Board Members Present · The TedMed Live Bristol Conference had taken place in Bristol on 18 April...

Minutes of a Public Meeting of the Trust Board of Directors held on 29 April 2013 at 10:30 in the Conference Room, Trust Headquarters,

Marlborough Street, Bristol, BS1 3NU

Board Members Present

John Savage – Chairman

John Moore – Non-executive Director

Lisa Gardner – Non-executive Director

Paul May – Non-executive Director

Iain Fairbairn – Senior Independent

Director

Emma Woollett – Non-executive

Director

Kelvin Blake – Non-executive Director

Guy Orpen – Non-executive Director

Robert Woolley – Chief Executive

Deborah Lee – Director of Strategic

Development and Deputy Chief Executive

Paul Mapson – Director of Finance and

Information

James Rimmer – Chief Operating Officer

Sean O’Kelly – Medical Director

Present or In Attendance

Claire Buchanan – Acting Director of

Workforce & organisational

Development

Helen Morgan – Acting Chief Nurse

Jill Foster – Interim Deputy Chief

Nurse

Prof David Wynick – Director of

Research (presenting item 08 –

Research & innovation Strategy

Progress Report)

Fiona Reid – Acting Head of

Communications

Charlie Helps – Trust Secretary

Victoria Church – Management

Assistant to Trust Secretary

Garry Williams – Patient Governor

Peter Holt – Patient Governor

Pam Yabsley – Patient Governor

Mani Chauhan – Patient Governor

John Steeds – Patient Governor – Local

Anne Skinner – Patient Governor – Local

Jacob Butterly – Patient Governor – Local

Florene Jordan – Staff Governor

Jan Dykes – Staff Governor

Sue Silvey – Public Governor

Clive Hamilton – Public Governor

Mo Schiller – Public Governor

Ann Ford – Public Governor

Sylvia Townsend – Governor, Bristol City

Council

Joan Bayliss – Governor, Community Group

Bob Skinner – Member

Item Action

1. Chairman’s Introduction and Apologies

John Savage congratulated Sue Silvey for taking over as Governor representative,

Mo Schiller for continuing in her current role, and John Steeds for completing a year

in his role as Governor representative.

There were no apologies.

2. Declarations of Interest

In accordance with Trust Standing Orders, all members present are required to

declare any conflicts of interest with items on the Board Meeting Agenda.

Guy Orpen declared a potential conflict of interest regarding Item 08 – Research &

of 19 of Minutes of a Public meeting of the Trust Board of Directors held on 29 April 2013 at 10:30 in the Conference Room, Trust Headquarters,


Innovation Strategy Progress Report. This was due to the University of Bristol and

University Hospitals Bristol NHS Foundation Trust having a close relationship

regarding research & innovation; Guy was employed by the University and was

particularly charged with developing its research strategy, although he believed that

there was a “mutual interest” regarding the research & innovation agenda.

3. Minutes and Actions from Previous Meetings

The Board considered the Minutes of the Public meeting of the Trust Board of

Directors dated Thursday 28 March 2013 and approved them as an accurate record.

There were no actions arising.

4. Chief Executive’s Report

The Board received a report by the Chief Executive, which included the activities of

the Trust Management Executive to note.

Robert Woolley highlighted the following items:

Monitor had formally contacted John Savage to advise that they had lifted the

red Governance Risk Rating over-ride and planned to take no further action in

respect of their concerns. However, they clearly remained interested in hearing the

Trust’s progress regarding plans to improve patient flow and deal with the

exceptional urgent and emergency care pressures that it, along with other hospitals

across the country, had experienced in recent weeks. Robert was pleased to report

that some of the pressure of Accident and Emergency demand had reduced in last

few days, probably due to the change in the weather.

The Bristol Acute Services Review had been subject to a change of scope and

its Terms of Reference had been altered by this Board, working collaboratively with

the Board at North Bristol NHS Trust. The project now focussed on completing the

Clinical Services Review that was already intended, but would not now work

towards an evaluation of a possible merger between the two Trusts. A new scope

and work plan had been agreed with PwC, who were the appointed external advisors

to the project, and three key pieces of work were being undertaken between now and

the end of June 2013, as follows:

1. To review the emergency care system as a whole, considering the entire

pathway of a patient requiring urgent care, both from home through

primary care, hospital, into the community and social care after discharge.

