCT.
Table 1. Research & Development Objectives for 2012/13
Item 13
NOT ACHIEVED – increased by
5%. See section 6 for further info.
NOT ACHIEVED – see section
4.1 for further info.
NOT ACHIEVED – see section
5.1.1 for further info.
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
Status (Achieved/Not Achieved)
ACHIEVED
4.0 SECTION 4:
RECRUITMENT INTO NIHR CRN STUDIES
4.1 Figure 2 (page 8) shows the total number of patients recruited into NIHR CRN
studies by each Trust included within the GMCLRN. The GMCLRN set PAHNT
a target of recruiting 1900 patients, which was based on our projected level of
recruitment for the year. Our total level of recruitment for 2012/13 was 1525
patients, which is slightly lower than the target set by the GMCLRN. However, it
should be noted that one of our high recruiting cancer studies was unexpectedly
suspended during 2012/13. We expected to recruit in excess of 500 patients
into this study and therefore the fact that this study was temporarily suspended
had a notable impact on our total recruitment for 2012/13. That we recruited
over 1500 patients is an impressive level of participation and highlights the
Trust’s commitment to supporting high quality studies, helping to improve patient
outcomes and experience across the Trust.
4.2 Figure 3 (page 9) shows PAHNT’s NIHR CRN recruitment activity in relation to
Local Speciality Group (LSG). A notable proportion of patients were recruited
into studies within the Cancer (26%) and Dementia and Neurodegenerative
themes (22%). Recruitment into Dementia and Neurodegenerative studies
increased by 645% in comparison to 2011/12. Three areas were specifically
identified for development during 2012/13; namely, paediatrics, cardiology and
respiratory. Recruitment into paediatric studies improved considerably in
2012/13. Indeed, 170 children and/or their parents (Paediatrics and Meds for
Children) were recruited into high quality studies, which reflects a 2329%
increase compared to last year. Furthermore, the Trust was the second largest
recruiter of children into Medicines for Children Network (MCRN) research trials
in the whole of Greater Manchester, Lancashire and South Cumbria.
Recruitment into cardiovascular studies increased by 1193% and 4 patients
were recruited into respiratory studies. The specific recruitment figures in
relation to each of the NIHR CRN studies open within PAHNT is documented in
Table 3 (Refer to Appendix, page 18).
7
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8
Figure 2. Recruitment into NIHR CRN Studies by Trust (2012/13)
Item 13
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9
Figure 3. Number of Patients recruited to studies by Speciality Group (2012/13)
4.3
Figure 4 (above) indicates that the Trust has NIHR CRN activity across 19
Speciality Groups. This represents an improvement on last year when the
Trust had activity across 18 Local Speciality Groups. Furthermore, the Trust
recruited patients into 108 NIHR CRN studies during 2012/13. This reflects a
26% increase on 2011/12 when the Trust recruited patients into 86 NIHR
CRN studies
4.4
Figure 5 (page 11) highlights PAHNT’s NIHR CRN activity by study design.
Forty nine percent of studies being conducted within the Trust are
interventional studies, which are also known as Randomised Controlled Trials
(RCTs). RCTs are used to test the effectiveness of a new medication or a new
therapeutic procedure. Individuals are assigned randomly to a treatment
group (experimental therapy) and a control group (placebo or standard
therapy) and the outcomes are compared. RCTs are the most accepted
scientific method of determining the benefit of a drug or a therapeutic
procedure. The high number of RCTs being conducted within the Trust
highlights the Trust’s commitment to supporting the highest quality NIHR CRN
studies.
10
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Item 13
Figure 4. Total number of NIHR studies by Speciality Group (2012/13)
Figure 5. PAHNT’s NIHR CRN Activity by Study Design Type (2012/13)
5.0 SECTION 5:
CANCER RESEARCH
5.1 RECRUITMENT INTO NCRN CANCER RANDOMISED CONTROLLED TRIALS
(RCTs) [GMCCRN TARGET = 7.5%]
5.1.1 The Greater Manchester and Cheshire Cancer Research Network (GMCCRN)
sets each Trust a target of recruiting 7.5% of new cancer admissions into
RCTs. The Trust recruited 5.3% of newly diagnosed patients into RCTs, thus
meaning that we did not achieve the 7.5% target set by the GMCCRN. There
has been a well documented reduction in the number of high recruiting cancer
RCTs during 2012/13, which has resulted in 55% of Trusts in the GMCCRN
not achieving the 7.5% target this year. However, despite not achieving the
GMCCRN target of 7.5%, it is noteworthy that the Trust recruited 91 patients
into cancer RCTs, thus making the Trust the fourth largest recruiter of patients
into cancer RCTs across the whole of Greater Manchester and Cheshire.
5.5 RECRUITMENT INTO NCRN CANCER STUDIES (PRIMARY RECRUITMENT)
[GMCCRN TARGET = 10%]
5.5.1 The GMCCRN sets each Trust a target of recruiting 10% of new cancer
11
Page 185 of 318
5.5.2 The Trust achieved 16.9% for primary recruitment in 2012/13. Indeed, the
Trust recruited 287 patients into cancer studies (the recruitment figure
presented in Figure 4 is higher because the GMCCRN figures only include
recruitment from certain cancer studies), thus making PAHNT the fourth
largest recruiter of patients into NIHR CRN Cancer trials within the GMCCRN.
This level of participation is extremely impressive and highlights that the Trust
places a high priority on ensuring that patients are provided with an
opportunity to participate in the highest quality cancer research studies. This
is the fourth consecutive year that the Trust has exceeded the primary
recruitment target set by the GMCCRN.
6.0 SECTION 6:
6.1
NIHR CRN COMMERCIALLY FUNDED TRIALS
Patients were recruited into 108 different NIHR CRN studies during 2012/13.
Twenty two percent of these studies were commercially funded trials (see
Figure 6). It can be seen from Figure 7 (page 113) that PAHTs primary areas
of commercial research activity in 2012/13 were in the Oral and
Gastrointestinal, Diabetes, Infection, Dementias and Neurodegenerative, and
Cancer speciality groups. It is particularly noteworthy that the Trust has NIHR
CRN commercial activity across 9 speciality groups. The Trust set an
ambitious target of increasing our number of actively recruiting NIHR CRN
commercial trials by 10% during 2012/13. The Trust opened 15 new NIHR
commercial trials this year but due to the high number of NIHR CRN
commercial studies that closed to recruitment, our overall number of actively
recruiting commercial activity trials increased by 5%. The fact that we
opened 15 new NIHR CRN commercial trials is impressive.
Figure 6. Breakdown of Actively Recruiting Studies at PAHNT (2012/13)
12
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Item 13
admissions into NIHR CRN cancer studies (referred to as ‘primary
recruitment’). Considerable effort was invested throughout the year to ensure
that the Trust achieved the 10% GMCCRN target.
Page 187 of 318
Figure 7. Commercial Research Activity during 2012/13
13
SECTION 7: Other Research & Development Achievements
7.1
Progressive Research Culture Health Service Journal
Awards 2012
Item 13
7.0
The Trust was highly commended in a prestigious national award for the work it has
done to develop clinical research activity across the organisation. The R&D team
were shortlisted for the HSJ award which recognises the importance of research in
developing better patient care. 120 Trusts entered the progressive culture award and
PAHNT made it to the final eight recognised organisations, and was then rewarded
with a highly commended recognition. Dr Jonathan Sheffield OBE, Chief Executive
of the National Institute for Health Research Clinical Research Network (NIHR CRN)
said: “It shows what can be done with a committed and driven Board. The Trust has
made excellent progress which will undoubtedly further embed into their clinical
services over time.”
7.2 Greater Manchester Clinical Research Awards 2013
The first Greater Manchester Clinical Research Awards 2013 were
held to celebrate the region's excellence in clinical research. The
ceremony, held in Manchester city centre, saw individuals and teams
awarded for their clinical research efforts across nine different
categories. Chief Executive of the NIHR CRN Dr Jonathan Sheffield
OBE, made a guest appearance to open the ceremony and present a
number of the awards. The Trust had 8 finalists across 7 of the 9
categories, which was more than any other Trust in Greater Manchester. Trust staff
were named as winners in 3 categories and runners-up in five categories, which was
an extremely impressive achievement.
Trust staff celebrating
their recognition at the
Greater Manchester
Clinical Research
Awards.
14
Page 188 of 318
8.0 SECTION 8:
8.1
Funding received from the Greater Manchester
Comprehensive Local Research Network (GMCLRN) and the
Greater Manchester and Cheshire Cancer Research
Network (GMCCRN)
In 2012/13, PAHNT’s total funding from the GMCLRN totalled £1,136,463. A
breakdown of PAHNTs allocation is provided in Table 2.
Table 2. Breakdown of PAHNTs Funding Allocation from the GMCLRN &
GMCCRN
ALLOCATION (£)
CLINICAL STAFF
Diabetes – 2.0 PA
Diabetes – 2.0 WTE Band 7 Research Nurse
Generic Band 7 Research Nurse
Infectious Diseases – 4.0 PA
Cardiovascular – 2.0 PA
Cancer – 4.0 WTE Band 6 Research Nurse
Cancer – 2.5 WTE Band 7 Research Nurse
Infectious Diseases – 1.0 WTE Band 7 Research
Nurse
Infectious Diseases – 2.0 WTE Band 6 Research
Nurse
Infectious Diseases – 0.75 WTE Band 3 CTA
Rheumatology – 1.0 PA
Stroke – 1.0 PA
Generic – 1.0 WTE Band 6 Research Nurse
Respiratory – 1.0 PA
Cancer – 0.5 WTE Band 4 CTA
Paediatrics – 0.65 WTE Band 6 Research Nurse
Exec Committee – 1.0 PA
24,000
100,634
37,840
48,000
24,000
138,489
121,160
49,331
69,288
15,900
12,000
12,000
30,844
12,000
65,400
25,000
12,000
KEY SERVICE SUPPORT
Pharmacy
Pathology
Radiology
148,235
21,945
15,000
SERVICE SUPPORT
Service Support
73,397
RESEARCH MANAGEMENT & GOVERNANCE
RM&G
80,000
TOTAL ALLOCATION
15
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1,136,463
Principal Objectives for 2013/14
9.1 Research & Development has a number of objectives for 20013/14. These
objectives are detailed below:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
Ensure that the Trust achieves its NIHR CRN recruitment target set by the
GMCLRN.
Seek to achieve the GMCCRN target of recruiting 7.5% of new cancer
patients into a RCT.
Exceed GMCCRN target of recruiting 10% of new cancer patients into a
research study (primary recruitment).
Proactively liaise with the Greater Manchester Comprehensive Local
Research Network to ensure that the Trust receives appropriate levels of
funding to maintain existing levels of R&D infrastructure support.
Implement R&D SOPs & Policies.
Update and further develop R&D Strategy.
Increase by 10% the number of NIHR CRN portfolio studies being hosted by
the Trust.
Increase by 10% the number of NIHR CRN commercial trials being conducted
within the Trust.
Develop commercial research activity in haematology (oncology) and
respiratory.
Develop research activity within obstetrics and gynaecology
Develop research activity within accident and emergency medicine
Ensure that at least 80% of NIHR CRN commercial trials recruit to time and
target.
Ensure that at least 90% of studies receive NHS permission in less than 40
days of the Trust receiving a valid research application.
Ensure that at least 70% of studies consent the first patient within 70 days of
the Trust receiving a valid research application.
10.0 SECTION 10:
10.1
Conclusion
During 2012/13, PAHNT has recruited a large number of patients into NIHR
CRN studies. In terms of specific NIHR CRN recruitment, there have been
particularly strong performances in Cancer, Dementia and Neurodegenerative
Diseases, Cardiovascular, Paediatrics and Diabetes. The Trust
continues to have very strong links with Industry and recruited patients into 24
commercial studies over 9 different speciality groups.
16
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Item 13
9.0 SECTION 8:
Page 191 of 318
APPENDIX
N. Maddock
P. McMaster
H. Greenfield
R. Prudham
J. Raw & J. Vassallo
A. Uriel
M. Bramley
C. Dang
S. P. Hanley
R. Halford
R. Namushi
P. Murthy
14
15
16
17
18
19
20
21
22
23
24
25
J. Valle
9
D. Gosal
C. Dang & D. Bhatnagar
8
13
J. Reed
7
N. Snowden
S. Ali
6
12
No Local PI
5
M. Bramley & M. Absar
P. Kamath
4
11
T. Oshodi
3
A. Baldwin
J. Swan
2
10
J. Raw
1
Principal Investigator
DeteQT
SOS
CR UK Stratified Medicine Pilot study
17
MALCS (Mesothelioma and Lung Cancer Study)
DRN 552 (Incident and high risk type 1 diabetes cohort - ADDRESS-2)
Multifrequency Bioimpedance in the Early Detection of Lymphoedema
CCRN 905 (Hep C)
PRoBaND: Parkinson's Repository of Biosamples and Network Datasets
Bowel Screening Follow Up Study
MYELOMA XI
AALPHI
Medicines for Neonates; Data Sharing in Neonatal Services
The genetic analysis of multiple sclerosis
Inflammation and Atherosclerotic Plaque Morphology in RA
Management of breast cancer for women aged 70+ in Greater Manchester
Head and Neck5000
NSCCG
DRN 602 (CODIFI)
EUROPAIN Survey Study
SEARCH
Cost efficient service provision in neurorehabilitation
Preventing asthma exacerbations by avoiding mite allergen
Calculating when AAA repair improves survival for individual patients
REVEAL
The Molecular Genetics of Dementias and other Neurodegen. Disorders
Acronym / Title
Table 3. Recruitment in relation to each of the NIHR CRN studies open within PAHT
SECTION 11:
Cancer
Stroke
Cancer
Cancer
Diabetes
Cancer
Oral and Gastro
DENDRON
Cancer
Cancer
Generic
Generic
Neurological
Musculoskeletal
Cancer
Cancer
Cancer
Diabetes
MCRN
Cancer
Generic
Generic
Cardiovascular
Cardiovascular
Dendron
Primary Topic
Academic
Academic
Academic
Academic
Academic
Academic
Commercial
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Academic
Industry
18
19
20
20
21
21
22
22
22
23
26
30
31
32
33
36
37
41
43
45
46
47
86
91
290
Recruitment
Page 192 of 318
A. Allameddine
J. Limdi
J. Livsey
J. Valle
B. Harrison
K. Ali
J. Sobolewska
N. Snowden
D. Bhatnagar & P. Wiles
D. Bhatnagar
48
49
50
51
52
53
54
55
56
J. Sobolewska
39
47
J. Raw
38
S. Mullamitha
R. Jones
37
46
J. Limdi
36
R. McDonald
K. Ajdukiewicz
35
45
J. Calleary
34
R. Namushi
J. Calleary
33
43
M. Bramley & M. Absar
32
B. Harrison
A. Ustianowski
31
K. Kawafi
A. Ustianowski
30
42
P. Wiles
29
41
A. Choudhury
28
J. Vassallo & U. Wadhwa
B. Ofoegbu
27
40
J. Sobolewska
26
DRN597
DRN345
Toxicity from biologic therapy (BSRBR)
CCRN 127 (CHF)
SHIFT
BRAGGSS Study
ESPAC-4
STAMPEDE
CONSTRUCT
AML 17
SCOT
18
NHS North West Advancing Quality Programme
Orthoses for people with stroke (AFOOT)
CCRN 382 (RA)
CLOTS-3
PD GEN
HOT (previously NEON)
PD COMM Pilot
NSHLG - National Study of Hodgkin's Lymphoma Genetics
Genetics of Inflammatory Bowel Disease
Meningitis NorthWest
The UK Genetics of Testicular Cancer Study
UK Genetic Prostate Cancer Study
POETIC
CCRN 987 (Hep C)
CNS penetration of antiretrovirals
DRN564
RAPPER
EXTUBATE
EMMACE-3
Diabetes
Diabetes
Musculoskeletal
Cardiovascular
Mental Health
Musculoskeletal
Cancer
Cancer
Oral and Gastro
Cancer
Cancer
Generic
Stroke
Musculoskeletal
Stroke
DENDRON
Cardiovascular
DENDRON
Cancer
Genetics
Infection
Cancer
Cancer
Cancer
Oral and Gastro
Infection
Diabetes
Cancer
Generic
Cardiovascular
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A. Elangovan
I. Lawrie
E. Wilkins
D. Fitzgerald
P. O’Donnell & I. Lawrie
J. Walls & M. Bramley
B. Padmakumar
J. Raw
78
79
80
81
82
83
84
85
D. Bhatnagar
70
77
C. Curley
69
S. Dasgupta
C. Dang
68
76
R. Jones
67
R. Rifkin, R. Levy & N. Prakash
Z. Borrill
66
75
A. Uriel
65
K. Kawafi
A. Uriel
64
74
E. Wilkins
63
J. Livsey
N. Saravanan
62
D. Osborne
J. Raw
61
73
A. Ustianowski
60
72
A. Uriel
59
T. Blanchard
K. Phelps
58
71
J. Raw
57
19
Dysphagia in Parkinson's patients: a TMS study
Prednisolone in Nephrotic Syndrome: The PREDNOS Study
NCRN154 - long term safety of Sativex in patients with cancer related pain.
Prevention of Lymphoedema after Clearance by External Compression
(PLACE)
BADBIR
Strategic Timing of AntiRetroviral Treatment (START)
NCRN137 - Sativex in relieving pain in patients with advanced cancer
BOCS (formerly FBCS)
DRN251 (TECOS)
PASS Study
ICISS
ENOS
RADICALS (MRC PR10)
AML 16
ENCEPH UK - Cohort Studies
CCRN 868 (Hypercholesterolemia)
A study of major system reconfiguration in stroke services
DRN 528 (Fibreglass casts for heel ulcers in diabetes)
Computerised Adaptive Testing for EORTC QLQ-C30
Identifying Blood and Sputum Biomarkers of COPD exacerbations
CCRN 714 (CHC Infection)
CCRN 607 (Hep C)
Study of transmission risk between HIV discordant partners
DARS: Dopamine Augmented Rehabilitation in Stroke
PD REHAB
CCRN 968 (Hep C)
CCRN 787 (Hep C)
ESCAPE 85+ (Establishing System Change for Admissions of People 85+)
DeNDRoN 070 (OXN PR for severe PD associated pain)
DENDRON
MCRN
Cancer
Cancer
Skin
Infection
Cancer
Cancer
Diabetes
MCRN
MCRN
Stroke
Cancer
Cancer
Neurological
Met and Endo
Stroke
Diabetes
Cancer
Respiratory
Oral and Gastro
Oral and Gastro
Infection
Stroke
DENDRON
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Oral and Gastro
Generic
DENDRON
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Page 194 of 318
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R. Jones
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P. McMaster
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P. Wiles
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106
B. Harrison
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B. Harrison
J. Raw
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105
L. Lee
96
No Local PI
R. Namushi
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V. Sen
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E. Wilkins
V. Misra
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A. Uriel
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E. Wilkins
S. Chaudhary
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R. Woodwards
R. Namushi
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J. Raw
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P. O’Donnell & I. Lawrie
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E. Wilkins
A. Ustianowski
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100
T. Mann
86
UK ChiMES
DRN 727 (Diabetes Care in UK Universities)
20
BRIGHTLIGHT: The 2012 TYA Cancer Cohort Study
T-POETIC v1
Drug induced pneumonitis in rheumatoid arthritis patients
Understanding mood management: A computer-based questionnaire study
CCRN 624 (HIV)
CCRN 547 (HIV)
Lugol's Iodine in Head and Neck Cancer Surgery
Algorithm for clinical diagnosis of Tubercular Meningitis in the UK
DRN464
Investigating genes in patients with polymyositis and dermatomyositis
DeNDRoN 059 CONFIDENT-PD
PET-NECK study
DNA Lacunar Resource
Myeloma X Relapse (Intensive)
SUPREMO
CCRN 966 (Hep C)
CCRN 928 (CONSTANCE)
EXTRAS
DeNDRoN 076 (Servier CL2-38093-012)
NCRN197 - Sativex in advanced cancer
The CNS as a sanctuary site for HIV
Visual impairment in stroke: intervention or not (VISION)
Generic
Diabetes
Cancer
Cancer
Musculoskeletal
Mental Health
Infection
Infection
Cancer
Infection
Diabetes
Inflam & Immune
DENDRON
Cancer
Stroke
Cancer
Cancer
Infection
Eye
Stroke
DENDRON
Cancer
Infection
Stroke
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Item 13
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Title of Report
Annual Fire Prevention Report – period April 2012 to
March 2013
Executive
The report provides information on how the Trust is
Summary
performing with regards to fire safety.
Actions
The Board is asked to note the levels of performance
requested
reported.
Corporate Objectives supported by this paper:
1) All Corporate Objectives are supported by the delivery of a fire safe
environment for patients and staff thereby allowing the Trust to meet its
objectives.
Risks:
The risk highlighted in this report is that the Trust is failing to meet its legal
target of ensuring all staff attend an annual fire lecture.
Public and/or patient involvement:
Not relevant for this paper
Resource implications:
Resources to improve the performance of fire detection systems and
management will be met from within existing backlog allocation.
Communication:
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
John Wilkes
Facilities Director
June 2013
[email protected]
Page 195 of 318
YES
√
NO
N/A
√
√
√
√
√
√
√
√
Item 13
Agenda Item:
Item 13
FIRE PREVENTION
REPORT
2012/2013
John Wilkes
Director of Facilities
1
Page 196 of 318
This report summarises the activities of The Pennine Acute Hospitals NHS Trust Estates
Fire Advisory service during 2012/2013.
CONTENTS
1. Fire calls to Trust properties
2. Training
3. Fire prevention planning
4. Appendices:
A – Fire Prevention Department duties and management structure
John Wilkes
Director of Facilities
2
Page 197 of 318
Item 13
FIRE CALLS TO TRUST
PROPERTIES
John Wilkes
Director of Facilities
3
Page 198 of 318
FIRE CALLS TO TRUST PROPERTIES
During 2012/2013 there were 221 fire alerts, this is an increase of 12% on last year’s figure.
On all occasions the fire service attended. Of the total number of alerts, 4 were actual fires,
which is a decrease of 60% on last year’s figures. Three of the fires were on the Oldham
site and were detected early by either staff or the automatic fire detection system and were
extinguished by staff/fire service before spread of fire could occur. One fire was on the North
Manchester site, this caused extensive damage to the Jewish Mortuary.
ACTUAL FIRES - SITE COMPARISON
Oldham
North Mcr
Bury
Birch Hill
RI
The above pie chart illustrates that The Royal Oldham site accounted for 75% of the Trust’s
actual fires. These fires have been caused by; patients setting fire to bedding, malicious
ignition of a container outside the laundry and a candle falling over in the chapel and setting
fire to a wreath.
Unwanted Fire Signals
The total number of unwanted fire signals, i.e. those that were not actual fires, was 197. This
is an increase of 5% on last year’s figure. The graph below shows the main problems are on
the North Manchester site under the category of other faults. Further investigation has
shown these unwanted fire signals have been due to a variety of reasons such as the use of
air fresheners, hair spray and problems with water and steam ingress. The problems on the
Oldham site have mainly been due to contractors not following procedures and creating
environmental issues such as dust.
John Wilkes
Director of Facilities
4
Page 199 of 318
Item 13
The category ‘others’ contains numerous items that are infrequent causes of unwanted fire
signals.
The graph below illustrates the cause of unwanted fire signals.
CAUSE OF UNWANTED FIRE SIGNAL
60
50
40
Oldham
No OF CALLS 30
North Mcr
Bury
Birch Hill
RI
20
Westhulme
10
0
Malicious
Good Intent
System Fault
Smoking
Cooking
Patient
Operating
Alarm
Others
CAUSE
UNWANTED FIRE SIGNALS BY SITE
0% 1%
0%
11%
42%
Oldham
North Mcr
Bury
Birch Hill
46%
RI
Westhulme
Regular meetings are held between the Trust’s Fire Advisors and Greater Manchester Fire
and Rescue Service to examine the cause of unwanted fire signals and find ways of
reducing them.
John Wilkes
Director of Facilities
5
Page 200 of 318
TRAINING
John Wilkes
Director of Facilities
6
Page 201 of 318
As in previous years, all clinical staff are required to attend at least one fire lecture. An elearning course is available for non-clinical staff, but a face-to-face fire lecture must be
attended every other year.
Estate records show the total number of Trust employees attending fire lectures during
2012/2013 was 6978 out of the 8598 staff available for training. This equates to 81% of
Trust staff. The number of staff completing an e-learning fire course was 1068 out of 8598
which is 12%. Therefore, the total number of staff receiving fire training during the year is
94%.
This figure is 8% up on last year’s figure of 86%. The introduction of e-learning has had a
significant impact on the figures.
The Trust’s legal obligation is to ensure all staff receive fire training at least annually.
NUMBER OF STAFF ATTENDING A FIRE LECTURE
2500
2000
1500
1000
Total Attending
Total in Division
500
0
DIVISION
The above graph shows that the Medical Directorate has trained more staff than there are in
the division. The figures for the number of staff in the division are those as at 31st March,
hence with a gradual reduction in staff throughout the year, it is possible to train more staff
than the resultant number of staff at year end. It is also possible for staff that change base to
receive more than one fire lecture in any one year.
John Wilkes
Director of Facilities
7
Page 202 of 318
Item 13
STAFF TRAINING
FIRE EVACUATION DRILLS
Fire evacuation drills should be carried out regularly throughout the Trust. This is very
difficult to achieve in clinical areas without putting patients at risk. It is therefore seldom
carried out.
The following premises had a fire evacuation drill during 2012/2013:
Bury
Outpatients
Pharmacy
Fairfield House
Oldham
Maternity Ground Floor
Diabetic Clinic
Laundry
John Wilkes
Director of Facilities
8
Page 203 of 318
Item 13
FIRE
PREVENTION
PLANNING
John Wilkes
Director of Facilities
9
Page 204 of 318
FIRE PREVENTION
Fire legislation and guidance applicable to hospitals and other Trust properties is as follows:
1
2
3
4
5
6
7
Regulatory Reform (Fire Safety) Order 2005
Building Regulations
The Health and Safety [Safety Signs and Signals] Regulations 1996
The Disability Discrimination Act
Standardisation BSEN3 Fire Extinguishers
Firecode
Housing Act
a
Regulatory Reform (Fire Safety) Order 2005
The Regulatory Reform (Fire Safety) Order 2005 has replaced The Fire
Precautions Act 1971 and The Fire Precautions (Workplace) Regulations
1999. Both of which were repealed in October 2006.
b
Building Regulations
This is enforced by the Local Authority Building Control Officers and is
applicable to all new build and refurbishment of all properties including
hospitals. These regulations have been amended and the amendments came
into force on the 1 October 2010.
c
The Health and Safety [Safety Signs and Signals] Regulations 1996
These regulations came into force on 1 April 1996, and requires that all
emergency ‘EXIT’ signs conform to one standard throughout the EC, namely in
the “Pictogram Running Man” symbol. In addition it also requires that all fire
fighting equipment be identified by signage. This regulation was to be
complied with no later than 24 December 1998.
d
Fire Extinguishers EN3
The purpose again of this is to standardise all portable fire extinguishers
throughout the EC to one colour, red. However, on this standard there is no
“to be complied with by” date. Extinguisher manufacturers have incorporated
the recognised colour coding of extinguishers into the manufacturer by
providing a relevant colour strip whilst the main body of the extinguisher is still
predominantly red.
e
Firecode
This is a set of national codes to be complied with by Trusts etc: and comprise
of fire alarms, training, new hospitals and existing hospitals in relation to
matters of fire safety.
A new series of documents have been published entitled ‘Firecode – fire safety
in the NHS’. These comprise of HTM 05-01, HTM 05-02 and HTM 05-03 Parts
John Wilkes
Director of Facilities
10
Page 205 of 318
f
Housing Act
This is relevant to premises let in multi-occupation and is enforced by the
Environmental Health Department of Local Authorities.
g
Department of Health
The Department of Health have now deemed it to be inappropriate to be
directly involved in fire safety issues. The initial point of contact for NHS trusts
on fire safety matters should now be the appropriate Strategic Health
Authority.
CONTRAVENTION NOTICES
In 2012/2013, no enforcement notices under The Regulatory Reform (Fire Safety) Order
2005 were served on the Trust.
BACKLOG MAINTENANCE
Backlog maintenance is classified as a service or equipment that is likely to fail within the
next 12 months unless action is taken to eradicate the problem. It also addresses areas that
are in contravention of the Fire Safety regulations.
The Trust has identified a budget of £100,000 for 2013/2014 to make significant reductions
in the fire safety backlog, which stands at £98,000 for this year. Future backlog costs are
estimated at:
2014-15
£160,666
2015-16
£206,666
2016-17
£113,666
STORAGE FACILITIES
As space is at a premium, materials are being stored in areas that are not designed for the
fire loadings that are being placed upon them.
ANNUAL STATEMENT OF FIRE SAFETY
The Department of Health no longer require Trusts to produce an Annual Statement of Fire
Safety.
John Wilkes
Director of Facilities
11
Page 206 of 318
Item 13
A, B, D, E, F, G, H, J, K & L. The new Firecode will significantly impact on
Training and Fire procedures.
CAPITAL SCHEMES INVOLVING FIRE PRECAUTIONS WORK COMPLETED 2012/2013
Rochdale Infirmary
Level C – Catering Facility
Level D – Booking & Scheduling
Level B – Dieticians
Work completed
Work completed
Work completed
Bury
X-Ray - Cardiology Unit
Labour Unit Refurbishment
Work completed
Work completed
Oldham
Phase 3
HSDU Extension
Training Rooms – Education Ctr
Demolition Works - Westhulme
Work completed
Work completed
Work completed
Work completed
North Manchester
Ward F2a
Ward E1 & F1
X-Ray B
X-Ray Room 1
Limbert Nurses Home Gd Floor
Ante Natal Day Unit
Women’s & Children’s Additional Beds
Ward J5 & J6
Work completed
Work completed
Work completed
Work completed
Work completed
Work completed
Work completed
Work completed
John Wilkes
Director of Facilities
12
Page 207 of 318
Rochdale Infirmary
OPD in Springfield/Sparthfield
AHPO’s Physio into Wolstenholme
Pharmacy into Silver Heart
Alterations to Day Case / ICU
Alterations to Endoscopy
Stonehill - decommission
Bury
A & E Extension
Oldham
Wards F2, F3 & F4 Refurbishment
Lucy Pugh Ground Floor
Wards F5 & F6
A&E
North Manchester
C3, C4 & DSU Alterations
Jewish Mortuary Repairs
Demolition of Old Laundry
J Block Alterations
John Wilkes
Director of Facilities
Pending business case approval
Pending business case approval
Pending business case approval
Pending business case approval
Pending business case approval
Awaiting GUM move
Work in progress
Work in progress
Work in progress
Work in progress
Pending business case approval
Pending business case approval
Pending business case approval
Options being considered
13
Page 208 of 318
Item 13
CURRENT/FUTURE CAPITAL SCHEMES INVOLVING FIRE PRECAUTION WORK
APPENDIX A
John Wilkes
Director of Facilities
14
Page 209 of 318
The department currently provides the services of three whole time Fire Safety Advisors
whose duties embrace the tasks described below: 1. Advising the Trust on implications and impact on new fire safety legislation and codes of
practice.
2. Liaison with Fire Service on upgrading of existing buildings.
3. Inspection of all Trust properties to ensure that all fire safety measures are being
complied with.
4. Inspection of all premises where Trust employees work and carry out fire risk
assessment in accordance with The Regulatory Reform (Fire Safety) Order 2005.
5. Liaison with Estates Department/GMC Fire Service/Architects/Local MBC/NHS Estates
on matters relating to new or refurbished buildings.
6. Fire training of staff approximately 10,000. This is provided through day and night time
fire lectures both on and off the hospital site.
7. Attendance to fire calls and fire investigations.
8. Forwarding fire reports to the Department of Health via the efm information portal.
9. Keeping records of all fire alerts.
10. Arranging maintenance of fire prevention equipment.
11. SLA with Manchester Mental Health Partnership and Dr Kershaw’s Hospice.
12. Continued liaison with GMC Fire Service operational section has taken place during
2012/2013 in order for the local station to use selected facilities to carry out breathing
apparatus training and visits which enables them to gain knowledge of hospital
topography. This liaison between staffs of the local fire stations and NHS Trust
Departments has been of great benefit to both parties.
John Wilkes
Director of Facilities
15
Page 210 of 318
Item 13
Fire Prevention Department
MANAGEMENT STRUCTURE
FOR
ESTATES FIRE ADVISORS
Chief
Executive
Director of
Facilities
Head of Estate
Development
Head of Estate
Operations
Estate
Manager
North/Bury
Fire Advisor
North
John Wilkes
Director of Facilities
Estate
Manager
Oldham/RI
Fire Advisor
Bury/Rochdale
16
Page 211 of 318
Fire Advisor
Oldham
Item 13
Title of Report
Equality and Diversity Annual Report 2013
Executive
Summary
This report demonstrates how the Trust has met its
legislative duties on Equality during this past 12 months
and the plans for the future
The Board is asked to note the report and support
current and future programmes of work
Actions
requested
Corporate Objectives supported by this paper:
2) Improving the Patient Experience
10) Equality
Risks:
Failure to meet legislative duties may result in punitive actions and
reputational damage.
Public and/or patient involvement:
Full consultation has occurred in developments in the report, staff and public
involvement in all related activities.
Resource implications:
No resource implications.
Communication:
The report will go on the Trust internet pages, in the weekly bulletin and be
made available to the public who are involved in equality activities
Have all implications been considered?
Assurance
Information Governance Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
Name
YES
x
x
x
x
x
x
x
x
x
NO
Job Title
Roger Pickering
Executive Director of HR and Organisational
Development
Date
June 2013
Email
[email protected]
Page 212 of 318
N/A
Equality and Diversity Annual Report
2012 – 2013
2
Naheed Nazir – Head of Equality & Human Rights June 2013
Page 213 of 318
Item 13
Contents
Section 1
Introduction
3
Section 2
Corporate and Individual Responsibilities
6
Section 3
Core Activities
7
Section 4
Current Activities and Progress
10
Section 5
Future work and challenges ahead
23
Appendix 1
Data Monitoring
28
Appendix 2
Implementation plan
29
Appendix 3
Local Demographics
37
All quotations used in this report have been taken directly from patient
and service user involvement events and from members of staff.
Grateful thanks to all those who contributed.
3
Naheed Nazir – Head of Equality & Human Rights June 2013
Page 214 of 318
1.0
Introduction
The Pennine Acute Hospitals NHS Trust is one of the largest Trusts in the North
West and employs over 9,000 staff. The Trust is committed to creating an
environment where all staff are able to have equal access to the employment
opportunities it provides. By creating opportunities for all staff to reach their full
potential, and ensuring that there is a fair and equitable organisational structure and
accountability. We are committed to ensure that our approach to our staff is the
same as our approach to our service users, being open and transparent, respectful,
accessible and of high quality.
We have seen a lot of changes across the nation within the NHS and these have
been reflected locally across Pennine Acute Hospitals. We have seen the
development of the Clinical Commissioning Groups and the development of the
Commissioning Support Unit in Greater Manchester. There have been significant
changes in the structure of the local NHS service in terms of how it is managed and
how it will provide more effective and efficient quality services to the public.
With an annual operating budget of over half a billion pounds, we work with four
Clinical Commissioning Groups – NHS Manchester, NHS Bury, NHS Oldham and
NHS Heywood, Middleton and Rochdale - to plan, develop and commission
healthcare services for local people.
1.1
Local Community Demographics
The Pennine Acute Hospitals Trust provides high quality general and specialist
hospital services to around 800,000 residents across the north east of Greater
Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham
and Rochdale. The Trust manages four main hospitals across the north east sector
of Greater Manchester, including North Manchester General Hospital, The Royal
Oldham Hospital, Fairfield General Hospital in Bury and Rochdale Infirmary.
The communities served by the Trust are diverse in their make-up, but are similar in
that they are generally less healthy when compared with the rest of the population of
England, with a higher proportion of people who have a long term illness. Many
areas suffer high levels of deprivation. Where there are high rates of unemployment
and deprivation, there tends to be poorer health and a greater demand for health and
social care services.
Public Health England's Longer Lives website, which ranks local authorities, shows
people in north-west England are at the greatest risk of dying early. Around 153,000
people die prematurely each year in England, with three quarters of those deaths
down to cancer, heart attack or stroke, lung disease and liver disease - according to
Public Health England. Manchester, Blackpool, Liverpool and Salford have the
highest rates of early deaths; the figures show. Socio-economic background plays a
large part in life expectancy and is part of the explanation of the regional divide. The
new analysis also allows councils to compare themselves with others with a similar
background. (Public Health England 2013)
4
Naheed Nazir – Head of Equality & Human Rights June 2013
Page 215 of 318
Common themes of ill health and death include circulatory diseases such as
coronary heart disease and stroke, diabetes, cancer, and respiratory diseases such
as pneumonia, asthma, bronchitis and emphysema.
The Trust’s local communities are geographically and culturally diverse, but remain
largely characterised by their industrial past. This has contributed to significant
health inequalities among residents.
Other issues facing the surrounding communities include proportionately larger
numbers of younger and older people, large and growing ethnic minority populations
whose health and access to healthcare have been poor, and heavy reliance on
public transport and low levels of personal car ownership.
1.2
Legislation
Pennine Acute Trust recognises the need to act responsibly and fulfil our statutory
and other core duties, such as the Equality Act 2010 and its associated public sector
Equality Duty. The Equality and Engagement Team have been reviewing and
monitoring systems to ensure that they are effective and efficient and are continually
working towards developing robust frameworks for embedding and mainstreaming
equality and human rights within the organisation.
The Equality Act 2010 brought together 9 pieces of primary legislation and over 100
pieces of secondary legislation with the aim of reducing bureaucracy and to ensure
that people are treated fairly when using services or whilst at work. The Act protects
people from discrimination on the basis of ‘protected characteristics’, which vary
slightly depending upon whether a person is at work or accessing services. For
example, ‘marriage and civil partnership’ is a protected characteristic for employees
but not for people using services.
The nine protected characteristics are:









