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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. C:\Users\244991-Admin\AppData\Local\Temp\740f47fe-a179-4396-b72b-59b7d35ad939.doc Page 3 of 318 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 C:\Users\244991-Admin\AppData\Local\Temp\740f47fe-a179-4396-b72b-59b7d35ad939.doc Page 4 of 318 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 C:\Users\244991-Admin\AppData\Local\Temp\740f47fe-a179-4396-b72b-59b7d35ad939.doc Page 5 of 318 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. C:\Users\244991-Admin\AppData\Local\Temp\740f47fe-a179-4396-b72b-59b7d35ad939.doc Page 6 of 318 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 Page 13 of 318 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 ta l Gr an d W ar d te r Pr es su re Un it E6 ria ge rg ica lT W in Su C4 ae (N ) En d os co p yD F4 ay S Gy n Un it (N ) -S ur ge ry F5 I6 ur ge ry H3 ) nt s at ie Ou t -P er ge nc (E m EA U Ac cid en t& yA ss Un i t- D5 Em er ge nc y DS U Th ea tre 0 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 Page 19 of 318 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 Page 20 of 318 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. 10 Page 21 of 318 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 Page 22 of 318 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 Page 23 of 318 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 Page 24 of 318 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 Page 25 of 318 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 Page 26 of 318 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 Page 27 of 318 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 17 Page 28 of 318 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) 18 Page 29 of 318 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 Page 30 of 318 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…” 20 Page 31 of 318 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 21 Page 32 of 318 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 22 Page 33 of 318 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. 23 Page 34 of 318 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. 24 Page 35 of 318 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 Page 36 of 318 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 Page 54 of 318 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 Page 55 of 318 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 Page 58 of 318 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 Page 59 of 318 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 1|Page Page 60 of 318 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 Page 61 of 318 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 3|Page Page 62 of 318 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 4|Page Page 63 of 318 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; 5|Page Page 64 of 318 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; 6|Page Page 65 of 318 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. 7|Page Page 66 of 318 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. 8|Page Page 67 of 318 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. 9|Page Page 68 of 318 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. 10 | P a g e Page 69 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 11 | P a g e Page 70 of 318 Item 10 Also, in December 2012, the NHS Trust Development Authority published its Planning Guidance 2013/14 which sets out clear expectations on: The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 12 | P a g e Page 71 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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; 13 | P a g e Page 72 of 318 Item 10 3.3.1 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 14 | P a g e Page 73 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 15 | P a g e Page 74 of 318 Item 10 The values that underpin the Trust’s mission statement are: The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 16 | P a g e Page 75 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 Item 10 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. 17 | P a g e Page 76 of 318 The Pennine Acute Hospitals NHS Trust 3.4.4 IM&T Strategy 2013-2017 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. 18 | P a g e Page 77 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 19 | P a g e Page 78 of 318 Item 10 IM&T needs to support the Trust in responding to national strategic initiatives through: The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 20 | P a g e Page 79 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 21 | P a g e Page 80 of 318 Item 10 Information Provision The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 22 | P a g e Page 81 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 23 | P a g e Page 82 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 24 | P a g e Page 83 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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; 25 | P a g e Page 84 of 318 Item 10 The strategic mission for IM&T is: The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 26 | P a g e Page 85 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 27 | P a g e Page 86 of 318 Item 10 In February 2013, an EPR solution appraisal paper was developed. The three main requirements arising from this paper were: The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 28 | P a g e Page 87 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 29 | P a g e Page 88 of 318 Item 10 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. The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 30 | P a g e Page 89 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 31 | P a g e Page 90 of 318 Item 10 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 32 | P a g e Page 91 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 33 | P a g e Page 92 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 34 | P a g e Page 93 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 35 | P a g e Page 94 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 36 | P a g e Page 95 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 37 | P a g e Page 96 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 38 | P a g e Page 97 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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; 39 | P a g e Page 98 of 318 Item 10 Its terms of reference are: The Pennine Acute Hospitals NHS Trust 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 40 | P a g e Page 99 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 41 | P a g e Page 100 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 42 | P a g e Page 101 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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. 43 | P a g e Page 102 of 318 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. 44 | P a g e Page 103 of 318 The Pennine Acute Hospitals NHS Trust 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 45 | P a g e Page 104 of 318 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 46 | P a g e Page 105 of 318 The Pennine Acute Hospitals NHS Trust 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. 47 | P a g e Page 106 of 318 The Pennine Acute Hospitals NHS Trust 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 48 | P a g e Page 107 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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: 49 | P a g e Page 108 of 318 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. 