A review with health and social care partners was being undertaken in the

locality;

2. Detailed reviews were being undertaken of eleven priority services

identified between UH Bristol and North Bristol NHS Trust, as agreed

jointly by the medical directors and chief nurses. They were chosen either

because it was thought innovative steps could be taken, there was

information to suggest that quality improvements could be made, or

because it was believed there was duplication of services between the

Trusts, which it would benefit patients to address;

3. The final part of the work stream would review a series of radical options

to address the financial gap that the two Trusts were identified as facing

by PricewaterhouseCoopers (PwC) in their initial “stocktake” review.

These options would be developed by referencing other health systems

nationally and internationally and would be filtered and assessed by



executive teams on both sites, prior to being brought back for information

to both Trusts Boards. Further action and evaluation would then be

considered at these meetings regarding any shortlisted radical options and

more detail would be provided at the end of June in this regard.

Following the review of divisional leadership arrangements, Bryony Strachan

had been appointed Clinical Chair in the Division of Women’s & Children’s

Services, with an immediate start. Andrew Hollowood was Acting Head of Division

in Surgery, Head & Neck, but had also been appointed Clinical Chair, with an

immediate start. Elisabeth Kutt had agreed to stay in the Division of Diagnostics &

Therapies as Clinical Chair, and Alan Bryan had been appointed Clinical Chair for

the Division of Specialised Services. It was confirmed that Peter Wilde would

remain in post until the end of June, prior to formal handover. Candidates for the

Clinical Chair role in the Division of Medicine would be interviewed this week,

along with applicants for Divisional Director posts.

The changes in divisional leadership were accompanied by a complete review of

ways of working and further steps included investing in new Clinical Director roles,

to replace Lead Doctors inside the divisions, and fulfil the Trust Management

Executives’ commitment in establishing an effective clinical and management

partnership in the running of the divisions.

Jonathan Benger was congratulated as he had been appointed a national

Clinical Director for Urgent and Emergency Care. Due to Jackie Cornish’s recent

appointment as National Clinical Director for Children & Young People, the Trust

now had two national Clinical Directors working with the NHS Commissioning

Board, working directly to Professor Sir Bruce Keogh. As such, the Trust could feel

justly proud that it had nurtured them in their ambitions to operate at a national

level.

The TedMed Live Bristol Conference had taken place in Bristol on 18 April

2013; this was put together to formally launch Bristol Health Partners. Robert

reported that this was a superlative occasion with fantastic speakers and good

attendance, and he thanked all at the Trust, and its partners, who were involved in

putting it together. In particular, David Relph, Head of Planning and Strategy, was

thanked, as it had been his idea to approach TedMed in the first instance.

The new Duty of Candour had been enshrined into Trust policies following

publication of the inquiry into the failings of Mid Staffordshire NHS Foundation

Trust (the “Francis Report”).

The new Interim Deputy Chief Nurse, Jill Foster, was welcomed to the

meeting. Jill joined the Trust while formal recruitment was underway for the

substantive Chief Nurse position.

Claire Buchanan had appointed Richard Lewis as Interim Head of HR, while

Alex Nestor picked up the Organisational Development and Teaching & Learning

agenda.

Comments:

Referring to the Trust Management Executive summary, Iain Fairbairn asked

for clarity regarding risks to the potential delay of implementing the Safe &

Sustainable Review of Paediatric Cardiac Services. Robert Woolley responded that

these uncertainties continued, particularly while the decision of the Joint

Commissioning Board remained under judicial challenge. A possible risk was that



the change to patient flows intended as part of the rationalisation of Children’s Heart

Surgical Centres would take longer to come into effect. Nonetheless, the Trust was

investing in developing the service in the way it required and had now established

two children’s cardiac high dependency beds, as promised to the Care Quality

Commission. These were located on the Paediatric Intensive Care Unit at present,

but as recruitment proceeded five beds would be opened on ward 32 to support this.

The Trust was starting to see some welcome organic change in patient flow, which

included referral patterns from the south west, which aligned to the

recommendations of Safe & Sustainable and also supported Trust development.