Age
Disability
Gender reassignment
Pregnancy and maternity
Marriage and civil partnership
Race (ethnicity)
Religion or belief
Sex (gender)
Sexual orientation
The General Duty, as set out in the Equality Act 2010,
was introduced in April 2011, and it is the General Duty
5
Naheed Nazir – Head of Equality & Human Rights June 2013
Page 216 of 318
Equality is
‘recognising and
respecting that
each person will
have their own
coping
mechanisms’
Item 13
Across the Trust’s footprint the rates of obesity, smoking, cancer and heart disease
related to poor general health and poor nutrition are significantly higher than the
national average, whilst life expectancy at birth in some areas is one of the lowest in
England.
which guides the work undertaken within the Trust. As a public body, the Trust must
have due regard to:

Eliminate unlawful discrimination, harassment and victimisation;

Advance equality of opportunity between people who share a protected
characteristic and those who do not; and

Foster good relations between those who share and do not share a protected
characteristic.
The Equality Act explains that advancing equality means removing or minimising
disadvantage that people experience due to their protected characteristic. It means
that we must take account of different people’s needs and encourage people from all
walks of life to participate in public life, and particularly those people who are often
unheard – for example, encouraging people from protected groups who do not
normally participate to become Foundation Trust members.
Specific duties, which explain how to implement the General Duty, were published in
September 2011.
The Age Discrimination legislation came into force 1st October 2012, it is unlawful for
service providers and commissioners to discriminate victimise or harass a person
because of age. A person will be protected when requesting, and during the course
of being provided with, goods facilities and services.
Positive use of age in providing, commissioning and planning services will be able to
continue. The Act does not prevent differential treatment where this is objectively
justified. Policy makers, commissioners, providers and individuals working in health
and social care should continue to take into account someone’s chronological age
when it is right and beneficial to do so, for example by:
 Ensuring that services and benefits are targeted at those who most need
them;
 Age appropriate provision for the benefit of the individual, for example
responding to a legitimate desire to mix with their own age group.
A review plan has been devised to review and monitor the systems, services and
policies within the Trust to ensure that we are in line with this legislation.
1.3
Equality Delivery System ~ (EDS)
This is the second year that the Trust has been successful in meeting the
mandatory requirement to participate in an Equality Delivery System (EDS)
developed for the NHS, which aims to improve the equality performance of the NHS
and embed equality into mainstream business planning processes. The EDS will be
used to benchmark and monitor organisations.
In order to support the organisation in meeting these requirements, the Equality and
Engagement Team have developed a framework of action in order to help staff to:
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understand the impact of discrimination and how to tackle prejudice;
2.
advance equality and human rights values in their day to day lives;
3.
monitor equality and human rights activity and take action where
necessary to address inequalities; and
4.
enjoy the benefits of a working environment that values each member of
its workforce and the wealth of experience and knowledge it brings.
These aims prompt and then support staff to move from misunderstanding to
understanding, inaction to action, and leave no room for passivity.
EDS is a tool for both current and emerging NHS organisations – in partnership with
patients, the public, staff and staff-side organisations - to use to review their equality
performance and to identify future priorities and actions.
It is identified that by using the EDS, organisations will be able to meet the
requirements of the Equality Act and providers will be better placed to meet the
registration requirements of the Care Quality Commission (CQC).
The EDS is a mandatory requirement and will enable benchmarking and monitoring
of organisations nationally.
The Trust has developed four-year equality objectives and priorities, based on an
analysis and grading of equality performance against a set of EDS objectives and
outcomes. There are 18 outcomes, grouped under four objectives:
1.
2.
3.
4.
Better health outcomes for all
Improved patient access and experience
Empowered, engaged and included staff
Inclusive leadership at all levels
Based on transparency and evidence, the Trust and local interested parties met and
agreed one of four grades for each outcome. Events were held across all sites and
evidence was presented, alongside draft objectives for comments and approval.
The grades that the organisation might achieve are:
o Excelling (Gold Star)
o Achieving (Green)
o Developing (Amber)
o Undeveloped (Red)
The Trust was pleased to be rated as Developing or Achieving in all of its outcomes.
Based on this grading, equality objectives have been set which will show how the
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Item 13
1.
most immediate priorities are to be tackled, by whom and when. Each year, local
interested parties will review progress the Trust has made and carry out a fresh
grading exercise.
2.0
Corporate and Individual Responsibilities
The new equality and human rights framework illustrates from where accountability
will come, the importance of transparency and, of course, how staff will be supported
within their roles. The key roles are described below.

The Chief Executive, in conjunction with the Executive Management Team and
Non-Executive Directors has ultimate responsibility for ensuring that the Trust’s
commitment to equality and human rights is evident, transparent and
accountable.

The Executive Director of Human Resources and Organisational Development
is the Equality Lead and responsible for the coordination of the overall equality,
diversity and human rights agenda.

The Patient Experience and Equality and Diversity Committee meets bi monthly
to discuss and progress issues around equality and diversity and to monitor
activity against objectives and statutory reporting requirements.

The Equality Champions were re-launched and have covered all gaps and built
in resilience with having two to three representatives for each directorate,
division across the Trust. The Equality Champions continue to be a much
valued resource within the Trust.

We have also completed a training audit for each of the Champions in order to
identify what supporting needs they
have and to be able to support them
to perform their role to their full
potential.
Respect is
“having the right
people for the right
jobs”
Equality Champions support managers
and staff in equality issues and have a key
responsibility for reporting on equality
activity to the Joint Patient Experience and
Equality and Diversity Committee.
 The Equality and Engagement Team is
an internal resource, providing a full range of support to all staff on equality,
diversity and human rights issues. The Team provide a source of equality and
human rights expertise – relevant and up-to-date – and recognise the importance
of education and training as key to challenging discrimination and advancing
equality at every level of the organisation.

All employees of the Trust have a responsibility to promote equality in their every
day working lives and to reflect the core values of the organisation as a whole.
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3.0
Core Activities
3.1
Equality Impact Assessments
The Trust continues to recognise the role it plays in ensuring that health inequalities
are identified and eliminated and equity and fairness are core qualities and values to
be embedded within the organisation. Equality Impact Assessments (EqIA) are the
key to achieving this aim.
The Trust reviewed its Equality Impact Assessment procedures and toolkit in
2011/12. This review had a number of complementary aims, including: the need to
simplify the existing guidance, the need to comply with new public sector specific
duties contained in the Equality Act 2010, the need to comply with new guidance
issued by the Equality and Human Commission.
The main features of the new legal requirements are:

To collect information relating to the effect that policies and practices may or
have had on employees, service users and others from the protected
characteristics (groups).

To provide evidence of the analysis that has been undertaken to establish
whether policies or practices will, or have, furthered the three equality aims of
the general duty (see pages 5 and 6
for General Duty).

To detail the information used in the
analysis
Autonomy

To detail the engagement
undertaken with people who have an
interest in the equality duty and who
use our services.
“When I was
diagnosed with
The new process applies to all strategies,
services and staff and public facing policies
only.
cancer I was
given a choice
It is now a legal requirement to consider the
nine protected characteristics of age,
about my
disability, gender reassignment, race
(ethnicity), religion and belief, marriage and
treatment – I was
civil partnerships*, pregnancy and maternity*, sex (gender), sexual orientation when
undertaking equality impact assessments.
happy with this”
*where applicable
The Trust will continue to monitor equality for carers and issues around social
deprivation. Human rights remain the highest priority and must be considered
alongside the other protected characteristics throughout all business planning,
development and implementation.
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Item 13
They should be enabled and positively encouraged to monitor their own areas for
attitudes, behaviours and values that advance and protect equality and human
rights
Having made significant progress on embedding equality impact assessment, the
Trust needs to be very aware of the continued responsibility to undertake them,
particularly being alert to any service changes that may be under consideration due
to financial pressures faced by the NHS.
We undertake these assessments to ensure that we provide a fair,equal and
inclusive service . We ensure this for all staff through the policies and procedures
that we have in place and also through our services that we provide to users of our
services.
By assessing the potential effects of a policy on particular populations, we can
increase the probability that a policy will promote equality of access and equity of
outcomes.
Progress reports based on the plans are monitored and discussed quarterly at the
Patient Experience and Equality and Diversity Committee
3.2
Equality and Diversity Web Pages
The Trust’s equality and diversity web pages are populated with a wide range of
information to help staff understand the key themes within equality and human rights
and to provide a useful resource when developing services and carrying out equality
impact assessments.
They have been updated to include information around each protected characteristic
and describe the Trust’s commitment to eliminating discrimination, advancing
equality and fostering good relations between different groups of people.
3.3
Equality and Human Rights Training for Staff
The Trust commenced a mandatory staff training programme in August 2011, in
addition to the mandatory equality and human rights induction session for all new
members of staff. The taught sessions have been designed to reflect the
requirements of the 4 levels of achievement in the NHS Knowledge and Skills
Framework (KSF) Core Dimension 6: Equality and Human Rights. Level 1 and 2
raises awareness of equality concepts. Levels 3 and 4 build skills in relation to
integrating equality into service improvement and delivering service and
organisational priorities. Equality and human rights training is also available by elearning.
As at the 31st December 2011, take up of equality and human rights training was
39.4%, which is well within the target range of 100% of staff having undertaken the
training by the 31st March 2015. All staff are expected to access the training every 3
years. The proportion of respondents to the national staff survey who reported
receiving equality and diversity training in the previous 12 months increased from
33% in 2009 to 42% in 2010 and in the last 12 months 70% which is an increase of
20% from 2011 and 15% above the national acute trust average.
In addition to training offered within the Trust, the Equality and Engagement Team
also offer training to organisations outside of the Trust, such as to Local Involvement
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Taught courses available at the present time are:
All staff
Equality and Human Rights Awareness (Mandatory)
Equality and Human Rights in Recruitment
Tackling Bullying and Harassment in the Workplace
Dignity in Care
Caring for Carers
Cultural Awareness
Supervisors and Managers
As above
Service and Equality Impact Assessment Master class
Foundation Year 2 Doctors
Equality in the Healthcare Setting
Consultants
Equality and Human Rights in the Healthcare Setting
VLE Training
On-line training packages remain available for those staff members who are unable
to access taught sessions, and these cover mandatory requirements.
National Staff Survey
The results of the 2012 National Staff Survey show that Pennine Acute Trust was
designated as being in the best 20% of Acute Trusts within 3 areas:
 Percentage of staff working extra hours 65% this was a 4% rise from 2011
but still represents a score of 5% below national Acute Trust Average.
 Percentage of staff receiving health and safety training in last 12 months
79% which is 5% above the national acute trust average.
 Percentage of staff receiving equality and human rights training in the last
12 months 70% which is an increase of 20% from 2011 and 15% above
the national acute trust average.
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Item 13
Networks and local schools. This type of activity is really important in fostering and
maintaining excellent working relationships with outside organisations and
community groups. In addition, the Trust has a duty to keep people informed of their
rights and responsibilities when accessing healthcare services. This ensures that
the Trust’s commitment to openness, transparency and accountability is
demonstrable and tangible.
The survey findings demonstrate that despite challenging times and considerable
change, staff have remained engaged and are receiving on going support from line
managers, senior managers and Equality and Engagement team. This is important in
taking forward future challenges associated with the formation of Foundation Trust
whilst continuing to improve the patient outcomes.
NHS Employers Equality & Diversity Partner Status
A rigorous process was applied to all submissions and the panel was impressed with
the evidence we provided. This evidence was informative and demonstrated the
enormous commitment of our Trust to embedding equality, diversity and human
rights into the core business of our organisation.
In total, 12 Trusts have been selected as Equality and Diversity Partners for 2012/13.
The Programme offers organisations the opportunity to work on Department of
Health Equality and Diversity Council priorities with a focus on organisational
development – in order to equip themselves for the challenges of the transition into
the new NHS environment. The Programme will enable us to share our good
practice locally and nationally – and across the wider public sector.
4.0
Current Activities
4.1
Active Community Engagement
Jewish Community Engagement
Local engagement activity in the Jewish community at North Manchester General
Hospital has been undertaken during the last year, with meetings and events
organised to support increased communication and partnership working.
These included:

A community meeting in February 2013 “Ezra Umarpeh” took place where
updates were given to the community and gave the community the opportunity to,
raise issues and offer suggestions to improve access and support for Jewish
patients accessing the Trust, including the visiting policy. At this particular meeting
the Director of Nursing , Marion Carroll, was presented with an award of
appreciation for the Trust’s support to the Jewish Community.