50 | P a g e Page 109 of 318 The Pennine Acute Hospitals NHS Trust 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 51 | P a g e Page 110 of 318 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 52 | P a g e Page 111 of 318 The Pennine Acute Hospitals NHS Trust 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 53 | P a g e Page 112 of 318 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. 54 | P a g e Page 113 of 318 The Pennine Acute Hospitals NHS Trust 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 55 | P a g e Page 114 of 318 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 56 | P a g e Page 115 of 318 The Pennine Acute Hospitals NHS Trust IM&T Strategy 2013-2017 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 57 | P a g e Page 116 of 318 The Pennine Acute Hospitals NHS Trust 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. 58 | P a g e Page 117 of 318 The Pennine Acute Hospitals NHS Trust 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 59 | P a g e Page 118 of 318 Item 10 GI Reporting Tool IM&T Strategy 2013-2017 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 Page 2 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 122 of 318 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 Page 3 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 123 of 318 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 Page 4 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 124 of 318 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 Page 5 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 125 of 318 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 Page 6 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 126 of 318 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 Page 7 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 127 of 318 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 Page 8 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 128 of 318 Pennine Acute Hospitals NHS Trust Risk Management Strategy EDQ011 Version 6 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 Page 9 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 129 of 318 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 Page 10 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 130 of 318 Pennine Acute Hospitals NHS Trust 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 Page 11 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 131 of 318 Pennine Acute Hospitals NHS Trust Risk Management Strategy EDQ011 Version 6 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 Page 12 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 132 of 318 Pennine Acute Hospitals NHS Trust Risk Management Strategy EDQ011 Version 6 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 Page 13 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 133 of 318 Pennine Acute Hospitals NHS Trust Risk Management Strategy EDQ011 Version 6 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 Page 14 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 134 of 318 Pennine Acute Hospitals NHS Trust 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 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet 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 Page 16 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 136 of 318 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 Page 17 of 22 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 137 of 318 Page 138 of 318 Expiry date: 26/05/14 Clinical Director ates Infection Preventi on NHSLA RISK MANAGEMENT STANDARDS It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet 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 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 19 of 22 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 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet 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 It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet Page 21 of 22 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* It is your responsibility to ensure that this print out is the most up-to-date version of this document Check on the ‘Documents’ pages of the Trust Intranet 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 2 Page 156 of 318 Annual Report for 2012/13 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) 3 Page 157 of 318 Emergency Preparedness, Resilience and Response Annual Report for 2012/13 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; 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. 4 Page 158 of 318 Annual Report for 2012/13 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) 5 Page 159 of 318 Item 13 Emergency Preparedness, Resilience and Response Emergency Preparedness, Resilience and Response Annual Report for 2012/13 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. 6 Page 160 of 318 Annual Report for 2012/13 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 7 Page 161 of 318 Item 13 Emergency Preparedness, Resilience and Response 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. 8 Page 162 of 318 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 9 Page 163 of 318 Item 13 Emergency Preparedness, Resilience and Response 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 10 Page 164 of 318 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 Page 165 of 318 Item 13 Emergency Preparedness, Resilience and Response Emergency Preparedness, Resilience and Response Annual Report for 2012/13 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. 12 Page 166 of 318 Annual Report for 2012/13 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 Page 167 of 318 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. 14 Page 168 of 318 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 15 Page 169 of 318 Item 13 Emergency Preparedness, Resilience and Response Emergency Preparedness, Resilience and Response 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. 16 Page 170 of 318 Annual Report for 2012/13 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 Page 171 of 318 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 Page 172 of 318 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 Page 173 of 318 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 Page 176 of 318 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 Page 177 of 318 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 Page 178 of 318 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 Page 179 of 318 Page 180 of 318 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 Page 181 of 318 Page 182 of 318 8 Figure 2. Recruitment into NIHR CRN Studies by Trust (2012/13) Item 13 Page 183 of 318 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 Page 184 of 318 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 Page 186 of 318 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 Page 189 of 318 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 Page 190 of 318 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 Commercial Commercial Academic Commercial Academic Academic Academic Academic Academic Academic Academic Academic Academic Commercial Academic Academic Academic Academic Academic Academic Academic Academic Academic Academic Commercial Academic Commercial Academic Academic Academic Item 13 5 5 5 5 5 5 5 5 6 6 6 7 7 7 7 7 8 10 11 11 12 13 14 15 16 16 16 16 17 17 Page 193 of 318 P. Wiles 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 Oral and Gastro Oral and Gastro Generic DENDRON Academic Academic Academic Commercial Academic Academic Commercial Academic Commercial Academic Academic Academic Academic Academic Academic Commercial Academic Academic Academic Academic Commercial Commercial Academic Academic Academic Commercial Commercial Academic Commercial 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 Page 194 of 318 M. Absar R. Jones D. Bhatnagar P. McMaster 107 108 109 P. Wiles 99 106 B. Harrison 98 B. Harrison J. Raw 97 105 L. Lee 96 No Local PI R. Namushi 95 104 V. Sen 94 E. Wilkins V. Misra 93 103 A. Uriel 92 E. Wilkins S. Chaudhary 91 R. Woodwards R. Namushi 90 102 J. Raw 89 101 P. O’Donnell & I. Lawrie 88 E. Wilkins A. Ustianowski 87 100 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 Academic Academic Academic Academic Academic Academic Commercial Commercial Academic Academic Commercial Academic Commercial Academic Academic Academic Academic Commercial Commercial Academic Commercial Commercial Academic Academic Item 13 1525 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 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: 6 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 217 of 318 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 7 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 218 of 318 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. 