This would provide UH Bristol with time to “pause” its expansion to the level it

intended on the back of the activity and income that the review had intended.

Iain Fairbairn asked if this decision would be made in time to ‘flex’ the Trust’s

premises changes, to which Robert Woolley that there was no timescale. Deborah

Lee added that it was important to note that current configuration plans were

significantly flexible and that, overall UH Bristol were not expecting significant

growth which would lead to a step-change in theatre capacity, for example.

Therefore, Deborah was confident delays would not impact on planning for Bristol

Royal Hospital for Children.

Robert added that the Trust had completed the update of Medway Phase 1b this

weekend, which was successful.

Responding to a question regarding divisional changes from Paul May, John

Savage explained that Divisional Chairs were not members of the Trust Board of

Directors. Robert Woolley added that there was no requirement or expectation that

Clinical Chairs and Divisional Directors should do so, but they would be welcome

to attend meetings of the Trust Board of Directors if they so wished, and this would

be encouraged.

Delivering Best Care1

5. Quality and Performance Report

The Board received and reviewed this report by members of the Executive. It was

noted that the Quality and Outcomes Committee continued to consider the quality

and performance report in detail prior meetings of the Trust Board.

a. Patient Experience

The Acting Chief Nurse, Helen Morgan, presented the Patient Experience report

which was submitted by the Division of Specialised Services. The report highlighted

the fundamental importance of good communication between staff and patients.

Comments:

John Moore felt that it was refreshing to have a patient experience which

highlighted the work of administration and clerical staff. He asked if the Trust had

phone tracking software to identify where calls were being missed. James Rimmer

replied that this system was in use in some areas of the Trust, such as the centralised

booking team, although was not widespread. The booking team used call centre

technology and plans were being considered to ensure this was more widespread.

The Trust was unable to log the telephone numbers of those who called, but

percentages of those patients whose calls were answered within a certain time

period were available. Staff were moved accordingly, depending on caller demand

1 Headings reflect the Transforming Care Programme



and staff were also increased in centralised booking at peak times. James also

confirmed that patients were called back when they left messages on answer phones.

Robert Woolley added that a large transformation project was underway for

outpatients under the Transforming Care Programme and this formed part of the

reason why booking was partially centralised. The Trust continued to consider total

centralisation and was reviewing wider administration support needs. Although

technological solutions seemed attractive, this was about setting standards of

behaviour and expectations and the values of staff.

Iain Fairbairn asked for an estimated figure of the general proportion of calls

processed through the centralised booking service, as opposed to the Trust as a

whole. Paul Mapson said that the figure was approximately half for out-patients.

Kelvin Blake reiterated Robert Woolley’s comment about the importance of Trust

Values in responding to phone calls, whether technological solutions were available

or not.

Regarding Quality in general, Helen Morgan said that she was pleased to report

a monthly improvement in the reduction of Hospital Acquired Pressure Ulcers.

Regarding Access in general, James Rimmer said that pressures on Accident &

Emergency 4-Hour targets remained unabated, both locally and nationally, although

April performance remained the same as March. Of additional note, the South West

Ambulance Service had incorporated Great Western Ambulance Service (GWAS),

so there might be potential for pinch points. However, the Trust was working in

partnership with them to mitigate issues and these had been highlighted to the NHS

England Local Area Team. Nevertheless, pressure remained on the acute trusts and

ambulance services.

b. Overview

The Director of Strategic Development, Deborah Lee, introduced the item, reporting

that overall, there had been a “significant improvement in the health of the

Organisation”. This was due to a reduction in Red-rated quality indicators by four,

and the movement of five further indicators to Green.

The Hospital Standardised Mortality Ratio (HSMR) continued to be positive at

the Trust, which demonstrated that despite a complicated case mix, patients were

being served well in terms of their outcomes under our care.

Whilst recognising that this was a ‘snapshot’ in time, the level of patients

readmitted quickly to hospital following discharge had declined in the month, which

was positive news.