Regular meetings between the Trust and representatives from the Jewish
Community, take place as and when needed to raise any issues and concerns.
South Asian Mental Health and Wellbeing – South Asian Mental Health and
Wellbeing Cluster
We have been aiming to develop better and closer community relations with the
communities we serve. The SAMH Cluster aims to raising awareness of mental
health and breaking down the barriers that the communities face. The group have
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Breathe Easy – BME Engagement
Further meetings have been held during June 2012 with community partners and
the British Lung Foundation and Community Respiratory Nurses to identify a
programme of support for BME communities with breathing difficulties who are not
accessing services.
The Trust support the provision of drop in information sessions and health checks in
Oldham community centres, to identify potential patients and increase access to
information and support. The Trust provided interpreters for the meetings via the
Ethnic health Team.
Equality Delivery System (EDS) Engagement Events
Since the launch of EDS in Summer 2011 the Trust has successfully implemented
this mandatory requirement within the organisation. Early 2012, eight local
engagement events were held with staff, service users, carers and community
groups. In February 2012 two RAG (Red, Amber, and Green) Rating Workshops
were held where community representatives validated the self assessment of the 18
outcomes. In addition they and the engagement events helped the Trust formulate its
equality objectives.
This year gave us the opportunity to monitor our progress and review our grading
against the 18 outcomes and the four goals. We were also able to review our
equality objectives and confirm with our stakeholders, patients, carers and staff that
the objectives developed were still pertinent.
We held review sessions during December 2012 and January 2013 across all four
sites. The sessions were attended by staff, patients and carers including members of
the local involvement networks. The conclusion that was agreed on was that good
progress was being made to achieve the objectives set out which were noted to be
very clear and concise.
The attendees were invited to make a Pledge on how they would support the Trust to
achieve the objectives set, providing support and solutions to the gaps and issues
which they have raised. This was very successful as all attendees at each session
pledged an action and these are reviewed and updated by the Equality Team.
Learning Disability Big Health Event
The Trust supported Manchester Learning Disability Partnership Board to plan and
hold an event for People with Learning Disabilities (PWLD) and their carers during
National Learning Disability Week in June 2012.
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Item 13
also been successful in gaining funding to run a dementia and mental health
programmes for the South Asian community in Bury.
By attending their Cluster group meetings it has allowed the Trust to open a two way
communication channel and another means to enable us to engage and consult with
this growing community.
The Trust provided advice and support to the attendees, undertaking blood pressure
and pulse checks as part of the wider ‘health check’ available on the day. Over 400
people attended and advice and support was also available from local GPs should
the health check results require intervention.
The Trust used the event as an opportunity to advise carers and the public of the
activity in the Trust that is being undertaken to support PWLD. A survey was also
undertaken to identify experiences of patients and carers accessing services or
barriers that they may feel are present.
The event has since enabled the Trust to start working on a project with a community
organisation which supports PWLD to identify and resolve issues for PWLD when
they are in transition from accessing child to adult services.
Dignity Action Day 2013
The Trust was active on 1st February 2013 in supporting Dignity Action Day 2013
which was identified as an opportunity for people to give the gift of time. The day
asked everybody - members of the public and health care staff to give the gift of time
and really make a difference!
The Trust was able to support the day by volunteers giving hand massages to
patients at Fairfield, North Manchester and Oldham and Reiki treatments were
offered to patients at The Royal Oldham Hospital.
Information stands were on display across the hospital sites, where advice and
information was given by Trust staff and the relevant town's Carers' Centre. Staff
were also offered the opportunity to sign up as dignity champions and join the
campaign.
Patients were visited on the wards by chaplaincy staff and volunteers and were
asked to give their own comments on the day, and when asked, most patients have
said that being given 'time to talk' was really important to them so they can share
their fears with staff, and that it helps them to feel reassured and less isolated or
vulnerable.
The Trust has now recruited 781 champions; this is an increase of 231 from the
previous year. These champions are becoming active across the Trust and
supporting privacy and dignity in all wards.
Dignity Matters – Dignity Champion Conference
The Trust held Dignity Matters conferences across all four sites during June and July
2012. The focus of these events was dementia and dignity. The events were well
attended and there was a mixture of presentations, displays, information stands and
workshops taking place throughout the day.
The events gave the Champions to explore further issues and raise any concerns
they had around dignity especially focussing on dementia. They were supported by
experts and specialists in this particular field.
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The Equality & Engagement team held information stands covering equality and
human rights, volunteers, carers and the ethnic health team. The team showcased
the Equality Delivery System, displaying the grading criteria and the grading results
and provided advice and guidance about the framework and answered any queries
related to this.
4.2
Bullying and Harassment
Bullying and harassment is taken extremely seriously in the Trust, and a range of
initiatives have been instigated in recent years to promote fairness, dignity and
respect for all whilst at work.
The Bullying and Harassment Advisory Service is designed to support staff members
in the workplace who either feel they are being bullied or harassed or have been
accused of bullying or harassing behaviour towards someone else.
The service is an independent advisory service that helps staff to understand what is
happening to them and to talk through their issues. Advisors guide staff through the
Trust’s Bullying and Harassment (Dignity at Work) policy and support people in
identifying practical solutions wherever possible. Naturally, the service is completely
confidential.
All the advisors are passionate about what they do and are fully committed to helping
staff through difficult situations. Tackling bullying in the workplace has its challenges
but, for most advisors, becoming part of this service has been a rewarding
experience for them in many ways.
The service will continue to be advertised and other ways of encouraging staff to
seek support will be investigated.
Tackling Bullying and Harassment in the Workplace Training
The Equality and Engagement Team have continued to deliver targeted training
around tackling bullying and harassment in the workplace, which has been extremely
well received. The session has been delivered to whole teams in their place of work
as well as within the education centres on each site.
Part of the session involves creating a ‘mission statement’ – a departmental
‘constitution’ to tackling bullying head on. Three examples have been chosen in
order to demonstrate how participants respond to this sensitive issue. If you would
like to see more of the mission statements contributed by staff, please refer to the
Trust’s Bullying and Harassment intranet web pages.
4.3
Carers
It is estimated that around six million carers in the UK provide unpaid care by looking
after an ill, frail or disabled family member, friend or partner. Around 2.3 million
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Item 13
Trust AGM
people become carers every year. Almost three quarters of carers suffer financially
as a result of caring, with many having to give up their jobs.
The Trust has pledged to help identify and support staff and patients with a caring
responsibility. We have also committed to helping signpost carers to appropriate
support and include them as partners in care.
Carers Outreach at Fairfield General Hospital
The Carers Centre at North Manchester Hospital and the Carers Information Point at
Fairfield General Hospital are both now up and running offering a support service for
anybody who is an unpaid carer using hospital services (this includes staff, patients
and visitors). The outreach point at Fairfield General Hospital is jointly staffed by the
Trust and The Princess Royal Trust Bury Carers Centre. The Trust has 3 dedicated
volunteers at each site who help the Carer Coordinator identify carers who need help
and support via weekly ward walks around the hospitals.
The carers centre staff have given out over 650 leaflets to carers in the last 12
months and most of these carers have received advice and support whilst on the
ward. We also have carers who use the telephone advice service available and
some that prefer to use the drop in service at one of the Carers Centres. In the last
12 months we have seen over 150 carers who have required one to one support at
the Carers Centre.
The aim is to make sure that carers feel supported in their caring roles, offering them
advice and information about the support services available to them but also to make
sure that there is an effective transition from hospital to home for the patient and
carer.
4.4 Equality and Diversity in the Learning and Organiational Development
Department (L&OD)
The Trust aims to enable its staff to provide high quality services and optimum levels
of patient care. This is achieved by providing learning opportunities which are
effective, flexible and fair to meet the needs of its staff, the teams they work in and
the organisation as a whole.
The Trust is committed to equal opportunities and an organisational culture which
supports and promotes life long learning through the ethos of a learning
organisation. In addition, the organisation recognises the crucial part education can
play in improving the working lives of staff. Learning opportunities are delivered in
environments which are:



conducive to learning
led by qualified and experienced staff
fit for purpose
Tailored to the needs of the individual, including making reasonable adjustments
where necessary.
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All staff have access to a full range of mandatory clinical and non-clinical training
opportunities, and training bulletins are widely available on the Trust’s web pages
and within the education and training departments.
All members of staff have access to training opportunities, although data shows that
male members of staff appear to access training more regularly than female staff.
Also, staff over 56 years of age access educational opportunities more regularly than
staff in the age range 31 to 55
The education, training and development team are working continuously to improve
access for all members of staff and to ensure fair and equal access to training and
career development opportunities.
Support worker Career Pathways
Supporting equality of learning opportunities for all staff within the organisation has
been a focus of the L&OD department in 2012. This year L&OD have commenced
work on the development of career pathways for support staff in the Band 1 to 4 staff
groups. This work has involved collaborative work with staff representing all groups
inclusive of facilities admin and clerical and health care support staff and union
learning reps. This work will provide the facility of accessing training information on a
specially designed web page demonstrating the career pathways for these staff
groups.
Development of support workers policy
In order to support the equitable approach to learning a policy is being created for
the development of a support worker career framework outlining the commitment
that the trust makes to ensure equal opportunities for all staff groups and to the
National Skills Pledge and Apprentice Promise
Adult Learners’ Week
The 2012 Adult Learners’ Week has focused on creating awareness of the training
opportunities for support workers, offering information and support on accessing
relevant training opportunities, access to IT and library facilities. The display stand
was presented across all the hospital sites throughout adult learners’ week and was
supported by the L&OD staff; ward and departments were also visited to promote the
training opportunities.
Other initiatives
The Promoting Equality and Diversity in Education and Life Long Learning (PEDELL)
group has a membership made up of education and training staff, with support by
attendance from ward staff with a special interest in dyslexia and representation from
the Equality and Engagement Team. Work of this group is reported to the
Educational Operations Group and the Education and Training Quality Forum. The
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Item 13
General Training
group receive reports on equal opportunities data. Current work streams of the group
are aimed at promoting educational opportunities to all staff within the Trust.
The PEDELL group have created a web page with links to information and support,
including a list of the resources available, such as assistive technology within the
department to support learners with dyslexia. The ‘Learning Difficulties’ link on the
web page provides a resource for trainers, students and managers with a focus on
visual and hearing difficulties.
Over recent months, the Education and Training Team have been developing
reasonable adjustment guidelines to support the learner undertaking training within
the department. These guidelines summarise the activity of the department in its
duty to incorporate equality for provision of learner support and environmental
considerations. The key principles or aims of the guidelines are to explain how the
Education Centres will manage reasonable adjustments, how Education Centre staff
will support learners in practice and to identify roles and responsibilities.
4.5
Ethnic Health Team
Effective communication is key to building any human relationship, whether in a
social or professional context. One of the main aims of the Trust is to ensure that all
our services are equitable and fair in terms of its accessibility. The Trust ensures
increase access to its services and to promote social inclusion, changing the way
interpreting services are used can improve patient care.
The Trust has been using interpretation and translation services for over 18 years to
ensure that people whose first language is not English and those with sensory
difficulties have access to support to enable them to make informed choices about
their healthcare.
The provision of these services has grown to 16 on-site interpreters at The Royal
Oldham Hospital and Fairfield General Hospital and approximately 150 bank staff.
These interpreters speak approximately 90 languages, (we have seen an increase of
30 languages from the previous year) from the more requested ones of Urdu,
Punjabi and Bengali, to diverse and rare languages such as Arabic, Farsi, Ukrainian
and even Yoruba. Other rarer languages are supported by agency interpreters or
telephone interpreting.
4.6
The Pennine Acute Learning Disability Partnership
Dignity is
“Asking if it is OK
if students observe
my examination ”
18
The Pennine Acute Learning Disability Partnership
meets bi-monthly and has developed good links with
the community teams in the local areas. The
membership has been increased to reflect the
requirements of planning and developing a
streamlined service for patients with learning
disabilities. Below are some key areas of activity
and development over the last year.

The Trust has been supporting quarterly inter
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
There is a Strategic Learning Disability Group that feeds into the Trust
Safeguarding Adults Group that in turn reports to the Trust Board via the
Executive Medical Director and Clinical Governance and Quality Committee.

It has been agreed that beds are being ‘ring fenced’ for patients with learning
disabilities for elective admission to ensure that planned complex pathways of
care do not fall down and that patients are admitted with the minimum of fuss and
disruption. This is working well and feedback from Community LD Hospital
Liaison Nurses is good.

We have a range of leaflets which have been developed in accessible, such as
the easy read complaints leaflet and newly developed ‘talking leaflets’. Links to
external websites have also been established on the learning disability internal
web page for staff to access accessible information for many types of medical
problems and surgical interventions should they be required.
4.7
Equality and Diversity in Recruitment
Over the last 12 months, the Trust has continued to create strong links with local
schools and colleges. In particular, work is on-going to develop networks with those
external organisations that provide career advice, guidance and continuous support
for people who have left school and are seeking local employment.
The Trust is committed to helping the local communities through difficult times and
believes that doing this leads to long-term benefits for both the Trust and local
communities.
Widening Access
This year the Trust has accommodated several school Year 10 placements on all
four sites through the Open Road Program, this has been a great success and whilst
some schools that took part last year have withdrawn due to funding, they have been
replaced with alternative schools. In addition to the school places there have been
over 300 ad hoc placements booked in 2011 and there are 170 booked in 2012 so
far.
The Trust has also arranged educational and career events, supporting local
communities, this has built very good relationships, promoting the Trust in a positive
manner, this includes specific job role workshops, and introduction to medicine
events aimed at prospective medical students.
The Bridging the Gap scheme has been further implemented this year, advising on
placements and arranging workshops for the students to gain an insight into some
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Item 13
professional full day training sessions for students from nursing, occupational
therapy, dietetics, physiotherapy, medical and speech and language therapy
disciplines.
job roles within the Trust. In addition the Trust has supported the team with admin
advice and support, sharing good practice ideas to benefit the scheme and students.
Foundation Trust Membership has also been a focus through the year, coordinating
school visits with the FT Manager, providing a presentation to be shown at the
events, and mailing all work experience students with membership forms to increase
the younger members and offering them the opportunity to potentially become
governors in the future.
New cohort for the Newbridge School Oldham and Royal Oldham Hospital link
during 2013/14 with expansion to Rochdale and North Manchester Sites
We are pleased to report that the New Bridge School initiative continues to grow.
Following the success of the first cohort of students, we have supported a further six
students this year. The students are aged 18 – 19 years old, from the Learning
Centre at New Bridge School. They are supported in real work placements which
provide the opportunity for them to develop the skills and qualities needed for
success in work and everyday life.
The programme has also expanded to a further two schools; Rochdale infirmary will
link with Redwood School and North Manchester General Hospital with Northridge
School. With 6 students for each cohort, plans are being finalised with a view to them
commencing with the Trust in September 2013.
The programme offers the students:
Employability – students have the opportunity to explore pathways into the world of
work. Enables them to practice the importance of reliability, working with colleagues,
practice good timekeeping and attendance, and be willing to learn new tasks and
follow instructions.
Independence Skills – these skills are vital for adult life. All students have the
opportunity to work with the travel trainers on independent travel skills, particularly
on the route to and from home to the hospital.
Communication Skills – The placements provide many opportunities to practice good
communication skills both within the workplace and class room setting. The
emphasis is on developing skills working effectively as part of a team.
Social/Life Skills – part of the programme allows time for developing social skills.
This includes specific time spent out of placements with other students on the project
as well as various off-site activities.
The programme is successful due to the commitment provided by the hospital based
managers supporting the programme, which covers areas within HSDU, Portering,
Health Records, Education and Training, Discharge Lounge, A1 ward, Laundry and
Catering.
20
Naheed Nazir – Head of Equality & Human Rights June 2013
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Other recruitment initiatives to support equality

The Trust’s Recruitment Code of Practice reinforces our commitment to value
diversity and remove unlawful discrimination, and sets out effective and equitable
processes. The policy has been widely disseminated across the Trust.

A recruitment training course is available for all managers and is held within the
Trust’s human resources training programme. The programme has been
designed to ensure managers understand the recruitment process and how to
implement staff policies and procedures in a fair and equitable manner.

The chairperson of each selection panel must undertake recruitment and
selection and equality and human rights training, signing documents within the
recruitment pack to identify their compliance.

As part of the Improving Working Lives Strategy, the Trust offers a
comprehensive adult and child care advice and information service to current and
prospective members of staff. Employees have direct access to the adult and
child care co-ordinator who will act as advisor, advocate and source of expertise,
providing support in all adult or child care requirements.

The Trust has the Two Ticks employer accreditation which demonstrates its
commitment to employing disabled people. In particular, applicants who disclose
a disability are guaranteed an interview if they meet the criteria for the role.

The Trust is continuing to raise disability awareness and provide information to
existing staff and new candidates to encourage them to feel comfortable in
declaring their disability. This will also help to ensure that applicants and existing
staff are aware of the support available from the Trust’s occupational health
department and how to obtain an assessment for reasonable adjustments if
necessary.
4.8
The Spiritual Care Team
According to Swinton (2005): “Illnesses are deeply meaningful events within people’s
lives, events that often challenge people to think about their lives quite differently.
Spirituality sits at the heart of such experiences. A person’s spirituality, whether
religious or non-religious, provides belief structures and ways of coping through
which people begin to rebuild and make sense of their lives in times of trauma and
distress. It offers ways in which people can explain and cope with their illness
experiences and in so doing discover and maintain a sense of hope, inner harmony
and peacefulness in the midst of the existential challenges illness inevitably brings.
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Naheed Nazir – Head of Equality & Human Rights June 2013
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Item 13
Without this fantastic engagement and support from the managers the programme
would not have been a success. The tutors from New Bridge who are based in the
Education Centre at Oldham throughout the duration of the placements, prove to be
an invaluable resource which has helped address initial reservations from some
placement areas. The feedback from managers who have supported a student
during the programme has been very effective in selling the programme to other
potential areas.
These experiences are not secondary to the ‘real’ process of clinical diagnosis and
technical care. Rather they are crucial to the complex dynamics of a person’s
movement towards health and fullness of life even in the face of the most traumatic
illness”.
Swinton J in Cobb M (Ed) (2005) The Hospital Chaplain’s Handbook, Canterbury Press: Norwich.
In other words, spiritual care is for everyone which is our whole approach as a Trust
as we continue to offer high quality input to patients, relatives and staff. The Royal
College of Nursing have seen good spiritual care as being an essential part of
holistic healthcare which has led to the creation of have an online module raising the
of awareness of the nursing profession. There is also a ‘Spirituality’ module on the elearning programme. Dignity lies at the heart of good spiritual care as individuals
needs are respected and valued at all times.
As part of our ongoing development, we have taken part in an audit looking at
spiritual assessment as part of the LCP and produced a guidance document that is
on the intranet which provides guidance for ward staff when caring for patients from
a wide variety of faith and belief backgrounds. This is document EDN011 V2 and
can be found under nursing documents and is also on our intranet page. The
document covers areas such as death and dying, hygiene, food, religious needs, as
well as giving some cultural and religious background for many Christian, Jewish,
Islamic faith groups and many more. We have also distributed A5 laminated locker
leaflets informing patients about our Spiritual Care Team and how to ask for some
input.
The chaplaincy team continue to work alongside all health professionals as the
importance of good spiritual care is mentioned more frequently in NICE guidelines
for Palliative care, by the Royal College of Psychiatrists working with people with
mental health issues and in basic nursing care as highlighted by the RCN. As a
team we have joined the current Listening into Action initiative to look at how we
work trying to be more effective and efficient in how deliver good spiritual care. We
continue to offer support to those who have suffered mis-carriages and still-births by
being there on the wards and in our annual baby memorial events. We also work
closely with the Palliative care teams, particularly those on the LCP and visit wards
on a regular basis. As we support staff living through uncertain times with all the
challenges that come with it we do so as a team that includes employed staff and
many valuable volunteers representing depth and diversity and wanting to promote
dignity through good, consistent spiritual care.
4.9
Equality and Human Rights in Voluntary Services
Pennine Acute Trust is very proud to have the largest group of known volunteers in
an acute trust throughout the United Kingdom with almost 900 volunteers. These
volunteers play a crucial role in assisting staff to support patients whilst in hospital
and ensure their human rights are maintained in a variety of ways. The volunteers
are an invaluable resource to the organisation (see the recent Voluntary Services
Annual Report for more information on volunteer activity). The authors of this report
would like to highlight several key areas where developments have been made, over
the last twelve months, regarding how volunteers contribute to advancing and
upholding patient’s human rights.
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Naheed Nazir – Head of Equality & Human Rights June 2013
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In June 2012 the Trust introduced a Cancer Buddy service. This service is delivered
by a team of 8 buddies (volunteers) who have experience of cancer, either as a
patient or family carer. They are able to talk about their experiences and offer
support in coping with a cancer diagnosis and offer emotional support and a
‘listening ear’ to people affected by cancer, with the aims of lessening feelings of
isolation and increasing confidence and self esteem. The support offered by a buddy
is pre arranged as a mutually convenient appointment and is time limited, generally
one hour. It is via face to face meetings at a location on one of the Trust sites.
Contact between buddies and patients are arranged via the Buddy Scheme
Coordinator following referrals from Clinical Nurse Specialists, Medical Staff or the
Macmillan Information and Support Centre.
Patient Forum
In October 2012 the Trust established a Patient Forum which meets once a month.
The Forum has been established to positively promote patient and public partnership
within the Trust, providing the patient and carer perspective on issues of discussion
both within the forum and in wider groups on which forum members serve. This
group which aims to be representative of the community in which the Trust serves,
have looked at a number of issues which include the future strategic direction of the
Trust, Pathology services, infection control and information management and
technology.
Meal Support FGH
Volunteers have been offering meal support across the inpatient wards for a number
of years, however to maximise the support provided ensuring the most vulnerable
patients receive the support, volunteers now report to Clinical Matrons at North
Manchester and Fairfield General Hospitals and Dieticians at The Royal Oldham
Hospital. Volunteers receive full training and through their input patients food intake
is increased, they are being given a choice in the food they are served and there is a
reduction in food wastage.
Outpatient Department Volunteers
This year the Trust has seen a significant increase in the number of volunteers
offering support in the Outpatient departments across the Trust particularly at North
Manchester General Hospital. Volunteers escort patients to the correct location
within in the department, give general advice and provide a much needed listening
ear.
Radiology Volunteers
Following the success of the introduction of volunteers within the Radiology
Department at North Manchester General Hospital, a new volunteer service was
established within Radiology at The Royal Oldham Hospital. Volunteers offer
23
Naheed Nazir – Head of Equality & Human Rights June 2013
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Item 13
Cancer Buddy Service
reassurance and support, and where appropriate helping patients to undress in
preparation for a scan.
5.0
Future Work and Challenges Ahead
Review of the Single Equality Scheme
We will be reviewing the Single Equality Scheme in light of recent changes to
legislation and public sector duties. There will be discussion with regards to replacing
this scheme with a strategy and decisions will be made following wide consultation
with our stakeholders, community groups, patients, carers and staff.
Donor Campaign
The Equality Team will be looking at a range of avenues to raise the awareness of
becoming a donor amongst the BME community in particular. The team will be
working alongside third sector and community groups in order to engage and involve
people at grass root level within the community. This will be a great challenge as this
is considered to be a taboo area amongst the BME communities and hence the need
for raising as much awareness as possible.
Disability and Access Audits
The Trust is required by legislation to ensure that we have disability and access
audits conducted on sites that we operate from. We have identified independent
organisation to conduct these audits across all four sites over the next year. A full
report and recommendations will be produced and published once they have been
completed.
Celebrating Diversity
A new project will be launched to celebrate the range of diversity that we have within
the Trust. We have staff that represent a wide range of countries and cultures from
around the world and we want to showcase the talent, perspectives and beliefs they
bring into the Trust. This offers opportunities to better meet the needs of the diverse
population that we serve and helps provide an environment which promotes positive
experiences for both staff and patients.
International Conference – Thinking Globally ‘Achieving Inclusion through
Partnership working’
The Trust has been invited to participate in an international conference being
held by the Fire Service in conjunction with the NHS. The Trust has been
approached to highlight and showcase the work it has achieved in developing
engagement with staff and patients through conversation.
NHS Employers Partner Status - A Personal, Fair and Diverse NHS
Achieving the partner status with the NHS Employers will now require the Trust to
demonstrate and highlight that equality and human rights is a golden thread within
our organisation. The Trust will need to follow the planned programme and show
24
Naheed Nazir – Head of Equality & Human Rights June 2013
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We are working with the Equality and Diversity Council (EDC) through NHS
Employers to encourage NHS staff to become champions. The aim is to create a
vibrant network of champions who are committed to taking action, however small, to
create a personal, fair and diverse NHS.
A personal, fair and diverse NHS is one where:









everyone counts
services are personal, designed to give patients what they want and need
fairness is built in- so that everyone has equal opportunities and treatment
the skills and experiences of employees from all backgrounds are used and
valued
people can choose the services they want and have as much support as they
need
everyone is treated with dignity and respect, and when they complain - we
listen and put things right
talent flourishes and nothing stops people going as far as they want
we are accountable and patients are informed and have more control
care doesn’t stop at the door, but helps people live healthier lives
Equality Objectives March 2012 – 2016
5.1
Following the EDS engagement events and workshops earlier in the year the
objectives below have been set to allow the Trust to move towards the next levels of
achievement in the grading.
These objectives will direct the four year action plan which will be monitored at the
Patient Experience and Equality and Diversity Committee, and via continuous
community engagement events that will occur over the next four years.
Overarching objective:
To undertake a data cleansing exercise for staff and patient equality data
monitoring information.

Set up/update existing systems to collect data for all relevant protected
characteristics

Design and deliver training for staff in the collection of equality monitoring
information
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Naheed Nazir – Head of Equality & Human Rights June 2013
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Item 13
their dedication by achieving the goals and targets set by them. One particular
campaign that we are asked to support and embrace is to actively promoting the
Personal Fair and Diverse Campaign.

Begin review of equality monitoring data collected from January 2013

Publish equality monitoring action plans from August 2013
Engagement:
At a local level, increase engagement with staff and staff-side organisations, and
patients, carers and local interest and community groups and Foundation Trust
members.

Build upon existing engagement activity and publish a long-term engagement
plan to ensure that staff and staff side organisations, and patients, carers and
local interest and community groups are afforded the opportunity to participate
in and contribute to the design and delivery of services.
Mainstream processes:
Promote and advance dignity and respect in the delivery of care by all staff for
all patients.

Service impact assessments through engagement

Caring for patients with dementia and their carers

Discharge planning processes

Complaints analysis
Promote and advance dignity and respect in the workplace through:
 Pay gap analysis

Flexible working reporting process

Tackling bullying and harassment in the workplace

Health and well-being initiatives

Equality and diversity corporate objective within all staff personal development
review objectives by March 2013
Disadvantaged groups:
Increase engagement with seldom heard groups within the Trust’s local communities
and workforce.