8 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 219 of 318 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. 9 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 220 of 318 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 10 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 221 of 318 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. 11 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 222 of 318 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 12 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 223 of 318 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. 13 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 224 of 318 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. 14 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 225 of 318 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 15 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 226 of 318 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. 16 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 227 of 318 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 17 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 228 of 318 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 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 229 of 318 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 19 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 230 of 318 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 Page 231 of 318 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. 21 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 232 of 318 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. 22 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 233 of 318 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 Page 234 of 318 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 Page 235 of 318 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 25 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 236 of 318 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 Page 237 of 318 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 Page 238 of 318 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 36 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 247 of 318 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). 37 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 248 of 318 Item 13 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%). 38 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 249 of 318 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. 39 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 250 of 318 Item 13 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. 40 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 251 of 318 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 41 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 252 of 318 Item 13 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 42 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 253 of 318 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% Naheed Nazir – Head of Equality & Human Rights June 2013 Page 254 of 318 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. 44 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 255 of 318 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. 45 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 256 of 318 Item 13 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 46 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 257 of 318 47 Naheed Nazir – Head of Equality & Human Rights June 2013 Page 258 of 318 Item 13 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 Page 259 of 318 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 Page 260 of 318 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 Page 262 of 318 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 Page 263 of 318 YES X X X X X X X X X NO N/A Item 13 Medical & Dental Education ANNUAL REPORT 2012 1 Page 264 of 318 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 Page 265 of 318 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 3 Page 266 of 318 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 Page 267 of 318 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 Page 268 of 318 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. 6 Page 269 of 318 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. 7 Page 270 of 318 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 Page 271 of 318 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 Page 272 of 318 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 Page 273 of 318 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 Page 274 of 318 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. Page 275 of 318 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. Page 276 of 318 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 Page 277 of 318 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 Page 278 of 318 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. 16 Page 279 of 318 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. Page 280 of 318 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. 18 Page 281 of 318 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. 19 Page 282 of 318 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. 20 Page 283 of 318 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 21 Page 284 of 318 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. 22 Page 285 of 318 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. 23 Page 286 of 318 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.” 24 Page 287 of 318 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. 25 Page 288 of 318 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. 26 Page 289 of 318 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 Page 290 of 318 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. 28 Page 291 of 318 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. 29 Page 292 of 318 Item 13 19. APPENDICES Appendix A Structure Chart 30 Page 293 of 318 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 31 Page 294 of 318 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 Page 295 of 318 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 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 Page 297 of 318 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 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 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 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 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 Page 304 of 318 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 Page 306 of 318 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 Page 318 of 318