Robert Woolley alluded to the challenging times that the Trust had been

through recently, which the Compliance Framework report had acknowledged. It

had not achieved 62- Day Cancer Standards or the Accident & Emergency 4-hour

standard, and the Methicillin-Resistant Staphylococcus Aureus (MRSA) standard

had exceeded its target in the year, so also did not achieve. However, Monitor were

currently satisfied with the quality of Board governance during these recent

challenges.

c. Quality and Outcomes Committee Chair’s Report

The Chair of the Quality and Outcomes Committee, Paul May, presented his report,

noting that the Committee had achieved a quorum this month, but apologies were

received from Iain Fairbairn.

Paul presented the following points to the Board:



1. Matters arising – Accident & Emergency – A paper was presented regarding

progress of the flow project, outlining the nine specific projects based on three main

themes: 1) Avoidance of admissions; 2) Reduction of length of stay; and, 3)

Improving morning discharge. The Committee agreed to monitor progress at each

meeting and asked for outcome projections, benefits and measures, to ensure 97%

achievement by September 2013. As a joint private/Trust project, excellent working

and backfill support had been provided if required.

A specific incident reported at the last meeting would be reviewed to ensure that

system improvements reduced/eliminated the risk of human error.

‘Black’ Escalation – A formal report presented 18 items recorded. Each division had

fed back specific responses to the corporate review. There had been an excellent

staff response, and staff had been thanked for demonstrating good practice. A key

issue was to review the policy regarding escalation and step-down after the event.

2. Draft Quality Report – Work was in progress to examine the latest draft

before external consultation. The format was similar to last year, but would be more

concise. Additional points raised would be picked up within the Chief Executive’s

introduction, such as the “Francis Report” and governance. The Hospital

Standardised Mortality Ratio target would be service-specific and amended to

reflect the subtlety of the task. Following a full discussion the detailed overview by

the committee was noted.

3. Quality & Performance Report

Quality – The Committee was delighted to note significant progress in many items,

but it would not lessen its scrutiny. After several ‘black’ escalation incidents, Trust

staff could feel proud of their dedication. Of key note, the Hospital Standardised

Mortality Ratio figure was excellent and Theatre Productivity was an issue. A

briefing about South Bristol Community Hospital would be provided by the Medical

Director.

Outlier figures for 30-Day Readmissions had been reviewed by the Quality

Intelligence Group and the Committee was reassured by the outcomes of this

review. Quality issues were examined, including Antibiotic Prescribing. A Falls trial

was being rolled out to a further ten wards across the Trust. A new unit for

Fractured Neck of Femur patients was seeing positive results. Transient Ischaemic

Attack - managed to keep 80% on ward despite ‘Black’ escalation.

Workforce – A Workforce deep dive would commence in May.

A Review of Bank & Agency was expected to be provided to the Board soon and

changes already made were showing improvements, including changing local

recruitment of nursing assistants. There was a visit to Dublin where a recruitment

drive was held for nurses. Sickness improvement was still under constant scrutiny,

and a detailed review of training definitions was being undertaken.

Access – Theatre capacity and patient choice. Intensive Care Unit capacity and Last

Minute Cancelled Operations.

4. Clinical Audit – This presentation covered the role of Clinical Audit, how the

process was supported, and answered Non-executive Director queries. There was

assurance about the process and discussion about how outcomes could be more

challenging in the future and how benchmarking could be more visible to Non-

executive Directors.

5. Clinical Effectiveness Strategy – It was agreed that this would be one of



three Quality Strategies and was welcomed by the Committee. The Strategy would

be submitted to the Board for formal approval, following the agreement of

amendments. This would move the agenda forward regarding responding to

“Francis”.

6. Clinical Annual Report and Plan – The Committee was pleased to note the

progress reports from the audits, but would welcome more structure regarding

priorities, planning and delivery in the future.

7. Clinical Quality Group notes. Some detailed issues arose from figures

provided, such as the clinical audit of medical records.

8. Due to the length of the meeting the Committee were unable to examine the

Corporate Risk Register and the Quarter 4 Compliance Framework, but these were

included on the main Board agenda.

d. Board Review

Referring to Hospital Acquired Pressure Ulcers, Iain Fairbairn noticed that one

of the Root Cause Analysis investigations had mentioned a shortcoming in “poor

nutrition and sepsis” as a cause, and asked if this had related to nutrition provided at

the Trust or externally. Helen Morgan said that this referred to patients admitted to

hospital with poor nutrition, and the importance of ensuring that if a person was at

high risk of poor nutrition that they were automatically highlighted as at risk of

developing a pressure ulcer. Kelvin Blake added that it was important to maintain

progress regarding pressure ulcers, including the requirement for provision of

appropriate mattresses.