Improve engagement work streams to ensure that all key disadvantaged
groups are informed and involved, such as women and men’s groups, lesbian,
gay, bisexual and transgender (LGBT) communities, Black, Asian and
minority ethnic (BAME) communities.
26
Naheed Nazir – Head of Equality & Human Rights June 2013
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The Trust’s four-year equality objectives were published in April 2012 and reviewed
in December 2012 and January 2013.The EDS will provide a framework for the
development of equality and human rights work in Pennine, and will form the
platform for the organisation of the Trust’s 4 year equality objectives and associated
action plan.
In the next twelve months, the Trust will be collating and developing relevant
datasets, with systems for providing updated reports and a regular reporting
structure, so that progress can be monitored. There will also be focus on collecting
data in the areas where the trust has less information – in particular in the areas of
disability, sexual orientation and religion/belief.
Current work in relation to reasonable adjustments, improving access for people with
physical disabilities, providing better access for people with learning disabilities and
increasing the numbers of staff who have completed the mandatory equality and
diversity e-learning will continue, along with current working actions with
stakeholders, strengthening the networks and developing links with local
communities.
Appendix 1
Patient and Staff Profile and Developments during 2012/13
Data monitoring figures as part of reports published Jan 2013 are available on the
Equality and Diversity web pages, including patient attendance, experience and
mortality, workforce profile, training data and workforce performance. Available at:
http://www.pat.nhs.uk/PublicDefault.aspx?tabindex=1&tabid=683
Please contact the Equality and Engagement Team if you require more information
Contact Details
Email:
Tel:
[email protected]
0161 604 5893
If you require any further information or would like to receive this report in an
alternative format, please contact us.
27
Naheed Nazir – Head of Equality & Human Rights June 2013
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Item 13
And finally……
Page 239 of 318
Improved
equality
monitoring
data collection
across all NHS
services
Equality
Objective
Trust Values
Equality Objectives Action Plan 2013-2018
Deliver
Improvement
in outcomes
for patients
Goal 1:
Better health
outcomes for
all
Relates to all
Groups
Meets
Equality aims
1, 2, and 3
1. To review
effectiveness of the
information and data
collection systems.
2. To identify areas
where there are gaps
and issues
3. Ensure we have
sufficient data in
order to establish
baseline covering all
protected groups,
across all NHS
services including
access, disease
specific, patient
experience and
complaints.
4. Set targets of
achieving a 10%
increase year on
year.
1. Trust to have a clear
demographic map of
the borough
2. Trust to have clear
understanding of
health needs of
each equality group
3. To map access to
services by equality
groups
4. Local services
tailored to needs of
community
5. Staff will be better
equipped to ask the
sensitive questions
as part of the data
monitoring of
protected
characteristics
6. Trust will be
meeting the Equality
IT / ESR
with
support
from L&OD
and E&E
Team
To be
reviewed on
annual basis
Bi-monthly
reporting to
Quality
Leads
meeting
Quarterly
Board update
Reported bimonthly at
Patient
experience &
Equality
committee
Treating everyone with respect and promoting good working relationships will support individuals in reaching their full Potential.
Strategic
EDS Goal
Equality
Equality
Action
Outcome
Lead
Timescale
Aims
&
Group
Aim
outcome
Accountability, honesty and integrity are keys to our success both individually and across the Trust.
Patient care is at the centre of everything we do. We work together to deliver a high quality service to provide the best
possible outcome for our patients.
Appendix 2
Page 240 of 318
Develop an
effective
partnership
approach to
delivering
robust
responsive
services
29
Improved
patient
access and
experience.
Relates to all
Groups
Meets all the
Equality Aims
Naheed Nazir – Head of Equality & Human Rights June 2013
Deliver
improvement
in outcomes
for patients
Deliver
through the
health and
wellbeing
board
improved
population
health and
reduction
inequalities
5. Design and deliver
training for staff in the
collection of equality
monitoring
information.
6. Review of equality
monitoring data
7. Publish equality
monitoring action
plans
1. Developing and
creating partnerships
with the third sector
and community based
organisations.
2. Involving and
communicating with
third sector and
community based
organisations earlier
in the planning of
services in order to
target health
inequalities.
3. Target health
campaigns via
community resources
to help deliver the
health campaigns.
4. Local services to be
tailored to needs of
community.
5. Equality target group
health needs
assessment
6. Promote diversity
through range of
events, focus on
specific health issues
1. That all patients,
carers are able to
access services
without
discrimination or
disadvantage;
2. That our services
are flexible and
accessible to all
communities;
3. That contractors
and service
providers share our
equality values and
help achieve our
objectives;
4. That we help to
improve health in
Equality Target
Groups and reduce
inequalities across
the communities.
5. Increase life
expectancy among
minority and
vulnerable
communities
6. Increase access to
cancer screening,
legalisation by
publishing the
reports.
To be
reviewed on
annual basis
Bi-monthly
reporting to
Quality
Leads
meeting
Quarterly
Board update
Reported bimonthly at
Patient
experience &
Equality
committee
Ongoing
Item 13
Director of
Nursing /
Patient
Experience
Lead /
Head of
ED&HR
Page 241 of 318
Promote and
advance
dignity and
respect in the
delivery of
care of all
patients
30
Goal 1:
Better health
outcomes for
all
Relates to all
Groups
Meets
Equality aims
1, 2, and 3
Naheed Nazir – Head of Equality & Human Rights June 2013
Deliver
Improvement
in outcomes
for patients
1. Review service
impact
assessments, to
ensure that
patients and
communities are
involved in
service plans and
developments
2. To ensure that
dementia patients
are receiving
appropriate care
and the Trust has
a strategy to take
this forward.
3. Review discharge
planning process
to ensure
vulnerable groups
are not
disadvantaged
4. Review of
complaints
analysis, to
ensure equitable
services are
being delivered
related to equality
target groups.
smoking cessation,
weight
management,
alcohol and
diabetes by
protected groups.
7. Improve patient
feedback ratings
among local equality
groups.
8. Ensures that the
patients, carers,
local interest groups
and communities
are afforded an
opportunity to
participate in and
contribute to the
design and delivery
of services
9. Improve patient
feedback ratings
among local equality
groups.
Across all
Divisions /
Head of
Complaints
/ Support
from E&E
Team
To be
reviewed on
annual basis
Bi-monthly
reporting to
Quality
Leads
meeting
Quarterly
Board update
Reported bimonthly at
Patient
experience &
Equality
committee
Page 242 of 318
Being a
employer who
embraces the
concept of
work life
balance
Develop
Trust
capability as
leaders
Empowered,
engaged and
well
supported
staff
Relates to all
Groups
1. Value individuals and
promote self
development.
2. Develop a workforce
which is well trained and
equipped
3. Develop mechanisms to
monitor requests and
agreement on flexible
working to ensure
equitable access to
provision
4. To reduce the incidences
of bullying and
harassment
5. To ensure all staff have
equality and diversity
corporate objective within
all staff personal
development review
objectives
6. Managers are supported
to deliver and support
staff to work in culturally
competent ways.
7. Ensure that all staff
receives the mandatory
equality and diversity
training.
8. Ensure that all staff
receives the EIA
masterclass, EDS
masterclass, Equality
monitoring training.
9. Encourage all staff to
become Personal Fair
and diverse champions
10. Building Human rights
into working practice –
1. Workforce to
reflect local
demographics
2. Staff is trained
and feel confident
in working with
diverse
communities.
3. Staff are free from
abuse,
harassment,
bullying, violence
from both patients
and their relatives
and colleagues,
with redress being
open and fair to
all.
4. Flexible working
options are made
available to all
staff, consistent
with the needs of
the service, and
the way that
people lead their
lives. (Flexible
working may be a
reasonable
adjustment for
disabled
members of staff
or carers)
To be
reviewed
on annual
basis
Bi-monthly
reporting to
Quality
Leads
meeting
Quarterly
Board
update
Reported
bi-monthly
at
Patient
experience
& Equality
committee
Item 13
Head of
ED&HR,
Workforce
manager,
Training
manager
All divisions
Director of
workforce
and
development
Page 243 of 318
32
Naheed Nazir – Head of Equality & Human Rights June 2013
equip staff to understand
their rights and
responsibilities under the
Act and build
development of human
rights into our policies
and practices.
Page 244 of 318
Being an
Inclusive
Leader
Develop
Trust
capability as
leaders and
Inclusive
leadership at
all levels
Relates to all
Groups
1. That Trust is an
example to the
community of equality
and diversity;
2. That we meet and
surpass all national,
regional and local
standards for
equality,
Diversity and human
rights.Ensure that we
equality assess all
policies, procedures,
strategies and services.
3. That we champion
best practice and
share it across the
community
4. Joint working with
Partners – work with
partners to share
knowledge and best
practice on equality
agenda.
5. Develop a Equality
Charter partnership
arrangement
6. Equality website
development –
prioritise development
of website to improve
information and
increase accessibility
7. Being an NHS
Employers Equality
Partner – apply to
work with NHS
Employers as an
‘equality partner’
1. To ensure the
organisation is
implementing the Equality
Competency framework
2. Meet legal and
statutory obligations
around equality
3. Influence local
partners to
improve
equity and community
cohesion
7. That we act as a good
corporate citizen.
To be
reviewed
on annual
basis
Bi-monthly
reporting to
Quality
Leads
meeting
Quarterly
Board
update
Reported
bi-monthly
at
Patient
experience
& Equality
committee
Ongoing
Item 13
Exec
Director of
HR
Lead
Manager –
Head of
EDHR /
Head of
Communic
ations
Page 245 of 318
34
Naheed Nazir – Head of Equality & Human Rights June 2013
Rochdale Demographics
Population: Rochdale currently has 211,700 people in the borough (ONS Census
2011). This is expected to rise by a further 3.8% over the next 20 years.
Deprivation: The population experiences high levels of deprivation. Two fifths of
Rochdale Borough residents experience relatively high levels of disadvantage, with
18% considered to be in the most vulnerable group and a further 22% at risk of
becoming vulnerable. Wealthy residents make up only 6% of the Borough (MOSAIC
segmentation - see section 4 of this document).
Ethnicity: The population is ethnically diverse, with 17,200 people from a Pakistani
origin. This is about 8.3% of the Borough (ONS 2010). In the most disadvantaged
groups, around a quarter of people are of Asian origin. These groups are also
generally younger than the general population.
Age: Rochdale has a greater proportion of 0-14 year olds than either Greater
Manchester or England and Wales (ONS Census, 2011). Compared to Greater
Manchester, Rochdale has a smaller proportion of 15 to 44 year olds, though a
larger proportion of older working age people, aged 45-64. Rochdale has a similar
proportion of people aged 65 and over to Greater Manchester. However, it also has
a growing proportion of older people. In future we expect there to be a greater
proportion of elderly residents compared to those of working age as people are living
longer. The population aged 65 or over in Rochdale Borough is expected to increase
by 34.6% between 2008 and 2025 (ONS 2010).
Lifestyles and Wellbeing
Smoking: Most local people are non-smokers, but 1 in 4 adults in the Borough do
smoke. For people who are in routine and manual jobs in the Borough, as many as 1
in every 3 will smoke. 1 in 5 pregnant women smoke throughout their pregnancy.
This is high compared with other places (DoH Health Profiles 2011). More local
people die from smoking than in other areas. Our smoking attributable deaths per
100,000 population is 281.7, 23% higher than the England average and 5% higher
than in the rest of the North West (DoH Health Profiles 2011).
Alcohol: A high number of local people end up in hospital because of alcohol.
Alcohol-related hospital admissions are higher in Rochdale Borough than in the rest
of England; 2,832 per 100,000 population compared to 1,743 per 100,000 in England
(DoH Health Profiles 2011).
More local people die early because of alcohol, compared with other areas.
Rochdale Borough’s Alcohol Profile 2011 (LAPE 2011) tells us that the average
number of months of life lost due to alcohol for males is 13 months, and for females
5.7 months. This is higher than the regional average of 12 for males, but lower than
the regional average for females (5.9). 1 in 4 people in the Borough binge drink and
Page 246 of 318
Item 13
Appendix 3
7% are estimated to be drinking at high risk levels, harmful to their health. Alcohol
misuse is one of our main contributors to chronic liver disease, crime and sexual
offences (DoH Health Profiles 2011).
Diet: Most local people try to eat well. However, almost 1 in 4 people in Rochdale
Borough have a poor diet. Healthy eating for adults in England is almost 5% higher
than for adults in the Borough (DoH Health Profiles 2011).
Physical Activity: 64% of children in our Borough are physically active, which is
above the England average of 55.1%. However, only 12% of adults in the Borough
take part in regular physical activity. This is a major risk factor for a range of chronic
diseases and disorders, and links directly to levels of adult obesity in the Borough
(DoH Health Profiles 2011).
Healthy Weight: 1 in 4 local adults are classed as obese (DoH Health Profiles
2011). In children, 11% of reception year are already obese (compared with 9.4% in
England, and 9.6% in the North West). In year 6, obesity rates are as high as 21%
(19% in England, 19.7% in the North West).
Wellbeing: Wellbeing is generally about realising one’s own potential, coping with
the normal stresses of life, working productively and contributing to society.
Wellbeing, physical health and lifestyles are all closely linked. Wellbeing is important
to health and important to local people. The North-West Wellbeing Survey in 2009
told us that Rochdale Borough had the 6th highest wellbeing of 19 Boroughs across
the North-West with an average score of 28 out of a possible 35. Whilst wellbeing in
our local population is generally good, we know there are groups of people that have
poor levels of wellbeing and may benefit from support. MOSAIC segmented data
tells us that wellbeing is lower in males in our most deprived groups.
Life Expectancy
Local people can now expect to live longer. Between 1991 and 2010 in the Borough:
• Male life expectancy at birth increased from 71.4 years to 76.3 years (risen
by 4.9 years)
• Female life expectancy at birth increased from 77.5 years to 80.6 years
(risen by 3.1 years) (APHO,1991-2012)
However, people in Rochdale Borough still live 2 years less than nationally, and
within the Borough a person in the most deprived group might expect to live 10 years
less than someone in the most affluent group. This is an unfair Health Inequality.
What Causes Earlier Deaths in Rochdale Borough?
A large proportion of early deaths are caused by heart disease, digestive disease
(including liver cirrhosis) and lung disease (including lung cancer) (NWPHO, 2011).
These conditions are largely preventable through not smoking, drinking alcohol
within recommended levels for health, maintaining a balanced diet, being physically
active and maintaining a healthy body weight. Some people find it easier than others
to have a healthy lifestyle and we need to understand and tackle those barriers. We
can also identify and support people who are at risk from developing these
conditions as they are more likely to e.g. smoke, have a persistent cough, have high
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Circulatory Disease
The death rates of Cardio-Vascular Disease (CVD) over the past 17 years have
fallen nationally and locally (by 54% since 1995). Despite this fall, early death rates
from cardiovascular disease (‹75 years) are still significantly higher than the national
rate (SEPHO 2010). Men are more likely to experience Coronary Heart Disease
(CHD) than women (159.18 per 100,000 population of men in the Borough compared
to 78.38 for women in 2007-9). Emergency admission rates for both CHD and stroke
are significantly higher than the national rate. The deprived groups are still more
likely to experience CVD than the more affluent groups – another unfair health
inequality in our population.
Stroke
More local people end up in hospital or die from stroke than in other places.
Rochdale’s stroke mortality is 22% higher than the England average. Emergency
admission rates are significantly higher than the England average, and men’s
emergency admission rates for stroke are much higher than the rate for women
(APHO, 2010).
Cancer
Lung cancer is the Borough’s most common cancer, contributing to the early deaths
seen in our population, particularly now in women. Rates for all cancers in the
Borough are higher than the England average for males (205.14 per 100,000). Our
more deprived groups are more likely to die from cancer. The difference in cancer
death rates between the most affluent and most deprived people in the Borough is
134.83 per 100,000 population for men and 48.19 per 100,000 for women (ONS
2007-9).
Long-term Conditions (LTCs)
LTCs are conditions that people live with day to day, and if not managed well can
mean unnecessary repeat admissions to hospital, reduced quality of life and lower
wellbeing. Our most prevalent LTCs include obesity, hypertension and depression.
LTCs take up: 50% of GP Appointments; 70% of Primary Care budgets; and 70% of
Inpatient bed days.
Mental Health and Learning Disabilities
Around 4,270 people in the Borough (2%) are likely to be affected by severe mental
health disorders requiring support from secondary mental health services. Of these,
800 are estimated to have a psychotic disorder. Levels of common mental disorders,
including anxiety, depression and phobias, are estimated to affect 30,178 people
(14% of the population).
About 600 local people (age 18-64) have learning profound or severe learning
disabilities. We think they are all receiving services. However, there are around
3,500 people with a moderate level learning disability, of whom only 17% are known
to services (Rochdale Borough Mental Health and Learning Disabilities Needs
Assessments, 2009).
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blood pressure, have high cholesterol, be overweight or obese and live in the more
deprived areas of the Borough.
Oldham
Population
Oldham has a population of 218,800 according to the 2009 Mid Year Population
Estimates. The 2008-based Sub-National Population Projections for Oldham indicate
that the population will grow by an estimated 5% from around 218,200 in 2008 to
around 229,100 in 2022. The composition of this population is forecast to change
significantly over this time.
Oldham’s population is projected to grow by 10,900 by 2022, and much of this
growth can be attributed to an increase in population size within older age groups:
 the population of people aged 65-84 is projected to increase by almost a
quarter (24.1%), from 27,800 in 2008 to 34,500 in 2022;
 the population of people aged 85 or over is projected to increase by over a
third, (35.7%) from 4,200 in 2008 to 5,700 in 2022
 The proportion of Oldham’s male and female population aged 65 or over will
increase from around 14.9% in 2009 to around 17.5% by 2022.
According to the 2007 Experimental Mid Year Estimates by Ethnic Group, Oldham
has a higher proportion of non-white Black and Minority Ethnic (BME) residents
(16.7%) than the North West (7.9%) or England (11.8%). The age structure of
Oldham’s population varies with ethnic group.
White British residents are the largest ethnic group in Oldham (81.5%). Around
19.9% are aged 0-15 (compared with 22.2% of all Oldham residents in 2007), 60.6%
are of working age (compared with 60.0% of all Oldham residents in 2007)
Pakistani-heritage residents are the next largest group (7.0%). This population has a
youthful age structure. Within Oldham’s Pakistani heritage population, around
35.3% are aged 0-15 (compared with 22.2% of all Oldham residents in 2007),
around 60.1% are of working age (compared with 60.0% of all Oldham residents in
2007) and an estimated 4.6% are aged above working age (compared with 17.3% of
all Oldham residents in 2007).
The proportion of Oldham’s population from Black and Minority Ethnic (BME)
groups is forecast to increase from about 18.3% in 2010 to around one-fifth (19.4%)
in 2012, and to one quarter (24.6%) in 2022. This is predominantly associated with
the growth of Oldham’s Pakistani and Bangladeshi heritage communities and is
due primarily to the relatively youthful age structures of these populations.
Asylum Seekers, Refugees and Migrant Workers
In August 2010, 599 asylum seekers were accommodated in Oldham. Oldham has
people from forty-four different countries of origin who are seeking sanctuary. About
two-thirds (68%) of asylum seekers living in Oldham are from seven countries: Iran
(19%), Iraq (11%), Eritrea (9%), Afghanistan (9%), Zimbabwe (8%), Pakistan (6%)
and China (6%).
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Alcohol
In Oldham the story is very similar to that across other parts of the country, with
alcohol related hospital admissions increasing year on year. Synthetic model based
estimates of current alcohol consumption for primary care trusts across England
(2005) suggests that in Oldham:
21% of people binge drink
22.5% of people drink at hazardous levels
7% of people drink to harmful levels
Mental Health
Mental health conditions it is estimated that across Oldham there are 10,335 people
with depressive disorders and around 21,101 people with other types of mental
health conditions. Of the people known to have a mental health condition 12.5% are
estimated to have been referred to psychological therapies with 6.5% of patients
entering psychological therapies, 5% are estimated to be waiting for referral.
Long-term Conditions (LTCs)
Cancer
Between 2005-07 the highest percentage of cases of cancer in males was prostate
cancer. There were approximately 149 cases of prostate cancer diagnosed in
Oldham between 2005 and 2007. The directly standardised rate for prostate cancer
incidence in Oldham in 2005-07 was (124 per 100,000) which is higher than both the
regional (99 per 100,000) and national rate (100 per 100,000). Amongst females
breast cancer had the highest percentage of cases, with 139 cases being registered
in Oldham between 2005 and 2007. Oldham‟s incidence rate of breast cancer was
(108 per 100,000) which is lower than both the regional (123 per 100,000) and
national rate (123 per 100,000).
Stroke
Between 2007/09 there were 1307 people admitted to hospital as an emergency with
a primary diagnosis of stroke, with just over half of all these admissions being in
people under 75 years. The highest number of strokes occurred in the most deprived
wards of Coldhurst, Werneth, Alexandra and St Mary‟s, where rates were more than
twice as high as the less deprived wards.
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Smoking
Currently over 47,600 (28%) people over the age of 16 years are estimated to smoke
in Oldham. (Information Centre, 2005 model based estimates) This is higher than the
national estimated average of 22% and the regional average of 19%. However
recent survey data (ONS, General Household Survey 2007) suggests that smoking
behaviour reached its lowest recorded level of 21% in 2007 nationally. To decrease
inequalities the prevalence of smoking needs to decrease by at least 8% in Oldham.
This will increase life expectancy by 1 year in the most deprived populations. As a
result this would decrease the inequalities gap for health outcomes and life
expectancy by 15% between the most deprived wards and the rest of Oldham.
Circulatory Disease
In 2009/10 there were 8,344 people registered with coronary heart disease at GP
practices within Oldham The predicted prevalence of 5.4% in Oldham is slightly
higher than that for England, and is around 15% higher that the observed prevalence
Between 2007 and 2009 there were 1313 people admitted to hospital for myocardial
infarction (heart attack). The rate of emergency hospital admissions varied across
the borough with Saddleworth South having the lowest rate and Royton North having
the highest. The emergency hospital admission rate also varied between males and
females with nearly twice as many men (814) than women (499) presenting with a
heart attack.
Life Expectancy
According to the 2007 index of multiple deprivations, Oldham is the 42nd most
deprived local authority out of 354 authorities in England. The index of multiple
deprivations is a proxy measure of deprivation that takes into account the 5 domains
of Income, employment, Health & disability, Education & training, barriers to housing
& services.
Life expectancy has been steadily increasing in Oldham, across Greater
Manchester, the North West and England. However the gap between England and
Oldham does not appear to be narrowing.
Healthy Weight:
In Oldham around a quarter of the population are estimated to be obese with more
than half the Oldham wards having higher estimated obesity prevalence than the
England average.
Determining the causes of obesity is central to tackling it. The exact extent of the
relative
Diabetes
Across Oldham there are around 4.3% of the population registered with diabetes
with the predicted prevalence being 4.9%. However across Oldham there are wide
variations in the distribution of registered diabetes patients with the highest
prevalence rate being around 6.8% and the lowest being around 2.8%
North Manchester
Population
The most up-to-date data from Mid-Year Estimates (MYE) released by the ONS
shows that, in 2010, it was estimated that Manchester's population had reached
498,000. Around 71% of the population are currently estimated to be of working age
(16-64 years). This is substantially higher than the England average of 62%.
However, North Manchester has a slightly lower proportion of working age
population than the city average if 72.4%.
The proportion of young adults age 16-29 varies between 23% in Moston and 58% in
City Centre. Proportion of adults age 30-44 varies between 19% in Moston and
24.5% in City Centre and Ancoats and Clayton whereas proportion of adults age 4564/59 varies between 9.4% in City Centre and 21.4% in Moston.
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Alcohol
In line with national trends, alcohol consumption in Manchester has increased
significantly in recent years. Recent estimates suggest that approximately 29% of
adult drinkers in Manchester drink at increasing or higher risk levels, which is broadly
in line with estimated regional and national averages. This equates to around 80,000
adults in Manchester. The population of abstainers in Manchester is higher than the
regional average (20% in Manchester compared to 15% regionally).
These statistics mask a more complex picture. In areas of high deprivation, levels of
abstinence are higher, but those who do drink are more likely to drink over the lower
risk limits. Additionally, in the most deprived areas, rates of alcohol-related deaths
are approximately 45% higher when compared to the least deprived areas (three
times higher for women and five times higher for men). Manchester currently ranks
as the fourth most deprived local authority area in England. Based on data gathered
as part of a national needs assessment process, it is estimated that currently there
may be approximately 13,000 dependent drinkers in Manchester. Source: Alcohol
Needs Assessment Research Project (ANARP). London: Department of Health,
2005.
Manchester has one of the highest rates in England for alcohol-attributable hospital
admissions, and these have increased significantly over recent years. In 2010/11,
there were 13,783 admissions to Manchester hospitals for alcohol-attributable
conditions - a 150% increase since 2002/03. In 2010/11, the alcohol-attributable
admission episodes rate in Manchester was 3,279 per 100,000 population,
compared to 2,429 per 100,000 for the North West and 1,898 per 100,000 for
England. The most common reasons for alcohol related admissions in 2008/09 were
chronic conditions (58%), and mental and behavioural conditions (28%). There is a
strong link between alcohol-specific hospital admissions and deprivation, with three
quarters (73%) being generated by people who live in the most deprived areas of the
city (3-4 times the rate of admissions from the least deprived areas of the city). It is
estimated that each alcohol-attributable hospital admission costs the NHS an
average of £1,800.
It is estimated that 35% of attendances at hospital Accident and Emergency (A&E)
Departments are alcohol-related; this can rise to 70% at peak times (between
midnight and 5am at weekends). Between September 2009 and August 2010, it is
estimated that there were approximately 89,500 alcohol-related attendances across
the three A&Es in Manchester. This includes a number of individuals who have
repeat attendances at A&Es. It is estimated that the average cost per A&E
attendance with intervention(s) is £127.
Rates of mortality from alcohol-related causes are higher in Manchester than the
North West and England averages, particularly among men. Between 2007 and
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Population projections suggest a reduction in numbers of young adults aged 20-29 in
most of the wards in North Manchester, although there is predicted to be an increase
in the City Centre as well as in Ancoats and Clayton and Cheetham. All of the wards
in North Manchester are predicted to see an increase in population aged between 30
and 34.
2009, 254 Manchester residents died as a result of alcohol-specific conditions (181
men and 73 women). The rate of alcohol-specific mortality for men in Manchester is
33 per 100,000 of the population (2.5 times the rate for England). For women in
Manchester the rate is 13 per 100,000 (twice the national rate). It is estimated that
alcohol misuse in Manchester results in an average of 16.6 months of life lost for
men, and 7.1 months for women, compared to national averages of 9.1 and 4.2
months respectively. Source: Local Alcohol Profiles for England (LAPE) quoted in
Manchester Alcohol Strategy 2012-2015
Smoking
In October and November 2009, a large scale face-to-face survey of just over 1,000
adults aged 16 and over was carried out across a sample of areas within Manchester
in order to assess the views of local residents in relation to their overall level of
health and quality of life and their behaviours and attitudes in relation to healthy
lifestyles. The survey found that smoking in Manchester is above the national
average, with a third of men in the survey (35%) reporting that they currently smoke
tobacco, while slightly fewer (28%) women are smokers. Both of these percentages
are higher than the national averages of 24% for men and 20% for women.
Compared with the population as a whole, the survey found that smokers were also
more likely to have a poor diet and to do little or no exercise each week. They are
also significantly more likely to be white (34% compared with 22% of non-whites).
Source: Manchester Points4Life Population Survey, March 2010
Diet
The Points4Life Survey showed that just under a third (30%) of respondents reported
that they eat five or more portions a day of fruit and vegetables a day, which is
broadly consistent with the national average of 26%. These figures suggest an
upward trend in the proportion of residents consuming five or more portions of fruit
and vegetables a day, which the earlier Manchester Residents Survey showed had
increased from 16% to 23% between 2004 and 2007. Respondents in the youngest
age group (16-24) are more likely to consume both 'fatty or fried foods' and take
away 'fast foods' than those in older age groups. In terms of ethnicity, non-white
respondents are more likely to eat red meat everyday (10% compared with 4%) and
to consume takeaway 'fast food' on a regular basis, i.e. three or four days a week
(7% compared with 2%) Source: Manchester Points4Life Population Survey, March
2010.
Physical Activity
As well as asking respondents to give detailed information about their diets (see
previous section), the Points4Life Survey asked respondents to say what forms of
exercise they do in a normal week. Over half of respondents (56%) identified 'brisk
walking' (i.e. unstructured physical activity) as the most commonly undertaken
activity, followed by 'aerobics or weights' (23% of respondents) and 'jogging or
running' (18% of respondents). Between 10%-15% of respondents reported doing a
range of other activities, including cycling, swimming, dancing or sports. More
crucially, the Survey identified a large proportion of respondents (19%) who said that
they did none of the physical activities listed in the survey. The characteristics of
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Long-term conditions
Long-term conditions refer to those conditions that cannot currently be cured but can
be controlled by medication and other therapies. This section looks at the overall
level of chronic ill health in the population as a whole and, more specifically, among
people of working age. It also looks in more detail at a number of specific conditions,
including cancer, chronic obstructive pulmonary disease (COPD), diabetes, heart
disease, dementia and stroke.
Long Term Illness or Disability
In the 2007 Residents' Survey 32% of Manchester residents reported to have a long
term illness or disability which was substantially lower than the proportion of
residents in North Manchester (37%). Within the North Manchester, the self reported
long term illness or disability varied between 12% in City Centre and 47% in
Harpurhey and Higher Blackley.
Information on the number of patients known to GPs as having one or more long
term conditions is collected on an annual basis as part of the Quality and Outcomes
Framework (QOF) process. The table below shows the number and proportion of
patients with specific long terms conditions registered with GP practices in North
Manchester (based on data for 2010/11) ranked in order of commonness.
Number of
patients
Hypertension
21,137
Depression
16,516
Asthma
9,634
Diabetes (ages 17+)
8,034
CHD
6,127
COPD
4,216
Hypothyroidism
3,665
Chronic Kidney Disease (ages 18+) 3,661
Stroke or TIA
2,971
Cancer
2,041
Mental Health
2,011
Atrial Fibrillation
1,730
Epilepsy (ages 18+)
1,324
Heart Failure
1,065
Dementia
714
Learning Disabilities (ages 18+)
576
Heart Failure Due to LVD
525
Condition
43
Prevalence
(%)
12.0%
12.3%
5.5%
6.1%
3.5%
2.3%
2.0%
2.5%
1.6%
1.1%
1.3%
0.9%
1.0%
0.6%
0.4%
0.6%
0.3%
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Item 13
these respondents matched those of typically 'hard-to-reach' groups, such as older
people, those who are overweight or obese and those in the most deprived
categories. Source: Manchester Points4Life Population Survey, March 2010
Data source: QMAS database - data as at end of June (2010/11 data as at end of
July 2011)
Copyright © 2009, 2010 and 2011, The Health and Social Care Information Centre,
Prescribing Support Unit. All rights reserved.
Hypertension (high blood pressure), depression and asthma are by far the most
common long term conditions among adult patients registered with GP practices in
North Manchester with over 1 in 10 patients known to be suffering from hypertension
(12.0% of registered patients) or depression (12.3%). Compared with other parts of
the city, patients registered with GP practices in North Manchester are more likely to
be identified as having one of the long term conditions listed in the above table (the
one exception being asthma). Note, however, that the figures collected as part of
QOF are not standardised to take account of differences in the age structure of GP
practice populations and therefore the higher prevalence of long term conditions in
North Manchester compared with city as a whole is largely a reflection of the larger
numbers of older people population registered with GP practices in this part of
Manchester.
3% of the residents living in North Manchester were registered as blind or partially
sighted which is slightly above the Manchester average of 2.8%. The highest
proportion of people registered as blind or partially sighted was in Higher Blackley
(4.4%) and the lowest was in City Centre (0.5%).
Cancer
There is little data available on the incidence and prevalence of cancer for areas
within Manchester. The North West Cancer Intelligence Service (NWCIS) has
produced age standardised incidence rates per 100,000 population. Incidence rates
refer to the number of new diagnoses of cancer that occur to residents of an area per
100,000 population.
In Manchester, the latest figures available (2007-09) show a substantial increase in
incidence rates of cancers among women and a decrease in incidence rates among
men compared with the 1995-97 baseline. For men, the biggest improvement is in
incidence rates of lung cancer that has gone down by 32%, for women the biggest
increase in incidence rates was noticed in breast cancer which has gone up by
almost 15%. These figures are likely to reflect changes to uptake of screening and
improved diagnosis as much as they reflect real changes to incidence of disease
among the population.
Mortality rates for cancer among persons aged under 75 in Manchester have fallen
steadily over the last decade from 189.3 per 100,000 in 1995-97 to 154.9 per
100,000 in 2008-10. The mortality rate for all cancers for people under 75 years in
North Manchester (168.4 per 100,000) is above the average rate for Manchester
(154.9 per 100,000). Overall, 6 out of 10 wards in North Manchester had a mortality
rate above that for the city as a whole. Excluding the City Centre, mortality rates
within North Manchester ranged from 144.7 per 100,000 in Crumpsall to 213.3 per
100,000 in Ancoats and Clayton.
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Cardiovascular disease (CVD) is an aggregate term for a collection of diseases that
includes Coronary Heart Disease (CHD), stroke and peripheral arterial disease. Data
collected as part of the Quality and Outcomes Framework (QOF) shows that in
2010/11 there were around 6,100 patients on the CHD registers of GP practices in
North Manchester - an average prevalence rate of 3.5% compared with 2.9% across
Manchester as a whole. A further, 1,600 patients (0.9% of the registered population)
were on a long term condition register by virtue of the fact that they had experienced
heart failure. The reported prevalence of CHD among GP practices in North
Manchester ranged from 8.1% of the practice population to less than 1% of the
practice population.
The latest mortality data for the period 2008-10 indicates that the mortality rate from
all circulatory diseases in people aged under 75 in North Manchester was 128.1 per
100,000 compared with the Manchester average of 123.2 per 100,000. The three
wards with the highest mortality rates for circulatory diseases in North Manchester
were Bradford (175.8 per 100,000), Harpurhey (161.6 per 100,000), and Cheetham
(155.5 per 100,000). City Centre (27.4 per 100,000), Higher Blackley (90.9 per
100,000) and Moston (94.9 per 100,000) had the lowest mortality for circulatory
diseases.
Learning disabilities and autism
Awareness of the numbers of adults with learning disability in the local authority area
is fundamental to planning. Figures for 2010-11, suggest that 4.7% of adults aged
18-64 in Manchester are known to have a learning disability by the local authority
(down from 4.7% in 2008-09). This compares with an England average of 4.3%.
The latest figures for 2010/11 show that around 4.2 per 1,000 patients registered
with a GP in Manchester have been identified as having a learning disability
compared with 4.3 per 1,000 patients registered with GPs across England as a
whole. Each year GPs are supposed to offer regular health checks to people with
learning disability in order to make sure that important health problems are identified
and treated. In 2010/11, GPs in Manchester reported that just over a fifth (22.5%) of
patients known to have a learning disability had received a health check in the last
year. This is significantly worse than the average for GPs in England as a whole
(48.6%).
Autism is a spectrum condition, which means that, while all people with autism share
certain difficulties, their condition will affect them in different ways. Asperger
syndrome and pervasive developmental disorder are forms of autism. Data gathered
from the PANSI predictive modelling tool suggests that in 2011 there were around
3,650 adults aged 18-64 with autistic spectrum disorders in Manchester. The number
of adults in Manchester with these conditions is projected increase by 18% between
2011 and 2030, with the largest increases expected to be seen in the 35-44 age
group. The rate of adults with autistic spectrum disorders in Manchester is predicted
to rise at a greater rate than in other neighbouring Local Authorities in Greater
Manchester and Cheshire as well as in other comparator authorities such as Leeds,
Liverpool and Newcastle.
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Cardiovascular Disease (CVD)
Mental health and wellbeing
The Manchester Mental Wellbeing Survey was carried out in 2009 as part of the
North West Mental Wellbeing Survey in response to a growing need to understand
more about the positive mental wellbeing of people in the city. The Survey attempted
to measure mental wellbeing using the Warwick-Edinburgh Mental Wellbeing Scale
(WEMWBS) - a validated tool that measures both positive functioning and positive
feeling using a 7 item scale.
The results of the Survey show that adults in Manchester were significantly more
likely to have low mental wellbeing compared with the North West average (North
West: 16.8%, Manchester: 23.7%) and significantly fewer had an above average
level of mental wellbeing (15.5% compared with the regional average of 20.4%).
The proportion of people in Manchester who said they were moderately anxious or
depressed (18.8%) was significantly higher than the North West average (14.8%).
This pattern varies in line with levels of mental wellbeing. Adults with a below
average level of mental wellbeing were more than three times as likely as those with
above average levels of mental wellbeing to be moderately anxious or depressed
(35.8% compared with 10.7%). People with below average levels of mental wellbeing
were also significantly more likely to say they were extremely anxious or depressed
(11.4%) than those with average (3.4%) or above average (2.0%) levels of mental
wellbeing. However, it is important to note that the majority of those with a below
average level of mental wellbeing said that they were not anxious or depressed and
therefore low mental wellbeing may be related to far broader factors than anxiety and
depression. Source: Manchester Mental Wellbeing Survey 2009
Mortality
Mortality in Manchester has been on a downward trend over the last decade.
However it is still significantly higher than mortality in England as a whole. Directly
standardised mortality rate in Manchester 2008-10 for people age 15 - 64, was 363.7
per 100,000 which compared to 212.2 in England. Mortality in this age group
contributes to almost a quarter of all deaths occurring (23.3% in Manchester).
Age-specific mortality
In the three year period 2008-10, there were 1,041 deaths to people aged 15-64
resident in North Manchester. This equates to an age specific mortality rate of 307.8
per 100,000 population. This is substantially above the city average of 251.1 per
100,000. Looking at the major causes of death in North Manchester among the 1564 age group in the period between 2008 and 2010 shows that there were:



305 deaths from cancer, which equates to age specific rate of 90.2 per
100,000. This is substantially above the city wide figure of 74.4 per 100,000.
224 deaths from cardiovascular disease (CVD) - an age specific rate of 66.2
per 100,000 population aged 15-64 years. Again, this is substantially above
the city wide figure of 57.3 per 100,000.
83 deaths from digestive diseases - an age specific rate of 39.3 per 100,000
population aged 15-64 years compared with a Manchester average of 30.3
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
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
per 100,000. Mortality from digestive diseases is often linked with alcohol
misuse and includes conditions such as liver cirrhosis.
68 deaths from suicide or other undetermined injury - an age specific rate of
20.1 per 100,000 population aged 15-64 years compared with the city
average of 15.2 per 100,000.
69 deaths as a result of an accident - an age-specific rate of 20.4 per 100,000
population aged 15-64 years compared with the city average of 16.6 per
100,000
BURY
Bury’s resident population is around 185,100 (Census 2011). The Trust is able to
gather data on the age profile of its local population and can correlate both
registered and resident populations to inform workforce planning and commissioning
service provision and planning.
In comparison to the previous year we can see that Bury has seen an increase in its
population. (182,600 (ONS midyear 2010 estimates) to 185,100).
It was projected the previous year that the resident population of Bury would rise to
187,300 in 2012 and to 193,000 in 2022, representing a potential growth of 2.3% and
5.4% respectively. As it can be seen there has been a substantial growth in the
resident population and the projected figures are very close to the picture in reality.
Bury continues to house an ageing population in line with the national picture. The
predicted significant rise in the over 65 population will place significant demands on
the local health services, particularly in management of chronic diseases, long term
conditions and various lifestyle interventions
Currently 50.3% of the population is female and 49.7% is male, this is expected to
remain static and compared to the figures last year this is certainly true to its word.
(51% female and 49% male 2011)
Almost 74% of Bury’s population is Christian. Bury houses the second largest Jewish
community (4.9%) outside London. The Muslim faith is followed by 3.7% of the local
population.
The ONS estimate indicate that 9% of Bury’s population is from black and minority
ethnic communities (BME) the Asian and Asian British community constitute the
largest ethnic group.
The data also shows that the largest concentration of the BME communities and also
of the increasing migrant communities, particularly from the Eastern European
groups is within East, Redvales, Sedgley and Moorside wards.
Mental Health
About one in six adults have a mental health problem at any one time, equating to
approximately 25,000 people in Bury. It can be estimated that there are around
2,000 people aged over 65 with late onset dementia in Bury, of which over 700
(37%) are likely to be living in care homes.
Disability
Learning disability affects some 2% of the population, approximately 3,300 adults
and 850 children in Bury. This level of prevalence is expected to remain constant
over the next 15 years although the number of older people with a learning disability
will increase substantially.
48
Naheed Nazir – Head of Equality & Human Rights June 2013
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Asylum seekers and refugees
Data from the border agency shows that there are 449 refugee and asylum seekers
in Bury, largely from Iran and Zimbabwe. Other refugee and asylum seekers are
from Iraq, Pakistan and the Congo Democratic Republic. The greatest concentration
of asylum seekers are within East and Moorside wards (53% of the total).
Cancer
Whilst incidence rose by 22% between 1993 and 2006 (Figure 15), many more
people in Bury are living with cancer. For example, the 5 year survival of breast
cancer is over 70%. The prognosis is also improving for a number of other cancer
sites, particularly prostate and melanoma.
However, there remain some cancers, notably lung where the 5 year survival
remains very poor at below 10%. There are many causes of cancer and the origins
of the disease in each person may differ. Genetic, environmental and lifestyle factors
interact with other broader causes of ill health, such as poverty and unemployment,
to increase an individual’s risk of cancer. For many common forms of cancer,
smoking and poor diet represent the most preventable lifestyle risk factors.
The rise in the incidence of cancer in Bury can to some extent be attributed to
general increases in life expectancy but also to the successes of cancer screening
programmes and public awareness initiatives, leading to people presenting earlier
with symptoms. As a result the increase in the number of new cancers diagnosed is
expected to continue in future years. Uptake of bowel cancer screening in Bury is
one of the highest in Greater Manchester at 51.6% (June 2009) and Bury is currently
performing well for breast screening (achieving 78.4% against thenational target of
70%) and cervical screening (covering 81% in 2008/09 against a national target of
80%). However, performance in the Human Papilloma Virus (HPV) vaccination
programme is relatively poor with only 70.8% completing all three doses for 12-13
years olds. The HPV vaccine protects against the two strains of HPV (16 and 18)
which have been linked to 70% of cervical cancers in women.
Long Term Conditions
 People with long-term conditions are the most intensive users of the most
expensive services, not only in terms of primary and specific acute services,
but also in social care and community services, urgent and emergency care.
 Nationally, it is estimated that people with long-term conditions account for
52% of all GP appointments, 65% of all out-patient appointments and 72% of
all in-patient bed days. The treatment and care of those with long-term
conditions account for 69% of the total health and social care spend in
England. For these reasons, there are huge benefits to the population, as well
as financial savings, if health and social care organisations invest in costeffective management of long-term conditions.

49
Naheed Nazir – Head of Equality & Human Rights June 2013
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Item 13
There is a consistent picture of increased mortality rates in areas of higher
deprivation, for all causes including circulatory disease and cancer. The high rates of
long-term limiting illness in Bury East, St Mary’s and Redvales wards also reflect the
significant role that deprivation plays in morbidity and mortality.
Limiting long-term illness
The 2001 Census identified over 34,000 people in Bury with a limiting long term
illness (LLTI), which equated to 18.9% of the population, nearly 1 in 5. Assuming this
rises in line with the growing and ageing population, there will be approximately
7,500 more people (1.9%) with a LLTI by 2025. The predicted significant rise in the
over 65 population by 2025 and the forecast increase in LLTI will place significant
demands on local services particularly in the management of chronic diseases and
long term conditions.
Levels of LLTI vary widely across the borough and between different BME groups.
The highest levels of LLTI were in Bury East, St Mary’s and Redvales wards.
The estimated prevalence of CHD in Bury is 6.5%, higher than the England average
of 5.3%. Bury has a recorded CHD prevalence of 5.4% prevalence of 5.4%, ranging
from 4.1% in semi-rural practices to 7.3% in practices in the town centre.
The premature mortality rate (aged under 75) from CHD is 98 per 100,000, equating
to 188 CHD related deaths per year. Although CHD and stroke mortality in Bury has
declined over the last 10 years, the reduction has been at a similar rate to the
national average, maintaining the inequality gap in life expectancy attributable to
CVD. Concern also exists about future trends in the light of rising levels of obesity
and other CVD risk factors, for example, diabetes.
Life Expectancy
There are just over 2,000 deaths per year in Bury with the main causes being
circulatory disease and cancer. Circulatory disease accounts for 32% of all deaths in
Bury (approx 1800 across 3 years) and cancer 26% (approximately 1400 across a 3
year period). There is a consistent picture of higher mortality rates in areas of higher
deprivation, for all causes including circulatory disease and cancer. As a result there
remains a clear link between health inequalities, life chances and the social
determinants of health.
An important measure of population health is the rate of premature deaths. These
are deaths below 75 years of age – which is well below average life expectancy.
Equality and Diversity Report
Published June 2013
50
Naheed Nazir – Head of Equality & Human Rights June 2013
Page 261 of 318
Medical and Dental Education Annual Report 2012/13
The 2012/13 Annual Report for Pennine Acute Hospitals
NHS Trust Medical and Dental Education. The aim is to
provide high quality medical and dental education which
can be evidenced within the report.
The key highlights include but are not exhaustive of:

The Trust was successfully awarded two projects
from Health Education England, the first in
Accident and Emergency department at The
Royal Oldham Hospital and the second within the
Infectious Diseases department at North
Manchester General Hospital;

The Dean, Professor Jacky Hayden, and her
team visited the Deanery in May;

In December 2012, the Trust welcomed Professor
Ian Jacobs, the Dean of the Faculty of
Medical/Human Sciences and Vice President of
the University of Manchester to open the Trust’s
new undergraduate and simulation facility which
is a state of the art simulation suite which offers
an excellent learning environment for all of our
staff, particularly students and junior doctors.
Actions
The Trust Board is asked to note the Annual Report.
requested
Corporate Objectives supported by this paper:
 Improving clinical effectiveness and patient safety
 Improving the patient experience
 Maintaining our regulatory obligations
 Environment and sustainability
Risks:
None
Public and/or patient involvement:
With other category one providers for joint planning for preparedness,
resilience and response.
Resource implications:
None
1
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Item 13
Title of Report
Executive
Summary
Communication:
The Annual Report will be placed on the Trust intranet.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Date
Email
Dr Christina Kenny
Medical Director
June 2013
[email protected]
2
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YES
X
X
X
X
X
X
X
X
X
NO
N/A
Item 13
Medical & Dental Education
ANNUAL REPORT 2012
1
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Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Message from the Director of Medical and Dental Education
Who we are, what we do
Undergraduate Training
Postgraduate Training
Foundation Training
Diagnostics and Clinical Support
Medicine
Surgery
Women and Children
General Practice
Dental Training
SAS Doctors
Trainee Support
Revalidation
Quality Control
CPD
Staff Awards
Supervisors
Conclusion
Appendices
A.
B.
C.
Structure
Annual Objectives
Faculty
2
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Message from the Director of Medical and Dental Education
Item 13
1.
Dear Friends
I am delighted to welcome you to our second Pennine Acute Hospitals NHS Trust Medical and
Dental Education Annual Report. Providing high quality medical and dental education is our goal
and we have all been busy this year providing just that.
We were delighted at the beginning of the year to be awarded two projects from Health Education
England – one is set in the Accident and Emergency department at The Royal Oldham Hospital and
the second within the Infectious Diseases department at North Manchester General Hospital.
Both projects use innovative approaches to the delivery of medical education and it has been a
bonus to be part of this national work where we can share learning and experiences with other
innovators.
We welcomed the Dean, Professor Jacky Hayden, and her team for a Deanery visit in May. This
was a positive experience and we were pleased to be able to share our improvements and
successes with our visitors.
Perhaps the real highlight of the year was in December when we welcomed Professor Ian Jacobs,
the Dean of the Faculty of Medical/Human Sciences & Vice President of the University of
Manchester to open our new undergraduate and simulation facility. This state of the art
simulation suite quite simply offers a fantastic learning environment for all of our staff, particularly
our students and junior doctors. It was thrilling to see the energy and enthusiasm of the
simulation faculty ably led by Dr Doogie Whitcombe, consultant anaesthetist, and the wonder and
fascination on the faces of the many guests who joined us that day.
We have had many other successes this year which you can read within these pages so I will sign
off now and leave you to browse at leisure.
Dr Tina Kenny
Deputy Medical Director/Director of Medical and Dental Education
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2.
Who we are, what we do
Medical and dental education within Pennine is a surprisingly large service. We provide over 2500
training weeks per year for undergraduates; and support to 198 Foundation trainees and over 500
Specialty trainee posts which include General Practice.
A small but significant team work hard to ensure the curriculum is delivered and we quality control
the standards of training, working within budgetary and regulatory constraints to ensure the very
best experience for our doctors of the future. The team is made up of 30 enthusiastic senior
educationalists, supported by 22 educational administrative and clerical staff, and together they
support 260 of our colleagues who provide the training and supervision. Work is guided by the
annual objectives (appendix B) which are aligned to the Trust corporate objectives.
We work closely with our external colleagues The North Western Deanery, The University of
Manchester Medical School and the Central Manchester Foundation Trust Undergraduate
Department to ensure requirements are met and our trainees supported to the best of our ability.
Away Day
2012 saw the first away day for the entire department (see Appendix A). The day was a success,
and provided an opportunity for senior educationalists and their administration support to come
together to discuss and review the challenges we share, and to inform and develop our work plan
and objectives for the year ahead. With so many challenges within medical education, feedback
was that for our next away day we should have more focus.
The away day for 2013 therefore is on the topic of GMC Standards for Trainers: Recognising and
Approving Trainers. Guest speakers are Andy Jones, Associate Dean, North Western Deanery and
Tista Chakravarty-Gannon, Regional Liaison Adviser, General Medical Council.
4
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Item 13
3.
Undergraduate Training
Report of Undergraduate Medical and Dental Education 2012/13
The academic year 2012/13 has been another busy year within Undergraduate Medical and Dental
Education, with significant activity, as well as progress, in all areas across the Trust. Highlights are below.
3.1
Activity
Number of student weeks (2011/12 – latest figures available)
o FGH
o NMGH
o RI
o TROH
Total across Trust
69 students
236 students
86 students
5 students
155 students
(283 student weeks)
(1241 student weeks) – MEDICAL
(172 student weeks) – DENTAL
(17 student weeks)
(764 student weeks)
551 students
(2477 student weeks)

Accommodation
The opening of the Limbert Education Centre on the NMGH site and upgrading of facilities for
undergraduate students on the TROH site;

Induction
Developing competencies in order that induction can be delivered by Undergraduate Administrators.

Educator Development Programme
Introduced across undergraduate and postgraduate medical and dental education. Successful
delivery of Objective Structured Clinical Examination (OSCE) and Problem Based Learning (PBL)
training for 25 Consultant / SAS doctors
3.2
Meetings
 Undergraduate Action Group (UGAG)
This group oversees all aspects of undergraduate medical and dental education across the Trust to
ensure consistency, quality and delivery, and to plan developments. During the year, the Paediatric
and Obstetrics & Gynaecology Action Groups were merged with UGAG to improve communication
and governance. The Terms of Reference of UGAG were updated to ensure appropriate membership
of the group.
 Associate Hospital Deans’ (AHD) Meetings
These meetings for AHDs across the University’s Central Sector are now attended by Dr Iain Lawrie
and Dr Raj Parikh. They have proved invaluable in ensuring the Trust is strongly linked in to all aspects
of the undergraduate agenda across the central sector. These meetings also allow our dates to
influence undergraduate medical education in the Sector.
 Undergraduate Dental Liaison Meetings
Dr Iain Lawrie attends these meetings, as his role also covers 4 th year Dental students who attend the
NMGH site for their block in Medicine and Surgery.
5
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3.4
Staffing
 Congratulations to Kath Robertson who has been appointed as Manager for Clinical Skills within
Learning & Organisational Development. We thank Kath for the tremendous work she did during her
time in the Undergraduate Department. We are pleased that medical and dental education will still
have access to Kath’s skills and experience as our undergraduate students will continue to receive
clinical skills training.
 Sharon Stone has been appointed as Assistant Manager - Undergraduate Training to coordinate and
lead administrative support for medical and dental undergraduates who come to the Trust.
 Undergraduate Specialty Lead Coordinators have been appointed in both Paediatrics and in Obstetrics
and Gynaecology to lead on undergraduate education, particularly for 4th year medical students, in
these areas. The new Coordinators are:
o
o
o
o
NMGH (Paediatrics):
NMGH (O&G):
TROH (Paediatrics):
TROH (O&G):
Dr Suparna Dasgupta
Mr Sachin Maiti
Dr Nandhini Prakash
Miss Annabel Dieh
 Dr Asad Khan has been appointed as the Undergraduate Coordinator (FGH) to oversee – and develop–
undergraduate medical education on the site.
 As part of a strategic plan to develop educators within the Trust, Dr Paddy Ross has been appointed as
Associate Undergraduate Tutor. This development post, for one year, sees Paddy overseeing 3 rd year
undergraduate medical education at NMGH and becoming more involved in undergraduate medical
education at TROH along with Dr Raj Parikh.
 Dr Raj Parikh was reappointed as Undergraduate Tutor – Pennine East based at TROH for a three year
term. He has made significant improvements to quality and provision of teaching on the site over the
past 2 years and is central to the education strategy being developed for Undergraduate Medical and
Dental Education.
 Dr Iain Lawrie was reappointed as Undergraduate Tutor – Pennine West based at NMGH for a three
year term and Iain continues to be a real wealth of knowledge and experience about undergraduate
education.
3.5
Medical Students
 Student Assistantships (SA)
Introduced across the Trust by the University of Manchester in early 2012 for final year medical
students. These placements provide the opportunity for students to gain further experience in clinical
work. Students are based solely in the ward under the supervision of the clinical team and gain
additional experience with hands on clinical work. Feedback from all SA has been extremely positive,
and Quality Assurance visits by University staff have congratulated the Trust on their provision of
excellent student placements for SA.
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 Electives Policy
The Elective Policy was updated by Dr Tina Kenny and Dr Iain Lawrie during 2012 to ensure that
appropriate information is gathered, and checks made, prior to student electives being approved
within the Trust.
 Undergraduate Medical Attachment in Acute Medicine
A new attachment has been introduced by Dr Paddy Ross and Katherine Robertson at NMGH during
the academic year. Students have evaluated this block very positively.
 Year 4 Information Day
Dr Asad Khan, Dr Iain Lawrie, Dr Raj Parikh and Mr Mohammed Zahir attended and presented at the
Central Sector information day for 4th year students early in 2013. This day serves to inform students
about available placements across the region, and it is hoped that many of them will choose to apply
to come to the Trust during their final year.
3.6
Dental Students
 Dental School exams
Dr Iain Lawrie and Katherine Robertson have been involved in examining for the Dental School at the
University of Manchester. Dr Lawrie has also been involved in setting both Multiple Choice Questions
(MCQs) and assisting design of OSCE stations for dental student final examinations, as well as
marking 4th year Case Reports for students who have been at NMGH.
 Feedback
The feedback received from dental students has been exceptionally positive, and the hard work of all
those clinicians in Surgery and Medicine at NMGH who contribute towards providing successful
clinical attachments for these students is greatly appreciated.
 GDC Visit / Review
The Dental School at the University of Manchester was reviewed in a visit by the General Dental
Council (GDC) in November 2012. The GDC was very happy with the course, and with the provision of
attachments by the Trust.
 Student Handbook
A handbook for all dental students coming to the Trust has been updated by Dr Iain Lawrie and Dr
Alison Qualtrough from the Dental School.
 Leeds dental students
Students from Leeds continue to come to the Trust each year for clinical attachments in the
Maxillofacial Surgery Department under the supervision of Mr Ewen Thomson and his colleagues.
Attachments are very positively evaluated by students.
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Item 13
 Mini Sector Review
A review of undergraduate medical education at TROH was undertaken by the Sector Teaching
Hospital in February 2012. The undergraduate team was congratulated on making significant
improvements in its provision of clinical and classroom-based medical education.
3.7
University / Deanery Links
 Behavioural Sciences and Sociology (BSS)
Dr Iain Lawrie has been appointed Clinical Co-Lead for BSS in the Phase I Programme of the Medical
School at the University of Manchester. He is assisting with redesign of the curriculum and course, as
well as contributing to both teaching and examination.
 Geriatric Teaching
Dr Raj Parikh has been asked to deliver a programme on geriatric teaching, first piloted at TROH,
across the Deanery.
 Communications Skills Teaching
Along with colleagues from Preston (Dr Louise Forman), Manchester (Dr Anna MacPherson) and the
University (Dr Sarah Collins), Dr Iain Lawrie has designed, developed and delivered a programme of 17
half-day workshops on ‘Patient experience of significant illness’ at the Medical School. The course,
which uses patients, carers, professionals and volunteers, has been very highly evaluated by students
and is now in its second year. Dr Lawrie is presenting this work at the European Association of
Palliative Care Conference in Prague in May 2013, and has contributed to an article which is currently
in press.
 Project Options (PO) / Student Selected Component (SSC) Committee
Dr Iain Lawrie sits on the PO / SSC Committee at the Medical School as a representative from
secondary care.
 Examinations
A number of clinicians across the Trust volunteer their time to act as examiners for both mock and
actual OSCE sessions at the University of Manchester. Their continued commitment to this important
part of undergraduate medical education is very much appreciated, and reflects positively on the
Trust.
 Interviews
A number of clinicians across the Trust volunteer their time to participate in admissions interviews for
the Medical School at the University of Manchester. This participation is vital to the University and,
again, reflects positively on the Trust.
8
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Postgraduate Training
4.1
Introduction
Item 13
4.
The General Medical Council is nationally responsible for the planning, delivery and quality
assurance of all aspects of postgraduate medical education. It fulfils these obligations through a
network of Deaneries which are responsible for quality management. The Trust falls within the
remit of the North Western (NW) Deanery.
The NW Deanery undertakes regular in-depth quality monitoring visits covering all aspects of
medical and dental education. A robust evidence pack is assembled by the Trust to support each
visit. The Deanery is particularly concerned to understand the views and experiences of the
trainees themselves and visits are designed as a series of discussions with different sets of
trainees. The Deanery also holds discussions with sets of supervisors. Following the visits a report
with an action plan is received and this forms the work of the education team for the following
year.
If the Deanery has particular concerns about a specialty area, an additional review of that specialty
area may be planned before the next routine monitoring visit is scheduled.
4.2
Post Approval
The Deanery approves training posts in the Trust. As a result of recent service reconfigurations,
the Trust has been working closely with the Deanery to ensure all new and reconfigured posts are
approved for training.
4.3
Lead Employer Organisation for Specialty Training
The NW Deanery has 3,300 doctors and dentists in specialty training across the region. A
dedicated team called the Lead Employer Organisation within Pennine Acute Hospitals NHS Trust,
acts on behalf of the Deanery as the lead employer for all of these trainees.
The Trust Medical Director, Deputy Medical Director/Director of Medical & Dental Education and
members of the Lead Employer Organisation Team meet regularly with the Deanery to review the
welfare and progress of this set of doctors.
9
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5.
Foundation Training
On completion of medical undergraduate training, new doctors participate in a two year
foundation programme. The Trust offers one of the largest foundation programmes in the North
West with 198 placements in a wide range of specialty areas. The 2013-2015 programme was
submitted to the North West Deanery in July 2012 and was approved without adjustment as
incorporating the appropriate balance of specialties as defined by national requirements. This
programme includes the first academic track at the Trust.
Mr Mohammed Zahir, Consultant in Emergency Medicine, The Royal Oldham Hospital, is the
Associate Director of Medical Education for Foundation and Undergraduate training.
Making up the foundation team across the Trust are four Foundation Programme Directors, and
four Foundation administrators. The team meets monthly as the Foundation Action Group and
trainee representatives are invited to attend these meetings. Trainees in difficulty are discussed
each month with appropriate advice from the Occupational Health Physicians.
The Trust enjoys strong links with the North Western Deanery and Dr Joanne Rowell, Associate
Dean, is actively involved with medical education within the Trust and invited to join the
Foundation meetings.
The teaching programme takes place on two sites -Oldham and North Manchester - and includes
repeated sessions. This allows trainees who may have missed a session to catch up. Trainees have
four hours protected teaching each week. It is not only clinical subjects which are taught as the
programme also includes interview skills, career planning and managing stress amongst other
useful topics. ‘Lessons Learnt’ is a particularly innovative part of the programme. This Deanery
supported initiative teaches trainees the value of reviewing clinical incidents as a group and
fosters an open and honest environment where issues are addressed and actioned. Human factors
training sessions are now incorporated into Foundation teaching programmes on both sites.
All Foundation trainees receive two half-day simulation training sessions as part of the Foundation
programme.
The Trust has introduced an end of placement audit which is used as evidence to supplement the
foundation annual report.
The Trust Foundation study leave guidance has been commended by the North Western
Foundation School.
10
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Item 13
Structure - Foundation Training
Mr Mohammed Zahir
Associate Director of Medical Education
(Undergraduate & Foundation Programmes)
Pennine West
Pennine East
Dr Doogie Whitcombe - FPD
Samantha Kessell
Miss Catherine Mammen – FPD (F1)
Dr Sarita Bhat - FPD
Assistant Manager Foundation
Training
Mr Mohammed Zahir – FPD (F2)
Rita Jackson FP Administrator
Joanne Edge FP Administrator (F1)
Bernie Lynch FP Administrator
Samantha Kessell FP Administrator (F2)
11
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6.
Diagnostics and Clinical Support
Dr R Bhishma – College tutor - Anaesthesia, Intensive Care and Pain Management North
Manchester General Hospital
6.1
North West School of Anaesthesia Training Board visit - 24th May 2012:
 Verbal comments from Regional Advisor – excellent.
 The trainee assessments and Induction programme at NMGH were highly commended.
6.2
Examination success in postgraduate training:
 3 passed the Part I exam (100% pass rate) and 3 passed the Final exam (100% pass rate).
6.3
The Trust has hosted the following National courses:
 Care of the sick child in the district general hospital- October 17th 2012 Multi Disciplinary team course run by A& E Consultant, Paediatricians and Anaesthetists.
93 delegates attended it with excellent feedback. 5 External CPD by RCoA.
6.4
The Trust has hosted the following Regional training courses:
 Chronic pain study day Oct 2012 – North West Anaesthesia School training Board approved
the regional study day for chronic pain to be held at NMGH bi annually.
Oct 2012 – 24 Trainees attended the study day. Feedback ranged from good to excellent.
 Regional Difficult Airway Workshop hosted by NMGH 3 times a year – for Trainees undertaking
higher and advanced anaesthetic training.
 MCQ (Multiple Choice Questions) exam practice days
 Simulation training days for all grades of medical staff
 The central school of anaesthesia regional weekly tutorial programme.
 Contribution to Primary and Final FRCA regional teaching programmes.
6.5
The Trust provided the following local courses:
 PROMPT obstetric drills has been established every month – multidisciplinary learning.
 Foundation year and CT 2 (Core Trainees) interview practice days.
 Primary and final FRCA exam practice days including OSCE and simulation – 6 /year
 Weekly tutorial programmes
Weekly trainee led tutorial programme introduced, with peer assessment in place, giving:




Trainees the opportunity to receive feedback from colleagues.
Tutorials for 4th year medical students on their obstetric attachment on obstetric anaesthesia
Training for A and E staff on RSI (rapid sequence induction) has been established and has
become part of the mandatory training programme.
Lessons learnt programme (Patient safety initiative) – 10 sessions / year
6.6
Simulation courses:
 Course for FY 1 doctors working at all hospitals across the Trust - 2 sessions / doctor - 20 days
in total
 Simulation courses for all grades of anaesthetic trainees.
Feedback for all courses has ranged from good to excellent.
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12
6.8
NMGH – Intensive Care Unit- training and Education:
 Accredited for Advanced level ICU training,
 The department supervise Joint CCT trainees 2-3 times a year,
 ECHO training opportunities has been extended to non-ICU senior trainees e.g. Acute medicine
trainees.
 2 Faculty of Intensive Care Medicine (FICM) posts are in place
 Well received rotational ICU placements for Respiratory & Infectious Diseases Specialty
Trainees.
 Under graduates: Excellent feedback on regular 5th year Assistant placements and
well received placements for Special study module students.
Courses organised:
 Primary FRCA – Regional Weekly tutorial programme held at NMGH ( Tuesday Pm )
 ACCS & Core Medical Trainee tutorials for Pennine
Audit:
 Involved in regional project reviewing the use of arterial lines.
6.9
Rochdale Infirmary:
 National Radio frequency Study day – Nov 2012 – Attended by Consultants and senior trainees
in Pain Medicine – Feed back excellent.
 ‘6th obstetric anaesthesia study day’ was organised on 20th April 2012 and attended by 95
delegates mainly from North West region. The study day had very good feedback from the
delegates.
6.10
The Royal Oldham Hospital
Report prepared by Dr Mirza – College Tutor TROH
School visit to Pennine Anaesthetic Department on 24th May. Positive verbal comments about
training. Written report still waited.
Courses held:
13
National and international
 Annual Critical care symposium.
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Item 13
6.7
Other information:
 In October we reviewed Positive GMC survey results.
 Regular meetings of College tutors of anaesthesia, intensive care and ACCS (Acute Care
Common Stem) lead were held quarterly. Trainee representatives from NMGH and TROH and
SAS (Staff grade and Associate Specialists) doctor representatives for all four sites attend the
meetings. Progress so far includes sharing best practice on the process for induction,
educational supervision agreement between the Trainee and Educational Supervisor, end of
placement feedback, review of GMC trainee survey reports and action plans for concerns
raised by trainees.
 Database has been developed for effective hand over. It has been introduced in clinical
practice.
 NMGH recognised and continues to provide training for Advanced Pain fellow.
 NMGH Pain Team is involved with national research project.
 4 honorary senior lecturers (Manchester University) in the department
 1 RCoA examiner at NMGH
Regional
 Tracheostomy training day in ICU, in March and September,
 One day course on renal failure in ICU.
 Day case Anaesthesia. One day update- December 2012.
 South School teaching organised by Oldham every March for primary trainees.( 2 day block)
Other information:
 Participation in Primary and Final FRCA regional teaching by Consultants.
 Participation in ICU teaching held at NMGH every week.
 TROH recognised and continues to provide training for an Advanced Pain fellow.
 1 RCoA examiner at Oldham
 Edic (European Diploma in ICU )exam centre at Oldham
 Access to screening echo training and ultra sound guided nerve block training.
Exam passes:
 Two trainees passed Final FRCA in 2012.
 Two trainees passed primary viva, unfortunately could not pass OSCE.
6.11 Clinical Radiology
 Maintained excellent feedback about training at PAT through the bi yearly Specialty Trainee
survey.
 continue to maintain a high level of ST success in FRCR examination
 Multiple ST presentations at national and international meetings.
 ST prize for best eposter at UKRC 2012
 expanded ST training to involve FGH and TROH sites with good initial feedback
 expanding training within paediatric radiology to include junior STs
 oversubscribed for specialty training in 2013 due to the popularity of PAT as a training centre
in radiology within the deanery
14
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Medicine
Medicine Update and Look Ahead for 2013:
7.1
College tutors:
We are delighted to congratulate Dr Tamer Al-Sayed, consultant acute physician at NMGH, who
has been appointed to the position of Royal College Tutor for NMGH last month. It will be great to
have a local link for the college at NMGH and Dr Al-Sayed will support our trainees and ensure
their education and training is given the highest priority.
7.2
CMT teaching Programme:
This continues to be very well supported by our colleagues across all 3 sites – we are extremely
grateful for those that provide the sessions for this programme – they are very highly rated and
appreciated by our CMT’s. We have continued to try and incorporate more clinical aspects to the
teaching, including patients and also aim to cover more specialised areas of the curriculum in the
future.
7.3
Practical Assessment of Clinical Examination Skills Sessions (PACES):
These continue to be organised and run by the education department – trainees find the sessions
helpful near the examination and we aim to provide intensive clinical exam focused teaching in
the run up to the exam periods – we are looking for more consultants and senior registrars to help
support these sessions and have set up a feedback system and also provide a certificate
recognising the valuable input from these individuals for their teaching.
7.4
PACES Exam, The Royal Oldham Hospital 2013:
Work continues on this exciting development, led by Dr. Venkat Sridharan, Royal College Tutor for
The Royal Oldham Hospital. The dates for the exam are 5th and 6th October 2013. We are finalizing
the details of the examination and we hope that it will be a success and that this will be the first of
many years of hosting the examination for the Trust.
7.5
Exam Success
We congratulate the following on their examination success and wish them well in their future
plans and will try and support them as best we can for their future.
Dr L Chan
Dr W Wentzlau
Dr B Singh
Dr C Winters
Dr M Wakefield
Dr J Unsworth
7.6
Trainee Feedback and Survey Results
We had overall positive feedback from both internal and wider national surveys. There are areas in
which we could do better and issues such as workload, cover out of hours and handover are
currently being reviewed. Much of the trainee and deanery feedback that we received was
overwhelmingly positive and this is a testimony to the hard work of our clinical and educational
supervisors and the robust medical education structure now in place for the Trust.
15
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Item 13
7.
8.
Surgery
ENT
 CTs successful in obtaining MRCS qualification maintaining the 100% record from previous
years.
 CT trainee from FGH successful in obtaining a national ST post in a very competitive national
selection process for the third consecutive year. (only 35 posts from 150-200 applicants)
 12 papers presented at the national ENT Conference (2012) from Pennine ENT compared with
4 in 2010.
 Prospective Handover monitoring audit established, and data are presented in every audit
meeting, ensuring that standards are maintained.
 Pennine representation at national ST interview panels.
 FGH ENT ST doctor nominated for “Pennine Doctor of the Year award” in recognition of his
achievements.
 Medical Staff Education awards: Two ENT consultants received commendations and one was
awarded the educator of the year award.
 Pennine consultants continuing involvement in: ARCP panel, STC, regional Royal College
Professional Affairs Board, and ENT UK Council.
 New ENT CT post allocated to FGH, increasing CT posts at FGH to 3.
 Teaching for Specialty trainees at NMGH was amalgamated with that at FGH following the
renewal of the NMGH training post.
 We’ve acted on feedback and set up a cross Pennine teaching programme for ENT due to start
shortly. We have made a commitment to the trainees that we will ensure that they will receive
a minimum of half day teaching per week be it local or regional.
 CT trainees have been encouraged and given the opportunity to attend ST calman teaching
days.
 Induction days received very positive feedback for ENT and Oral surgery.
 - Red outliers re Handover for max fac on GMC survey. It appears a clear handover system
now is in place for Max fac at NMGH.
 CTs have been given the opportunity and encouraged to utilise new ENT simulation equipment
at Wigan.
 The Oral Surgery team were awarded the best presentation prize in the Ground Round Awards
for 2012.
 Decommissioning and reconfiguration of services in July impacted on consultant timetables
although the impact on trainee timetables was minimised. There has been some impact on
training opportunities for SAS doctors, and more limited Paediatric ENT experience for Junior
Doctors.
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Women and Children
Item 13
9.
9.1
Paediatrics
Achievements this year include:









9.2
Resolution of trainee concerns about TROH with a further survey showing significant trainee
satisfaction at TROH.
Adapting training following major reconfiguration between NMGH and FGH.
Initiation of novel trainee feedback ( biweekly ) and feedback on trainers (pilot study)
Support mechanisms with introduction of trainee led and Consultant supervised interactive
weekly teaching.
Incorporating simulation in 6 monthly teaching rota
Introduction of trainee representation in quarterly Paediatric Tutor’s meeting
Appointment of 2 more Paediatric Consultants as Examiner for the RCPCH thus augmenting
trainee teaching for MRCPCH examinations.
new induction programme , involving interactive rotation around ‘workstations’
Development of a new CPD programme for non trainees.
Obstetrics & Gynaecology
Educational Governance:
A new O&G Education committee meets every 2 months. O&G were the first team in the Trust to
ensure representation from all groups of trainees (Foundation year, GP trainees, ST trainees etc) in
governance meetings.
Induction:
O&G have a well established and robust two stage induction process (apart from the Trust
induction) along with feedback.
Handover system:
O&G have pioneered a formal electronic handover system which is also centrally stored and
audited every month.
Teaching programme:
 We have established a formal departmental teaching programme every Wednesday at the two
sites (NMGH & TROH)
 We have also established a formal monthly Trust-wide teaching programme when generic
teaching is delivered. External speakers are a regular feature on this programme. Formal
feedback is given to each speaker.
Simulation:
A new laparoscopy simulation course was introduced this year.
Special coaching for examinations:
O&G provided special coaching for the MRCOG exam. The Trust achieved 100% pass rate for these
candidates.
Ultrasound training:
Ultrasound training has been offered to all trainees who were identified, both at basic and
intermediate level.
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17
ATSM:
Trainees received training for ATSMs, e.g. Labour ward ATSM (Advanced module) has been
completed by our senior trainee; also in way towards of completion of Sub-fertility ATSM.
MDT meeting aimed at teaching:
A monthly emergency Gynaecology MDT has been set up.
Research:
A new Pennine Research Group in Obstetrics & Gynaecology has been set up.
Special training programme
A special programme has been established for F1 trainees in O&G who, instead of spending all the
time in one ward getting limited exposure, now rotate through different clinical situations,
maximising their experience. Junior trainees (like ST2) have been supported to progress towards
more senior role (ST3). MTI (Medical Training Initiative – for overseas doctors who join the Trust
for a limited time) these are doctors who are looking to experience life in the NHS
Consultant led training/WBA:
The high number of hours of labour ward resident consultant cover ensures time for training and
for offering work placed based assessments.
Deanery / GMC survey:
The most recent GMC and Deanery visit have been very favourable compared to the previous
visits.
Emergency Gynaecology:
The gynaecology emergency service has been transferred to NMGH Following a period of settling
down; the current trainees are receiving improved training. The current Associate Specialty Tutor
at NMGH site has taken up a new role in the directorate.
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General Practice
Item 13
10.
Pennine GP Education
Well what a year with Jubilee and Olympic celebrations, but despite all the partying we have
continued to develop our GPST programme.
As always we started the year off with induction breaking the GPST1’s in gently with a day at TROH
Education centre. Our GPST3 had a baptism by fire with an “Olympic” outward bound day at Burrs
Park- ‘what fun!’. We have continued to develop our education programme especially when GPST
are in their GP Plus post and the feedback has been very promising. Our Quality at Pennine trophy
for term 1 was won by Alpha Male practice but currently is neck and neck for our term 2 trophy!
We have been working on improvements with our trainers groups and our fantastic website
provides a great resource for our trainees.
GP education is involved in regular DME meetings and GP educators attend the medical educator
forum. Unfortunately due to our local panel review we were unable to attend the Pennine away
day.
Our theme days this year were surgical and Musculoskeletal days - both of which had fantastic
feedback and involved lots of Pennine staff- well done to all involved.
We also hosted our own GP Update course which again was very well received.
We are endeavouring to develop the GPST hospital clinical supervisor roles including access to the
RCGP e-portfolio. We aim to improve the attendance at SEP for those in hospital posts. We have
been improving early identification of GPST’s who are struggling. We wish to work closely with
clinical supervisors to encourage early sharing of information so we can give specific educational
prescriptions to the GPST.
So far signs are promising for pass rates for all 3 components of the MRCGP.
Looking to the future, GP training needs to expand so we are currently looking at possible ways to
increase posts within Pennine to increase our tracks, any suggestions are always welcome.
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11.
Dental Training
11.1 Dental Foundation Year 1
The Pennine Acute Dental Foundation schemes welcomed 25 new Dental Foundation Year 1
dentists on Friday 7th September 2012..The DF1s do not work clinically within the Trust but are
employed by dental practices within the area and attend the structured educational programmes
(SEP) at the Medical & Dental Education Centres at Royal Oldham and North Manchester hospitals.
The SEP augments the practical experience gained by working with an appointed Educational
Supervisor in a North Western Deanery approved training practice.
11.2 Dental Foundation Year 2
Currently there are 6 DF2s within the Trust mainly working within the Oral and Maxillo-facial
department at North Manchester General Hospital. These are 1 year posts and similar numbers
have been appointed for 2013-2014
Pennine Acute Trust also has 1 Career Development post at North Manchester General Hospital.
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We have over 145 staff grade and associate specialist doctors (SAS) within the Trust. Within the
structure we have a network of SAS Co-ordinators for each Specialty. The co-ordinator role works
closely with the educational Specialty Lead to ensure two way communications within their area
for education, encouraging all SAS doctors to take advantage of the funding and opportunities for
training available to them.
CESR is the Certificate of Eligibility for Specialist Registration, the process by which non consultant
non training grades can demonstrate their skills and become eligible for consultant posts. The
North Western Deanery has introduced a CESR Champions Project. The Trust fully supports this
project and is proud that we have our own ‘champion,’ Dr Emad El-Malek, consultant in
Emergency Medicine at NMGH, running this initiative.
The Deanery offer funding for SAS Doctor Education and training initiatives and this supports
bespoke events.
This year saw a number of “Atrainability sessions” being delivered across the Trust for the SAS
doctors. This course received excellent feedback. More are booked for 2013. Example comments
included:




Eye opening! Would recommend course to everyone
Very good course – thoroughly recommended
An absolute eye-opener. It should be a mandatory part of any medical training.
Definitely, being human we should learn ‘human factors’ before anything else! Learning
medicine is lifelong and learning human factors and humans (self, colleagues, patients)
should also be lifelong
Opens your eyes to the possibility of missing something standing right in front of you
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Item 13
12. SAS Doctors
13.
Trainee Support
The Trust provides a pastoral care network so that trainees are fully supported at all times. This
network includes the dedicated Undergraduate, Foundation and Specialty Administrators, the
Clinical and Educational Supervisors, those in senior education roles, and support from the
Occupational Health services.
To ensure that pastoral care needs are understood and addressed swiftly, trainee representatives
are invited to Foundation Action Group meetings, Specialty meetings and focus groups. Dr Ella
Checkley is our Careers Lead for the Trust.
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Revalidation
The appraisal year 2011/12 saw just 50% of doctors appraised within the Trust. 2012 saw the
General Medical Council implement year zero of appraisal and revalidation, during which 100% of
doctors would require appraisal and our first 100 doctors would go through actual revalidation
itself. This was supported by statute which came into force in December 2012.
The Head of Medical & Dental Education supporting the Responsible Officer/Medical Director led
the development & implementation of the new arrangements to ensure we were successful.
These include:







A monthly Revalidation Steering Group was set up with key people from within the
organisation
Administration staff were recruited
A strong communications strategy was put into place
All doctors were asked to have their appraisal by 31st January 2013
A Trust Wide Appraisal Lead and Appraisal Team Leaders were appointed from our senior
appraisers and consultant body
A Training programme was developed for appraisers
A procurement exercise was undertaken to purchase an e-portfolio system for use
commencing April 2013.
The year has been one of many challenges, however as we approached the end of 2012 and
moved into the final three months of the appraisal year over 85% of doctors had been appraised,
with plans in place for the remainder to complete their appraisal in time.
2013 will see the Trust seeking to raise the quality of a robust appraisal.
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Item 13
14.
15.
Quality Control
Safeguarding
Dr Hannah Davies, FY2 doctor at Pennine West, presented her recent work on safeguarding
awareness amongst Foundation Doctors at the National Foundation Doctors Presentation Day and
scooped Best Poster in the Original Work Category. We asked Hannah for an overview of her
work...
“A number of surveys of children, adolescents and parents suggest that the prevalence of child
maltreatment, both physical and emotional, is significantly under recognised and under reported.
Key reports following the deaths of children that have been victims of physical and emotional
abuse have recognised the need for comprehensive training of doctors who work with children and
their families. Junior doctors often occupy frontline positions where they frequently come into
contact with children in departments such as accident and emergency, general practice,
paediatrics and obstetrics and gynaecology. They may be the only medical staff to have contact
with these children and it is essential that they are trained to recognise and respond to child
maltreatment.
Supported by Dr Suparna Dasgupta, Consultant Paediatrician, NMGH, I have completed a survey of
FY1 and FY2 doctors across Pennine, to assess their confidence in recognising and responding to
suspicions of child maltreatment.
Initial results showed that junior doctors were low in confidence across all the domains which
included recognising alarming features of the history given and examination findings. The junior
doctors also identified a lack of teaching in this area and were dissatisfied about the guidance they
had received regarding what to do if they suspected child maltreatment.
The FY2 doctors were then re-surveyed following a dedicated teaching session delivered by Dr
Andrew Rowland, Paediatric A&E Consultant, NMGH. This teaching session led to a significant
improvement in both confidence and satisfaction.
Domain
% confident pre-teaching
% confident post-teaching
History
42
89
Interaction between child and carer
42
74
Clinical examination
33
89
Radiological images
3
42
Responding to NAI
25
89
Based on these results we have recommended that all junior doctors should receive teaching on
safeguarding children, which is mandatory, structured and tailored to the needs of foundation
trainees and the foundation programme curriculum.
The results of the survey were presented at the National Foundation Doctors Presentation Day in
February and we were fortunate enough to win best poster in the original work category. We have
also been chosen to present a poster at the Royal College of Paediatric and Child Health (RCPCH)
conference in May. Hopefully this will raise awareness of the need for better training and
education for foundation doctors on safeguarding children.”
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During my general surgical Foundation Year 1 (FY1) rotation, I found that my weekend on-call shifts were
dominated by hours of taking blood for tests that were requested by the weekday ward teams. In addition
to these tests, I was expected to perform the normal ward jobs for inpatients and also review any patients
who were unwell. This meant I was unable to review the blood tests I had taken and so handed this onto
the night team who had similar problems to myself. Having heard colleagues describing similar experiences,
I decided to perform an audit to see if this was a common occurrence, in the hope I might prove the need
for a weekend phlebotomist to ease the pressure on the FY1s.
The audit involved checking the patient notes of anyone who had received a blood test at the weekend. I
looked at 3 weekends in April, May and June. If the blood results were not written in the notes, they were
recorded as un-reviewed.
Surprisingly, I found that 49% of these tests were not reviewed in the notes over these weekends and they
were therefore pointless. Potentially, this could be endangering patient safety and wasting the Trust
money. I spoke to the Foundation Programme Director, Miss Mammen, who suggested that I try to present
this audit. I responded to a flyer from the Union of Risk Management for Preventative Medicine in Tokyo by
sending an abstract of my work. They accepted my abstract and I presented my work at the World Congress
in London.
I received some great feedback and it was suggested that I approach the Trust management with my
results. Miss Mammen is helping me with this and we hope to progress this work to actuate change within
the Trust.
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Item 13
Dr James Collins, FY2 at Pennine East
16.
Continuing Professional Development (CPD)
Highlights of the CPD Team Year
16.1 Grand Rounds
We have now successfully established the Grand Rounds across three sites at lunchtimes and
these happen fortnightly or weekly depending on local needs and demands. CPD leadership has
been established for each site with Dr Sridharan at Oldham and Dr Devakumar at Fairfield, Dr
Sivaraman and Mr O Reilly at North Manchester. Speakers from different specialties have
addressed topics of common interest and the Grand Rounds provide a platform for multidisciplinary and interactive learning. Prizes have been instituted at each site for the best
presenting teams annually. Grand Rounds provide valuable local CPD opportunity that is directly
recordable on the revalidation databases.
16.2 Mandatory Training
After the problems of achieving Mandatory Training Targets were realised, various measures have
been taken to improve compliance. Training has been made available more often and across more
locations by increasing the number of scheduled sessions. E-learning has been encouraged with
good results. Easy access to mandatory training compliance reports for the individual as well as
Departmental reports for Divisional and Clinical Directors is now showing results with improving
individual compliance.
16.3 Specialty Training Internal Survey
The first Trust wide internal audit of all Specialty trainees was introduced this year. There was an
excellent response rate and improvements suggested are included in the team action plan.
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Staff Awards
Item 13
17.
Medical and Dental Education held their 2nd annual Staff Awards Ceremony on Thursday 24th
May 2012 at The Royal Oldham Hospital Education Centre.
Throughout April, nominations were received for the titles of:


Medical Educator of the Year
Outstanding Achievement in Medical Education
With some truly outstanding entries this year the judging panel had a very difficult time picking
out winners. So difficult in fact, they picked two Medical Educators of the Year!
Hosted by Dr Tina Kenny, Deputy Medical Director and Director of Medical & Dental Education,
Tina was joined by Trust Chairman, Mr John Jesky who presented the awards for the second time.
The ceremony highlights some of the outstanding work that has been undertaken within Medical
Education over the past 12 months, some of which you will have seen in past editions of Medic.
All the nominees should be extremely proud of themselves and we are sure you will join us in
congratulating them. The 3 winners all received tickets to attend the Trust’s Staff Award Ceremony
at the Etihad Stadium on Wednesday 20th June 2012.
The team celebrated the event with a buffet lunch and following the ceremony, Tina delivered a
presentation on the proposed GMC changes for clinical and educational supervisors.
Dr Suranjan Ghoshal, wins Medical Educator of the Year
MEDIC’s very own Dr Hussain Ahmad, FY1, Pennine East
wins Outstanding Achievement in Medical Education
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27
18.
Clinical and Educational Supervisors
A database of the above is kept centrally by the team. All new consultants are asked on arrival for
their qualifications in this respect, and all doctors who work in these roles are given guidance and
support from the department as to what qualifications are required and how these can be
obtained.
The department also has implemented a 12 month rolling programme of Educator Development
to support both new Clinical and Educational Supervisors and those wishing to develop through
continuing professional development. Both internal and external stakeholders have joined
together to provide the in-house sessions, which have received excellent feedback from
attendees.
In October 2012 the North Western Deanery wrote to the Trust to provide information from the
General Medical Council in terms of recognising and approving trainers in 2013 onwards. The
General Medical Council in conjunction with the Academy of Medical Educators will be raising the
bar during 2013 in terms of the standards expected moving forward. For many of our existing
Clinical and Educational Supervisors this will mean providing annual evidence at appraisal of
continued development in Medical Education. For doctors new to this role formal qualifications
will be required in future.
The Trust left 2012 and commenced 2013 from a strong position. Teams have used a self
assessment tool to renew their educational service. Full recognition for Supervisors is not
mandatory until 2016 but there remains work to do to ensure we meet all requirements on the
journey.
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Conclusion
We are working in a time of continual change, and financial challenge. Despite these challenges
the department has worked hard and has been a credit to the Trust. Our thanks go to the staff of
the medical and dental admin and clerical team, the medical education forum and the clinical and
educational supervisors who work hard on a daily basis to deliver in challenging times.
2012 saw our department take on appraisal and revalidation as an additional work stream, it also
saw a very successful and positive visit from the North Western Deanery. Our relationships with
other key stakeholders for example The University of Manchester Medical School and Central
Manchester Foundation Trust continue to develop and grow.
We are fortunate to have great support together with enthusiastic and capable staff, and
colleagues that can keep all those plates spinning. As we move into 2013 we are pleased to report
improvements in all areas and more to come.
Our thanks go to all contributors.
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Item 13
19.
APPENDICES
Appendix A
Structure Chart
30
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Item 13
Appendix B
Annual Objectives
Corporate
Objective
Improving clinical
effectiveness and
patient safety
Associated Trust Objective
Medical Education Objective
Achievement
Reduce hospital acquired
VTE ( venous
thromboembolism)
95% of adult admissions to
have a VTE assessment
Healthcare acquired
infections
No more than 4 MRSA
and100 C Diff
All staff both in Medical
Education Admin & Clerical and
Medical Education Forum to
ensure mandatory training is
up to date and green or amber
at all times.
Audit of effective handover
Monthly review of reports from
OLM system for admin &
clerical.
Monthly updates issued to
staff.
Individual reports produced
quarterly for all members of
the Medical Education Forum
Monthly updates issued to
Forum Members
Handover audit to be included
in Trust wide teaching plan
2012
Already happening in Ortho at
TROH – Audit presentation at
TROH w/c 5.11.12
Improving the
patient experience
Improve the experience of
our patients
Ensure all student and trainee
doctors have high standards of
quality training at all times.
Following external reviews all
services affected will have clear
objectives developed.
Maintaining our
regulatory
obligations
We will ensure that we
meet or exceed the
requirements of the
external NHS regulatory
frameworks
To ensure all education and
clinical supervisors are working
towards a minimum Level 2
GMC requirement.
Database to be maintained by
Asst Manager QA and reported
against showing measured
increase month on month.
25% achieve level 2 by July
2012; 50% by November 2012
and 75% by March 2013
Successful revalidation of first
st
100 doctors by 31 March 2013
Develop and implement a
revalidation communication
plan to all doctors. On track to
meet target.
Refurbishment of Limbert
Home to provide state of the
art simulation facility.
Upgrade of Clinical Skills Lab
TROH to provide better
undergraduate training
facilities.
Upgrade of G20 TROH to
provide clinical skills room
equipped to high standard for
all trainees.
Environment and
sustainability
North Manchester estate
Deliver year on year
improvement to estate
condition survey result
To develop and implement a
robust process to support
revalidation of doctors within
the Pennine Acute NHS Trust,
ensuring all doctors holding
formal management or
leadership roles (as determined
locally by the RO) participate.
To continually review the
estate and ensure that it is fit
for purpose for medical
education
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Appendix C
Faculty
The high quality of medical and dental education provided at the Trust would not be possible
without the dedication of the large team of people involved.
Medical and Dental Education Administration Team:
Sharon Taylor
Gillian Webb
Dawn Richardson
Samantha Kessell
Emma Roche
Sharon Stone
Anthony Hoy
Josh Murray
Joanne Edge
Rita Haworth
Bernie Lynch
Dawn Collins
Linda Cockcroft
Christine Clarkin
Carole Hardisty
Billy Cutler
Diana Eden-Maughan
Jane Mitchell
Taria Eckersall
Simone Scorah
Michelle Lutkevitch
Head of Medical and Dental Education
Medical Education Manager
Assistant Manager, Quality Assurance
Assistant Manager, Foundation Training
Assistant Manager, Specialty Training
Assistant Manager, Undergraduate Training
Revalidation Administrator
Revalidation Administration Support
Foundation Programme Administrator
Foundation Programme Administrator
Foundation Programme Administrator
Specialty Administrator
Specialty Administrator
Specialty Administrator
GPST Dental Administrator
GPST Dental Administrator
Undergraduate Administrator
Secretary/Administration
Secretary/Administration
Secretary/Administration
Secretary/Administration
Lead Educators:
Mr Mohammed Zahir
Miss Catherine Mammen
Dr Doogie Whitcombe
Dr Sarita Bhat
Dr Iain Lawrie
Dr Rajkumar Parikh
Dr Prabha Sivaraman
Dr Ella Checkley
Dr Vinodh Devakumar
Dr Rip Gangahar
Mr Chetan Katre
Dr S Dasgupta
Dr Suranjan Ghoshal
Dr Rob Levy
Dr Jaysheel Mehta
Mr Taohid Oshodi
Associate Director of Medical Education (ADME)/Foundation
Programme Director (FPD)
FPD
FPD
FPD
Undergraduate Tutor
Undergraduate Tutor
CPD Lead
Careers Lead
Specialty Lead, Medicine
Specialty Lead, A&E
SAS Drs Lead
Specialty Lead, Paediatrics
Specialty Lead, O&G
Associate DME for Women and Children
Associate DME for Surgery/Specialty Lead, Orthopaedics
Specialty Lead, General Surgery/Vascular/Urology
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32
Specialty Lead, ENT/Ophthalmic/Maxillofacial/Dental
Specialty Lead, Pathology
Specialty Lead, Radiology
Associate DME for Diagnostics & Clinical/ Specialty Lead,
Anaesthetic/ACCS/ICU
Dr Paromita Biswas
Dr Maad Jasim
Mr Saf Ghobrial
Mr Manzoor Sheik
Mr Shantanu Singh
Mr Joseph Odey
Dr Shankar Patil
Dr Arpita Jain
Dr Sandeep Ghuliani
SAS Co-ordinator, Medicine
SAS Co-ordinator, A&E
SAS Co-ordinator, O&G
SAS Co-ordinator, Orthopaedic
SAS Co-ordinator, General/Vascular
SAS Co-ordinator, Urology
SAS Co-ordinator, ENT/Maxillofacial
SAS Co-ordinator, Ophthalmology
SAS Co-ordinator, Anaesthetic/ICU
Mr David Read
Ash Hussain
Associate Director of Dental Foundation Training
Dental Foundation Training Programme Director
Item 13
Mr Mehdi Motamed
Dr Khalid Ahmed
Dr Rafik Filobbos
Dr Radhika Bhishma
We are particularly grateful to all colleagues who have contributed to Medical and Dental
Education across the Trust and who have stepped down this year.
Our thanks go to our entire current faculty for their hard work and dedication to the teaching and
support of our junior doctors:Name
A
B
Surname
Abbas
Abbasi
Abouzeid
Absar
Adedokun
Adegbite
Adnan
Affram
Afify
Agarwal
Agrawal
Ahmad
Ahmed
Ahmed
Ajdukiewicz
Akram
Ali
Ali
Ali
Ali
Allen
Al-Sayed
Amonkar
Amu
Anjum
Annamalaisamy
Appiah-Saki
Asumu
Atkinson
Aziz
Badh
Bagewadi
Forename
Andrea
Atta
Hisham
Mohammed
Joshua
Adedayo Leo
Moataz
Kofi
Samir
Ravi
Shailesh
Gaity
Usman
Khalid A
Katherine
Noreen
Kassim
Saad
Huda
Baqar
Carolyn M
Tamer
Suraj J
Olubusola
Zul
Rajesh
Koby
Theo
Paul
Nagui
Charnajit
Sunil
Educational Role
Clinical
Educational
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Page 296 of 318
Department / Speciality
Acute Medicine
Gastroenterology
Obstetrics and Gynaecology
Acute Internal Medicine
Anaesthetics
Obstetrics and Gynaecology
Emergency Medicine
Paediatrics
General Surgery
Neonatal Medicine
Otolaryngology
Obstetrics and Gynaecology
Geriatric Medicine
Histopathology
Infectious Diseases
Oral and Maxillo-facial Surgery
Emergency Medicine
Obstetrics and Gynaecology
Paediatrics
General Surgery
Clinical Radiology
General (Internal) Medicine
Clinical Radiology
Obstetrics and Gynaecology
Obstetrics and Gynaecology
Clinical Radiology
Obstetrics and Gynaecology
Trauma and Orthopaedic Surgery
Cardiology
Obstetrics and Gynaecology
Intensive Care Medicine
Paediatrics
33
C
D
E
F
Barberan
Barrie
Batra
Bayman
Benatar
Bhalla
Bhat
Bhatnagar
Bhatnagar
Bhishma
Bhutta
Blanchard
Bonington
Bonshahi
Borrill
Bose-Haider
Boulos
Bowden
Brammer
Brocklehurst
Buch
Butler
Byrne
Calleary
Cardwell
Carlos
Cartmill
Chadwick
Chandran
Chandrasekara
Charan
Chaudhary
Checkley
Cherian
Chougle
Chow
Chung
Coates
Cochran
Cook
Cook
Coupe
Cullen
Dabritz
Dang
Dasgupta
Davies
De'Liguori Carino
Derbyshire
Desai
Deshpande
Devadoss
Devakumar
Dhanasekar
Dibble
Dickson
Dieh
Doyle
Drake
Drummond
Duncan
Dutta
El Malek
Farook
Fernando
Filobbos
Finlay
Elisa
Janet
Shivani
Patricia
Brian
Rita
Sarita
Deepak
Sadhna
Radhika
Aqeel
Tom
Alec
Ardeshir
Zoe
Bratati
Anan
Andrew
Roger
Ian C
Keyur
Jim
Peter
John
Mary
Adrian
Ivor
Simon
Suresh
Hemantha
Vinita
Shuaib
Ella
Jacob
Aslam
Wai Man
Angela
Mark
Diarmid
Paul
Laurence
Michael
Claire
Grit
Cuong
Suprana
Stephen
Nicola
Stephen
Niranjan
Rahul
Vilayakumar
Vinodh
Boopathy
Colin
Malcolm
Annabel
James
Henrietta
Andrew
Tracy
Madhu
Emad
Saleem
Rashika
Rafik
Michael
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Rehabilitation Medicine
Anaesthetics
Obstetrics and Gynaecology
Occupational Medicine
Histopathology
Obstetrics and Gynaecology
Stroke Medicine
Endocrinology and Diabetes Mellitus
Histopathology
Anaesthetics
Trauma and Orthopaedic Surgery
Infectious Diseases
Infectious Diseases
Trauma and Orthopaedic Surgery
Respiratory Medicine
Paediatrics
Obstetrics and Gynaecology
Rheumatology
General Surgery
Anaesthetics
Trauma and Orthopaedic Surgery
Emergency Medicine
General Surgery
Urology
Intensive Care Medicine
Trauma and Orthopaedic Surgery
Medical Microbiology
Anaesthetics
Acute Medicine
Acute Medicine
Histopathology
Ophthalmology
Intensive Care Medicine
Urology
Trauma and Orthopaedic Surgery
Urology
Intensive Care Medicine
Emergency Medicine
Intensive Care Medicine
Palliative Medicine
Anaesthetics
General (Internal) Medicine
Trauma and Orthopaedic Surgery
General Surgery
Endocrinology and Diabetes Mellitus
Paediatrics
Anaesthetics
Hepatology
Emergency Medicine
Clinical Radiology
General Surgery
Trauma and Orthopaedic Surgery
General (Internal) Medicine
Anaesthetics
Emergency Medicine
Obstetrics and Gynaecology
Obstetrics and Gynaecology
Trauma and Orthopaedic Surgery
Anaesthetics
Anaesthetics
Intensive Care Medicine
Clinical Radiology
Emergency Medicine
Emergency Medicine
Clinical Radiology
Clinical Radiology
Respiratory Medicine
34
H
I
J
K
L
David
Fletcher
Rip
Abdul
Sherif
Suranjan
Sandeep
Peter
Uma
Mudiyur
David
Kathryn
Richard
Tim
Hayley
Mukesh
Deepankar
Rachel
Victoria
Simon
Mark
Beverley J
Ziauddin
Steve
Kunal
Saqif
Catherine
Jennifer
Joanne
Zahirul
Zahid
Riza
Balakrishnan
Chitra
Arun
Pavel
Nick
Narayanasamy
Nadeem
Nicholas
Amanda
Neville
Perunkulam
Prakash
Vikas
Amar
Kewal
Chetan
Hervinder
Khalil
Alka
Jonathan
Mohammad Idrees
Asad
Navin
Paul
Howard
Adeniyi
Rajasekarappa
Salah
Jagadhish
Salim
Elzy
Shuk
Iain
Tom
Rob
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Page 298 of 318
Dermatology
General (Internal) Medicine
Emergency Medicine
Histopathology
Obstetrics and Gynaecology
Obstetrics and Gynaecology
Anaesthetics
Geriatric Medicine
Paediatrics
Paediatrics
Otolaryngology
Cardiology
Oral and Maxillo-facial Surgery
Cardiology
Haematology
Urology
Anaesthetics
Histopathology
Obstetrics and Gynaecology
Acute Medicine
General (Internal) Medicine
General (Internal) Medicine
Emergency Medicine
Genito-urinary Medicine
Trauma and Orthopaedic Surgery
Trauma and Orthopaedic Surgery
Respiratory Medicine
Respiratory Medicine
Anaesthetics
General Surgery
Urology
General Surgery
Trauma and Orthopaedic Surgery
Obstetrics and Gynaecology
Urology
Clinical Radiology
Cardiology
Clinical Radiology
Paediatrics
Intensive Care Medicine
Obstetrics and Gynaecology
Clinical Radiology
Obstetrics and Gynaecology
Paediatrics
Anaesthetics
Anaesthetics
Anaesthetics
Oral and Maxillo-facial Surgery
Obstetrics and Gynaecology
Stroke Medicine
Obstetrics and Gynaecology
Anaesthetics
Cardiology
General (Internal) Medicine
Clinical Radiology
Anaesthetics
Gastroerology
Genito-urinary Medicine
Anaesthetics
Endocrinology and Diabetes Mellitus
Endocrinology and Diabetes Mellitus
General Surgery
Anaesthetics
Anaesthetics
General (Internal) Medicine
Emergency Medicine
Paediatrics
Item 13
G
Fitzgerald
Fletcher
Gangahar
Ganjifrockwala
Ghobrial
Ghoshal
Ghuliani
Gibson
Ginjupali
Gopi
Gordon
Gow
Graham
Gray
Greenfield
Gupta
Haldar
Hall
Hall
Hanley
Hargreaves
Harrison
Hassan
Higgins
Hinduja
Hossain
Houghton
Hoyle
Humphreys
Huq
Hussain
Ibrahim
Ilango
Jain
Jain
Janousek
Jenkins
Jeyagopal
Jilani
Jones
Jones
Joshi
Jothilaskshmi
Kamath
Kapoor
Karmarkar
Kataria
Katre
Kaur
Kawafi
Kedia
Kenworthy
Khalid
Khan
Khanna
Kirk
Klass
Komolafe
Kotemane
Kouta
Krishamurthy
Kurrimboccus
Kuruvilla
Lam
Lawrie
Leckie
Levy
35
M
N
O
P
Lian
Limdi
Limdi
Lipton
Longshaw
Lyons
Macfoy
Mackillop
Maddock
Madhavan
Magadevan
Maiti
Malik
Mammen
Marthi
Mastan
May
McCahill
McCallum
McCulloch
McGeachie
McGettigan
McGivney
McMaster
Mehta
Miles
Mir
Mirza
Mishra
Mohan
Moise
Morcos
Motamed
Mukherjee
Murthy
Namushi
Narayanan
Nasir
Nasry
Nayak
Naylor
Naz
Ng Man Kwong
Odeka
O'Donnell
Ofoegbu
Oluwole
Ondrousek
O'Reilly
Orton
Oshodi
Oyegade
Padmakumar
Page
Paiva-Correia
Panasa
Panigrahi
Panwar
Parikh
Parker
Parkes
Patel
Pattrick
Paul
Phaltankar
Pradhan
Pradhan
Paul
Sonali
JK
Jonathan
Mark
Jane
Donald
Andrew
Natasha
Gopal
Talaivirichan
Sachchidananda
Isha
Catherine
Ravi
Muntimadugu
Gabrielle
Jim
Shona
Sarah
John
Clare
Ronan
Paddy
Jaysheel
Jon
Pervaiz
Shahid
Biswa
Rama
Jonathan
Fayez
Mehdi
Anindya
Prad
Robert
Sathay
Nabila
Hany
Sandeep
Katherine
Sophia
Georges
Egware
Paul
Bibian
Oluyemi
Karel
Derek
John
Taohid
Adegoke
Beena
Fiona
Antonio J
Sri Nagesh
Hari
Nitin
Raj
Gabrielle
Andrew
Santosh
Martin
Joel
Padmanabh
Shubhra
Sweta
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Page 299 of 318
Occupational Medicine
Clinical Radiology
Gastroerology
Ophthalmology
Intensive Care Medicine
Audiological Medicine
Obstetrics and Gynaecology
Intensive Care Medicine
Paediatrics
Anaesthetics
Paediatrics
Obstetrics and Gynaecology
Endocrinology and Diabetes Mellitus
Obstetrics and Gynaecology
Anaesthetics
Anaesthetics
Emergency Medicine
Emergency Medicine
Respiratory Medicine
Neonatal Medicine
Anaesthetics
Obstetrics and Gynaecology
Trauma and Orthopaedic Surgery
Paediatrics
Trauma and Orthopaedic Surgery
Respiratory Medicine
Paediatrics
Anaesthetics
Endocrinology and Diabetes Mellitus
Trauma and Orthopaedic Surgery
Neonatal Medicine
General (Internal) Medicine
Otolaryngology
Paediatrics
Otolaryngology
General (Internal) Medicine
Anaesthetics
General Surgery
Oral and Maxillo-facial Surgery
Anaesthetics
Anaesthetics
Rheumatology
Respiratory Medicine
Paediatrics
Palliative Medicine
Neonatal Medicine
Paediatrics
Anaesthetics
General Surgery
Anaesthetics
General Surgery
Histopathology
Paediatrics
Occupational Medicine
Histopathology
Paediatrics
Medical Microbiology
Paediatrics
Trauma and Orthopaedic Surgery
Emergency Medicine
Anaesthetics
Anaesthetics
General (Internal) Medicine
Medical Microbiology
Trauma and Orthopaedic Surgery
General (Internal) Medicine
Acute Medicine
36
S
T
Parameshwara
Nandhini
Morag
Roger
Uma
Bashir
Vinay
Anthony
Nagaraja
Jason
Ritwik
Abdul
Caroline
Antony
David
Graham
Mark
Patricia
Patrick
Nicola
Andrew
Martin
Susannah
Alan
Michael
N Girish
Bhaskar
Saad
Rohit
Milan
Mark
Birgit
Robin
Nita
Vivek
Pradeep
Raashid
Riaz
Ravi
Virendar
Patrick
Manzoor
Ian J
Zhaeer
David
Deepak
Ritesh
Ankush
Anton
Prabha
Helen
Jolanta
David
Samuel
Evin
Venkat
Shyam
Sridhar
Catherine (Kate)
Jon
Arunachalam
William
Sylvio
Anton
Lipika
Wilson
David
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Page 300 of 318
Endocrinology and Diabetes Mellitus
Paediatrics
Obstetrics and Gynaecology
Gastroerology
Obstetrics and Gynaecology
General (Internal) Medicine
General Psychiatry
General Surgery
Anaesthetics
Geriatric Medicine
Acute Medicine
Paediatrics
Obstetrics and Gynaecology
Anaesthetics
General Surgery
General Surgery
Emergency Medicine
General (Internal) Medicine
Anaesthetics
Acute Medicine
Emergency Medicine
Haematology
Endocrinology and Diabetes Mellitus
Obstetrics and Gynaecology
Emergency Medicine
Anaesthetics
Anaesthetics
General Surgery
Trauma and Orthopaedic Surgery
Clinical Radiology
Endocrinology and Diabetes Mellitus
Obstetrics and Gynaecology
Trauma and Orthopaedic Surgery
Respiratory Medicine
Haematology
Geriatric Medicine
General Surgery
Anaesthetics
General (Internal) Medicine
Otolaryngology
Otolaryngology
Trauma and Orthopaedic Surgery
Otolaryngology
Clinical Radiology
General Surgery
Anaesthetics
Emergency Medicine
General Psychiatry
Acute Medicine
Obstetrics and Gynaecology
Endocrinology and Diabetes Mellitus
Cardiology
Trauma and Orthopaedic Surgery
General (Internal) Medicine
Rheumatology
General (Internal) Medicine
Clinical Radiology
Anaesthetics
Clinical Radiology
Cardiology
Anaesthetics
General Surgery
Occupational Medicine
Paediatrics
Clinical Radiology
General (Internal) Medicine
Anaesthetics
Item 13
R
Prakash
Prakash
Preston
Prudham
Ramalingam
Rameh
Rao (Sudhindrarao)
Rate
Ravishankar
Raw
Raychaudhuri
Rehman
Rice
Richards
Richards
Riding
Riley
Ritchie
Ross
Rothwell
Rowland
Rowlands
Rowles
Russell
Saab
Sadhu
Saha
Salman
Samuel
Sapundzieski
Savage
Schaefer
Seagger
Sehgal
Sen
Sethi
Shahbazi
Shaikh
Sharma
Sharma
Zaid Sheehan
Sheikh
Sheppard
Sherazi
Sherlock
Shetty
Shetty
Singhal
Sinniah
Sivaraman
Smithurst
Sobolewska
Sochart
Solomon
Sowden
Sridharan
Sunder
Surapeneni
Swainson
Swan
Swayamprakasam
Tait
Tamin
Tan
Tandon
Thomas
Thomasson
37
U
V
W
Y
Z
Thomson
Tierney
Titi
Ustianowski
Vallance
Varshney
Vickers
Vilar
Waits
Wallace
Walsh
Watt
Weir
Whitcombe
Wilkins
Wood
Woodwards
Yadav
Yusuf
Zahir
Ewen
Nick
Sami
Andrew
Harry
Seema
Gareth
Javi
Patrick
Jane
Luke
Tracey
David
Doogie
Edward
Christopher
Robert
Vivek
Harun
Mohammed
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Oral and Maxillo-facial Surgery
Anaesthetics
Histopathology
Infectious diseases
Anaesthetics
Anaesthetics
Anaesthetics
Infectious diseases
Anaesthetics
Acute Medicine
Occupational Medicine
Anaesthetics
General (Internal) Medicine
Anaesthetics
Infectious Diseases
Emergency Medicine
Oral and Maxillo-facial Surgery
Anaesthetics
Oral and Maxillo-facial Surgery
Emergency Medicine
38
Page 301 of 318
Risk Management Committee Minutes – 14 May 2013
Executive
Summary
The minutes from the Risk Management Committee in March 2013
reflect discussions on the following agenda items:
 Needle-stick Injuries
 Document Management Report - Red Incidents
 Risk Management Committee Assurance Statement
 Trust Health & Safety Annual Report
 Emergency Preparedness Resilience & Response Annual
Report
 Breakdown of RPST Key Themes Report 2011-12
 Secure Passwords
 Email Archive
 Coding Presentation
The Board is asked to note the content of the minutes
Actions
Requested:
Corporate objectives supported by this paper:
All Corporate Objectives are supported by a risk assessment which is included in the
Corporate Risk Register.
Risks:
Risks identified at the meeting are all on the corporate risk register and linked to the
assurance framework both of which are monitored at this meeting
Public and/or Patient Involvement:
Not relevant for this paper
Resource Implications:
Not relevant for this paper
Communication:
The Risk Management Committee communicates its work through Trust Board,
Clinical Governance and Quality Committee, Divisional Governance Committees and
the Health and Safety structure. Any incidents likely to attract media coverage are
handled with the communication department.
Have all implications been considered?
YES
NO
N/A
Assurance
√
Contract
√
Equality and Diversity
√
Financial / Efficiency
√
HR
√
Information Governance Assurance
√
IM&T
√
Local Delivery Plan / Trust Objectives
√
National policy / legislation
√
Sustainability
√
Name
Job Title
Month and Year
Email
Mr J Saxby
Chief Executive
March 2013
[email protected]
Page 302 of 318
Item 14
Title of Report
MINUTES OF THE RISK MANAGEMENT COMMITTEE
14th May 2013 AT 10.30AM IN THE MONSALL ROOM, NMGH
Mr J Saxby
Mrs H Curtis
Mrs D Ashton
Mrs C Guereca
Ms J Keogh
Mr H Mullen
Ms J Moore
Mrs J Nolan
Mrs M Ollerenshaw
Mrs D Pullen
Mr C Sleight
Mr S Taylor
Mrs C Trinick
Mrs C Walters
Mr J Wilkes
Chief Executive (Chair)
Governance Director
Divisional Director for Surgery
Non Executive Director
Elective Access Manager
Executive Director of Operations
Divisional Director for Women & Children’s Division
Governance (Minutes)
Non Executive Director
Head of Legal & Regulatory Services
Divisional Director for Clinical Support and Diagnostics
Divisional Director for Medicine & Community Services
Deputy Director of Women & Children Division
Director of IM&T Services
Director of Facilities
IN ATTENDANCE
Ms S Naylor
Clinical Audit Manager, RI & ROH
APOLOGIES
None received
RM/040/13
MINUTES OF RISK MANAGEMENT COMMITTEE MEETING
The minute of the Risk Management Committee meeting held on 12th March
2013 was accepted as a correct record with an amendment to the attendance of
Mr Mullen.
MATTERS ARISING
RM/041/13
RM/022/12 RM/003/13 RM/114/12 RM/086/12 – Trust Health & Safety
Committee – Chimney Filters at FGH
Mr Wilkes reported that the gas mains are now installed at FGH and step one is
now complete. A decision regarding the national bid is due on 24th May 2013.
Mr Wilkes will update the Committee on a regular basis.
Action: JW
RiskMgmt/ 14th May 2013
Page 1 of 7
Page 303 of 318
Item 14
PRESENT
RM/042/13
RM/023/12 RM/007/13 RM/118/12 GOVERANCE DASHBOARD/ VIOLENCE
Agenda item – Needle-stick injuries
Specific incident topics will be presented at the future meetings:
Manual Handling incidents- June 2013
Action: HC/JW
RM/043/13
RM/024/13 RM/008/13 RM/126/12 TRUST SECURITY COMMITTEE
Mr Wilkes reported to the Committee that Manchester Mental Health have been
advised they will be billed if Pennine was surcharged if the numbers of fire
alarm call outs exceeded the Trust’s quarterly limit.
Action: Closed
RM/044/13
RM/025/13 RM/009/13 DOCUMENT MANAGEMENT REPORT
Agenda item
RM/045/13
RM/027/13 RM/011/13 RPST KEY THEMES ADDENDUM REPORT
Agenda Item
RM/046/13
RM/028/13 GOVERNANCE DASHBOARD
Violence Report / Presentation
Mr Wilkes reported that the Violence presentation shown at the Committee
meeting in March will be n agenda item at the next CNJCC and on the LIA
Action: Closed
RM/047/13
RM/031/13
ASSURANCE REGARDING HORSEMEAT
Mr Wilkes reported that he has been given total assurance that there are no
pork has been identified in any Halal meat products provided by the Trust.
Action: Closed
RM/048/13
RM/033/13
INFORMATION QUALITY ASSURANCE GROUP (IQAG)
Coding Presentation - Agenda item. .
RM/049/13
RM/035/12 INFORMATION GOVERNANCE STEERING GROUP
IG Mandatory Training
Mrs Walters reported that the Trust reached 96.23% compliance target for IG
Mandatory Training and the compliance was better than most Northwest Trusts.
RiskMgmt/ 14th May 2013
Page 2 of 7
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RM/050/13
GOVERNANCE DASHBOARD
Needle-stick Injuries
Mrs Trinick reported to the Committee that the EU Directive for Needle-safe
Devices has been implemented and commenced on 13th May 2013. The Trust
is taking a staged approach to adhere to all standards and significant
improvement in sharp/needle-stick injuries has been noted. The Trust recorded
injuries was 6% however it currently stands at 0.3% (better than the national
average) also improving patient safety.
Banners have been ordered and will be placed in departments and good
practice will be communicated across the organisation using staff inductions,
incident recording and follow-up re-enforcing the message.
Mrs Trinick to present a further update to the Committee at the September 2013
meeting.
Action: CT
Dashboard
Highlighted was the continuous incident reporting with slips trips and falls still
an issue across the Trust. Discussed was the incidents which could and could
not be avoided.
RM/051/13
DOCUMENT MANAGEMENT REPORT
Mr Saxby raised his concerns regarding the unacceptable high numbers of red
incidents recorded within the report.
Mrs Curtis agreed that she will investigate the policies that are under the
Community Services umbrella however it is noted that some policies have gone
through the amber system and therefore should not have reached red. Some
policies are also out of date.
Mr Saxby requested the Document Management Report is to be reviewed by all
authors of the policies as it is their responsibility to ensure the policies are
reviewed and updated in a timely manner adhering to the process. No
document to be Red by the next Committee meeting otherwise the author will
be requested to attend the meeting to explain the reason as to why.
RiskMgmt/ 14th May 2013
Page 3 of 7
Page 305 of 318
Item 14
Work is ongoing working closely with the Supplies Department who have to
move across to ensuring it orders needle-safe devices following the legal
requirement implemented. It was noted that the Trust could demonstrate
adherence to the standard if an external inspection was carried out.
Mrs Curtis also requested that there should not be a mass of authors
requesting extensions to policy renewal dates.
Action: ALL
RM/052/13
HR POLICIES
Mrs Curtis presented to report on behalf of HR. The proposal submitted by HR
was to use a disclaimer on HR Policies in order to satisfy concerns raised by
staff side regarding the use of expiry dates on HR policies within the Document
Management System. The disclaimer would be used for any new or updated
HR Documents as required and HR policies would not expire and will continue
until a revised policy has been agreed or it is agreed that the policy is no longer
required or noticed is served by either party to terminate the policy/agreement.
The Committee discusses the requested and agreed the Document
Management System is in place to monitor policy renewals and therefore the
Committee did not approve the request. HR and Staff side to negotiate new
dates on policies or update policies jointly and follow the correct processes.
RM/053/13
RISK MANAGEMENT COMIITTEE ASSURANCE STATEMENT
Mrs Curtis presented the Risk Management Assurance Statement to the
Committee for approval. The Assurance Statement provides assurance that the
Committee has effectively discharged its responsibilities during 2012/13 as set
out in its Terms of Reference.
The Committee approved the Assurance Statement which will be presented at
the Audit Committee.
RM/054/13
TRUST HEALTH & SAFETY ANNUAL REPORT
Mrs Curtis spoke to the Health & Safety Annual Report.
The Committee noted the annual report which provided information regarding
the Trust’s performance in health and safety management throughout 2012/13
and highlights policies which have been introduced or reviewed by the Health &
Safety Advisors.
The report gives reference to the Laundry Incident and the involvement with the
Health & Safety Executive (HSE) and the prompt action taken by the Trust
which helped prevent an improvement notice or prosecution
Changes in Reporting of Injuries Disease and Dangerous Occurrence
Regulations 1995 (RIDDOR) have been highlighted including Incident statistics
and will be presented to the Clinical Governance & Quality Committee and the
Trust Board. Mrs Curtis to liaise with Mr Barclay and Mr Lynn to discuss any
media interests prior to the Trust Board.
Action: HC
RiskMgmt/ 14th May 2013
Page 4 of 7
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RM/055/13
EMERGENCY PREPARDENESS RESILIENCE & RESPONSE ANNUAL
REPORT
Mr Wilkes presented the report to the Committee.
The report provides a
comprehensive overview and presents a successful year and looks forward to a
new set of objectives for 2013/14 which are based on the Trust’s annual
business plan and the risks identified nationally and regionally.
The Committee agreed the report and positive feedback from Committee
members was noted.
BREAKDOWN OF RPST KEY THEMES REPORT 2011-12
Mrs Pullen spoke to the report. The breakdown presented was an addendum to
the original report summarising the key themes and issues from non-clinical
claims against the Trust in the year 2011/12 with data for Trust contributions to
non clinical claims for the years 2010/11 and 2011/12 which was presented to
the Committee in December 2012.
The Committee was asked to note the significant payments made by the
NHSLA in non clinical claims which was set out grouping the type of claim and
highlights the increasing costs associated by RPST (non-clinical) costs.
Discussion ensued in relation to risk assessments being carried out, staff
accountability and unavoidable incidents
RM/057/13
SECURE PASSWORDS
Mrs Walters presented a report to request agreement from the Committee to
authorise the time between password resets for staff members to log onto the
Trust’s computer network to be increased from 30 days to 90 days and in
conjunction to this to enforce self-service password management and improved
personal identification checks when required.
The Committee approved the request.
RM/058/13
EMAIL ARCHIVE
Mrs Walters presented the report to the Committee to request agreement to set
up a project to review suggested changes to the email archive and the Subject
Access Request processes. The Trust has recently received requests from
staff asking for copies of emails and any other electronic information held about
them which is causing significant operational issues from the HR and IM&T
departments
RiskMgmt/ 14th May 2013
Page 5 of 7
Page 307 of 318
Item 14
RM/056/13
RM/059/13
INFORMATION QUALITY
PRESENTATION
ASSURANCE
GROUP
(IQAG)
-
CODING
Mrs Walters presented a Coding Information presentation to the Committee.
The Committee was given an overview of how clinical coding organises clinical
language into statistical groups and condenses it into aggregated, tabulated
and referenced data. The presentation illustrated how the coding procedure
works and the documentation required and how information is used to secure
accurate reimbursement clinical information. The presentation was well
received by the Committee.
Mrs Walters reported that a paper is being presented to the Execs for the
request to approve 12 WTE staff plus annual intake of trainees within the
Coding Department. A new Clinical Coding Manager will be starting within the
Department shortly
Mrs Curtis suggested there needs to be a cross-reference to Clinical Coding in
the Clinical Record Keeping Policy and agreed to review the policy to ensure
this is incorporated.
Action: HC
RM/060/13
RECORDING MANAGEMENT GUIDELINES (REVISED) - FOR APPROVAL
Mrs Curtis spoke to the policy and reported these guidelines, formerly known as
the Records Management Strategy, haven been revised and responsibilities
and minor amendments have been made to update the policy.
The Committee approved the revised guidelines.
RM/061/13
CLINICAL RECORD KEEPING POLICY (REVISED) - FOR APPROVAL
Ms Naylor attended the Committee to present the revised Clinical Record
Keeping Policy for approval, formerly known as the Record Keeping Policy.
The policy has been substantially revised and seeks to increase compliance
with recognised clinical record keeping standards from the current rate of 60%
to the 75% rate required for a successful assessment by the NHSLA at Levels 2
and 3.
A set of essential standards have been agreed following extensive consultation
with multi disciplinary teams and in addition new aspirational good practice
standards have been introduced that the Trust will work towards achieving.
Progress towards achieving these standards which are based on national
guidance and requirements published by the respective professional bodes.
Progress will be monitored via the annual recording keeping audits carried out
by the Clinical Audit Department
RiskMgmt/ 14th May 2013
Page 6 of 7
Page 308 of 318
The Committee discussed several points including the recording of date and
times within out-patient records and identifiable pharmaceutical information.
Ms Naylor agreed to liaise with Dr Kenny regarding the education and training
especially middle-grade Doctors in relation to record keeping and how to ensure
the message gets cascaded amongst clinicians. Mrs Pullen agreed to liaise
with Ms Naylor regarding a suggested for an additional column to be added to
the documentation.
Action: SN
FOR REVIEW
RM/062/13
INFORMATION QUALITY ASSURANCE GROUP
RM/063/13
RESILIENCE FORUM
The minute of the Resilience Forum meeting held on 13th February 2013 was
received and noted.
RM/064/13
INFORMATION GOVERNANE STEERING GROUP
The minute of the Information Governance Steering Group meeting held on 12 th
April 2013 was received and noted.
RM/065/13
TRUST SECURITY COMMITTEE
The minute of the Trust Security Committee meeting held on 16th January 2013
was received and noted.
FOR INFORMATION
RM/066/13
ANY OTHER BUSINESS
None received
RM/067/13
DATE OF NEXT MEETING – RISK MANAGEMENT COMMITTEE
The next meeting will be held on TUESDAY 9th July 2013 at 10.30AM in the
Monsall Room, North Manchester General Hospital
RiskMgmt/ 14th May 2013
Page 7 of 7
Page 309 of 318
Item 14
The minute of the meeting of the Information Quality Assurance Group held on
23rd April 2013 was received and noted. No significant issues raised.
Executive
Summary
Clinical Governance & Quality Committee Minutes – 17th May
2013
The minutes from the Clinical Governance and Quality Committee
in May 2013 reflect discussions on the following agenda items:







Mortality
Red Incidents
VTE
Role and Functions of the Corner – Mr David Lewis
Cancer Action Plan
Missing Patient Guidelines (For ratification)
Divisional Governance Minutes
Actions
The Board is asked to note the content of the minutes
Requested:
Corporate objectives supported by this paper:
All Corporate Objectives are supported by the work of the Clinical Governance and
Quality Committee
Risks:
Any risks identified at the meeting are referred to the relevant manager for possible
inclusion on the relevant part of the risk register.
Public and/or Patient Involvement:
Not relevant for this paper
Resource Implications:
Not relevant for this paper
Communication:
The Clinical Governance and Quality Committee communicates its work through the
Trust Board, Divisional Governance Committees and the Health and Safety
structure.
Have all implications been considered?
Assurance
Contract
Equality and Diversity
Financial / Efficiency
HR
Information Governance Assurance
IM&T
Local Delivery Plan / Trust Objectives
National policy / legislation
Sustainability
Name
Job Title
Month and Year
Email
Mr J Saxby
Chief Executive
June 2013
[email protected]
Page 310 of 318
YES
√
NO
N/A
√
√
√
√
√
√
√
√
√
Item 15
Title of Report
THE PENNINE ACUTE HOSPITALS NHS TRUST
Clinical Governance & Quality Committee
17th May 2013
IN ATTENDANCE:
Ms A Jones
Mrs L Kerwin
Mr D Lewis
APOLOGIES:
Mrs D Ashton
Ms C Cullen
Mrs H Curtis
Dr I Lawrie
Dr C Rice
Chief Executive (Chair)
Director of Nursing
Consultant Microbiologist
Consultant, Palliative Care
Non Executive Director
Non Executive Director
Chief Pharmacist
Acting Executive Medical Director
Non Executive Director
Divisional Director, Women & Children
Governance (Minutes)
Interim Head of Corporate Development
Divisional Director, Diagnostics & Cl Support
Head of Safeguarding
Divisional Director, Medicine & Community
Deputy Divisional Director for Women & Children /
Head of Midwifery
Clinical Nurse Manager, Surgery
Quality and Service Development Manager
Head of Regulatory Services - Weightman’s LLP
Solicitors
Item 15
PRESENT:
Mr J Saxby
Mrs M Carroll
Dr I Cartmill
Dr P Cook
Mrs S Dixon
Mrs C Guereca
Ms P Jones
Dr C Kenny
Mrs C Mayer
Ms J Moore
Mrs J Nolan
Mrs D Pullen
Mr C Sleight
Dr S Smith
Mr S Taylor
Mrs C Trinick
Divisional Director of Surgery
Consultant, Orthopaedic Surgeon
Governance Director
Consultant, Palliative Care
Consultant in Obstetrics and Gynaecology
051/13 MINUTE OF CLINICAL GOVERNANCE COMMITTEE HELD ON 19th April
2013
The minute of the Clinical Governance Committee Meeting dated 19th April 2013 was
received and noted. Amendments would be made to the minutes of the previous
meeting held on 15th March 2013.
CG&QC/HC May2013
1
Page 311 of 318
052/13 MATTERS ARISING FROM THE MINUTE
85/11 Inter-ward Transfers: Ongoing - Divisions to monitor and produce a
report on a six monthly basis ie September 2013 to ensure that progress is
maintained.
Action: DDs
Mrs Trinick to present an overview of transfers - Right Place Right Time- at
the June 2013 meeting.
Action: CT
284/12 Monitoring Scorecard - Red Incidents: Divisional Directors were
reminded that no incident should be outstanding for longer than 6 months. In
line with the changes to the roles and functions of the Coroner it was noted
that the timeline of red incidents would need be amended. Mrs Curtis would
discuss the implications of this with Division Directors.
Action:HC
009/13 Elective Access Policy: Mrs Pullen reported that the policy is to be
presented at the Clinical Director Strategic Advisory Forum in July.
Action: Closed
023/13 / 024/13 Morbidity & Mortality Meetings: Ongoing - It was noted that
M & M Meetings were taking place within the Divisions.
Action: DDs
030/13 Mortality: Divisional Directors were asked to discuss the way forward
at their Divisional Governance Meetings and update the Committee in June
2013. The first draft of the joint work carried out by Mrs Anne Uttley and
Deloittes will be available in June 2013 and will be circulated to members of
the Committee.
Action: HC/DDs
031/13 VTE: Work ongoing : Mr Taylor presented an update paper on work
being undertaken within the Division of Medicine and how it has consistently
improved its performance for VTE assessments on non-elective patients
admitted via emergency care and currently meets the 95% standard.The
report highlighted the review that had taken place and sets out the process in
place to monitor and improve performance within the Division across the four
Trust sites.
The report shows that wards which have direct admissions and transfers
without electronic support continue to underperform. Clinical leads need to
ensure that all junior doctors are aware of their responsibility to undertake
VTE assessments for those patients. FGH continues to improve in its
performance.
CG&QC/HC May2013
2
Page 312 of 318
The Divisional Director will continue to receive monthly data to share with the
Clinical Directors, Directorate Managers and Divisional Nurse Managers.
Where wards have been identified as underperforming against the standard
monthly exceptional reports will be required.
039/13 CQC Quarterly Update: Mrs Pullen reported that the Trust has
received assurance of compliance from the CQC in line with Outcome 5 and
Outcome 9. Internal checks will be continue to ensure progress is maintained
.
044/13 Critical Care Steering Group: Mr Sherlock is leading on the “High
Risk Surgical Patient” and a Task and Finish group has been set up. Mrs
Ashton would report to the CGQC when the work was completed.
Action: DA
045/13 Patient Experience & Equality Committee : Friends and Family Test
(FFT) – Mrs Carroll reported that the results have not yet been received
however it was noted that there was a poor compliance within the A&E
Department in completion of the cards. Mr Saxby requested assurance that all
ward staff were made aware this test is taking place and to ensure cards are
completed for all discharge patients
Action: DDs
053/13 PRESENTATION : ROLE AND FUNCTIONS OF THE CORONER – MR
DAVID LEWIS
He identified changes in how the Coroner will interact with the Trust. There were
likely to be an increase in costs and there is an expectation that there should be an
earlier admission of liability prior to the inquests taking place. There is also the
distinct expectation that documentation will need to be submitted within a shorter
time-frame. This will have a significant effect on timely internal investigations.
Hearings for inquests will be made public and the list of Coroner’s business will be
published thus increasing the likelihood of greater press coverage of the work of
Coroner’s Inquests.
Changes are to be made to Rule 43 and it is expected that the Coroner will make
greater use of Rule 43 to gain greater clarity of actions taken by an NHS Trust in the
light of Coroner findings. There is also the expectation that the newly established
post of Chief Coroner will subject the work of local coroners to greater scrutinisation.
The changes carry risks for the Trust because the inquest process will be much
shorter—from start to finish in no less than 6 months. There is also the possibility
that Serious Incident Reports will be asked for by the coroner and this has
implications for staff in being open and honest.
CG&QC/HC May2013
3
Page 313 of 318
Item 15
Mr David Lewis, Head of Regulatory Services from Weightman’s LLP Solicitors
attended the Committee to highlight the changes that are scheduled to be
implemented from the 1st July 2013 in relation to the role and functions of the
Coroner.
Mr Lewis stated that he expected there to be much greater rigour taken in
scrutinising Coronial work at local level.
Mr Saxby believed that it would be helpful for all clinical staff to be made aware of
the new rules and regulations including the implications of the Duty of Candour
outlined in the Francis Report.
Discussion concentrated on the need to ensure that the Trust gave proper support to
staff who needed to attend a Coroner’s Inquest.
All clinicians needed to be briefed on the changes. Mrs Pullen would liaise with Mr
Lewis to create an information sheet and Divisional Directors would need to cascade
this through their Divisional Governance meetings.
Dr Kenny agreed to look at training requirements for investigators and to consider
how incidents are reported and documented with a possible.
Action: DP/DDs/CK
054/13 PAHT MONITORING SCORECARD
The Monitoring Scorecard was presented to the Committee and its contents noted.
It was noted that an amendment is required regarding C Diff and the Trust’s internal
trajectory target. There has been an outbreak of C Diff in April and work is ongoing
to address this. No significant single cause has however been identified to account
for the number of C Diff cases. The cases reported in April 2013 are lower than
those reported in April 2012 ( 10 compared to 17)
055/13 MORTALITY
The Mortality report was presented by Dr Kenny. Dr Kenny highlighted the format of
the report which will be presented to the May Trust Board.
Dr Kenny reported that data quality has improved. Work on “Untoward deaths”
continues concentrating on clinicians with higher than expected mortality rates.
Dr Kenny believed that more work was needed to ensure the report is written to an
expectable standard and easy to read. It was noted that an amended report will be
submitted to the Trust Board.
056/13 VTE
The VTE CQUIN 95% standard was achieved for February 2013 and is currently
96.37%. Divisions still need to continue to improve the pick-up of non-elective
CG&QC/HC May2013
4
Page 314 of 318
admissions. Divisional Directors are asked to cascade this information through their
Divisions for action.
Action: DDs
057/13 MONITORING REPORT
The monitoring report was presented by Mrs Carroll. A number of incidents have
been closed during the last month. Red incidents are being reviewed by the Clinical
Commissioning Groups (CCGs) and the Trust is awaiting a response from them.
Mrs Carroll reported that she has seen an updated STEIS report which shows only
one red outstanding incident and the Trust is awaiting for a response from Heywood
Middleton & Rochdale CCG. The updated STEIS report would be circulated to all
members of the Committee.
Action: MC/JN
058/13 PATIENT EXPERIENCE INCLUDING CQUINs
Nothing of significance was reported this month.
059/13 CLINICAL EFFECTIVENESS INCLUDING CQUINs REPORT – CANCER
ACTION PLAN
Item 15
Dr Kenny presented the Cancer Action Plan synopsis to the Committee. No
significant problems were identified and good progress is being made in maintaining
the national standards.
POLICIES, STRATEGIES AND REPORTS
060/13 MISSING PATIENT GUIDELINES (FOR RATIFICATION)
Mrs Kerwin presented the Missing Patient Guidelines for ratification to the
Committee. The document needs to be followed by all staff when an inpatient is
identified as missing or when a discharged patient/outpatient with a critical condition
is un-contactable.
An extra section has been added following a serious incident regarding a former
patient
Discussion ensued in relation to making contact with GP and Police service in cases
where an individual patient could not be contacted and in identifying a single named
lead in all such cases who would be responsible for contacting external bodies as
appropriate.
CG&QC/HC May2013
5
Page 315 of 318
Dr Kenny agreed to devise accountability information and incorporate this into the
guidelines.
The Committee agreed the guidelines.
Action: CK
FOR SCRUTINY AND FOLLOW UP
061/13 PACC
The minute of the Pennine Acute Cancer Committee meetings dated 11th April 2013
were received and noted. It was noted that CCGs might fund a North East sector
lymphoedema service in 2013/14.
062/13 SAFEGUARDING EXECUTIVE MEETING
The minute of the Safeguarding Executive meeting held on 2nd April 2013 was
received and noted. The large volume of child safeguarding issues in Rochdale was
highlighted and in particular the numbers of requests for the Trust to become
involved with investigations that had little or no specific Trust involvement. Dr Kenny
and Dr Smith would liaise with Ms Moore and Mrs Trinick to establish whether
additional resources were needed to ensure the Trust could respond appropriately.
Action: SS/CK/CT/JM
Dr Smith reported that the take up of Safeguarding adult training continues to
improve.
063/13 NURSING / MIDWIFERY & QUALITY PERFORMANCE GROUP
The minute of the Nursing/Midwifery & Quality Performance Group meeting dated
15th April 2013 was received and noted.
Mr Saxby requested Divisional Directors to ensure that all wards are informed and
made aware about the Friends and Family Test (FFT). Results will be monitored by
the Patient Experience & Equality Committee and will be made public both at local
and national level.
The Quality Accounts for 2012/13 are now in draft format and would be audited by
KPMG before being submitted to the Trust Board.
Action: DDs
CG&QC/HC May2013
6
Page 316 of 318
064/13 TRUST INFECTON & PREVENTION CONTROL COMMITTEE
The minute of the Trust Infection & Prevention Control Committee meetings dated
22nd March 2013 was received and noted. No significant issues raised.
065/13 CRITICAL CARE STEERING GROUP
The minute of the Critical Care Steering Group meeting dated 1st March 2013 was
received and noted. The Greater Manchester Acute Kidney Injury Strategy
developed by the GM Kidney Care Network is now agreed and the strategy group
will re-convene after April in order to agree the implementation of the strategy.
066/13 DIAGNOSTIC MINUTES
The minute of the Division of Diagnostic and Clinical Support Governance Divisional
Governance Committee meeting dated 2nd April 2013 was received and noted. Mr
Sleight reported that a private Podiatrist has been visiting wards asking patients if
they want private treatment. An investigation into this is ongoing.
Action: CS
The minute of the Division of Surgery Clinical Governance & Quality Committee
meeting dated 3rd April 2013 was received and noted. Ms Jones reported on behalf
of Mrs Ashton. Significant improvement has been made to close Red incidents. M&M
meetings were now taking place.
068/13 MEDICINE MINUTES
The minute of the Division of Medicine Clinical Governance & Quality Committee
meeting dated 10th April 2013 was received and noted. A new reporting structure
has been agreed to comply with Trust CGQC requirements especially in relation to
M&M meetings. Timely completion of Red incidents was being closely monitored.
069/13 WOMEN & CHILDREN GOVERNANCE COMMITTEE
The minute of the Division of Women and Children’s Governance Committee
meeting dated 1st May 2013 was received and noted by the Committee. Terms of
Reference had been reviewed and amended to reflect the changes within the
Division.
CG&QC/HC May2013
7
Page 317 of 318
Item 15
067/13 SURGERY MINUTES
070/ DATE, TIME AND PLACE OF NEXT MEETING
The next meeting of the Clinical Governance & Quality Committee will be held on
Friday, 21ST JUNE 2013 in the Monsall Room, North Manchester General Hospital
at 12.30 pm
CG&QC/HC May2013
8
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