Referring to Inpatient Falls per 1,000 Bed Day statistics, John Moore said that

the Trust should review patients with cognitive impairments, and he requested an

additional graph to show these figures separately. Helen Morgan confirmed that

Xanthe Whittaker planned to include this graph at the next meeting of the Board.

Guy Orpen referred to the Accident & Emergency 4-Hour standard, saying that

the transfer of Great Western Ambulance Service to the Trust covering the whole of

the south west might unbalance the relationships previously formed and require

them to be re-built. James Rimmer confirmed that a pilot of protocols was being

worked through at present in this regard.

Robert Woolley asked the Board to note that while it had been a positive

month for Infection Control in March, the Trust had breached the MRSA target for

the year and the targets for the current financial year would be considerably more

challenging regarding Clostridium Difficile, and a “zero tolerance” approach would

be taken towards MRSA. A review into whether more significant reporting was

required at Board would be considered in this regard.

There being no further questions or discussions, the Chair concluded this review of

the Quality and Performance Report.

Chief

Executive

6. Quarterly Transforming Care Report

The Board received this report by the Chief Executive to note.

Robert Woolley said that there was both a need to refresh the programme and was a

sterling opportunity to do so, with changes now being implemented in divisional

leadership. A new Programme Director, Simon Chamberlain, had been appointed

for the Transforming Care agenda, commencing work in the first week of June. He

would advise James Rimmer and Robert Woolley on how the programme could be



re-launched as a whole, and refresh work streams such as the Enhanced Recovery

from Surgery Programme, which was showing a significant impact and improving

Length of Stay.

Robert wanted the Board to have greater visibility of these improvements, and for

there to be a significant push regarding staff engagement, towards continued

delivery of high quality and compassionate care for the individual needs of patients.

James Rimmer referred to NHS Change Day, which was held on 13 March 2013.

The aim, nationally, was to involve at least 5% of the NHS. Locally, people planned

to pledge over 400 changes. Stations were placed across the Trust throughout the

day and over thirty patients also gave their opinions regarding change, particularly

in respect of outpatient services, which reemphasised the Patient Experience.

Comments:

Emma Woollett welcomed the re-launch of the Transforming Care agenda

within the Trust. She said that given how busy staff were, it is always difficult to

find the time to stop and think about how to do things differently; however, this re-

launch provided a valuable opportunity for innovative thinking.

John Moore asked if the Trust was setting itself ambitious targets in aiming to

find £3m of Non-Pay savings and if these might be too ambitious for the new

leaders of the Divisions in terms of their responsibility to save costs and achieve

targets without losing staff. Robert Woolley responded that he had been

communicating this challenge to colleagues and a detailed review regarding Non-

Pay and Procurement had been taken to one of the Board sub-committees. A number

of divisions had taken significant steps and positive engagement in the Non-Pay

savings work stream. Although the targets were ambitious, Robert felt that they

were realistic and proportionate.

Kelvin Blake requested the report continued to take this format and also

highlighted the key blockages stopping the Trust from “going the extra mile”.

Robert Woolley confirmed that the next time the item would be brought to Trust

Board, a new Programme Director would be in place and reviewing how reporting

could be adjusted.

Guy Orpen stated that one of the benefits of working in a research and teaching

organisation was the opportunity for capacity to be an ‘innovative organisation’.

The mind set for developing practice allowed it to be more readily implemented

than other organisations, and Guy was interested to explore how Research &

Innovation could be synergised with the Transforming Care Programme. Robert

Woolley acknowledged Guy’s observation and added that more thinking was

required to build the research agenda, whilst demonstrating outcome improvements

through this programme.

There being no further questions or discussions, the Board resolved to note the

Quarterly Transforming Care Report.

7. Timetable for Responding to the Mid Staffordshire NHS Foundation Trust Public Inquiry Report (the “Francis Report”)

The Board received and considered this report by the Medical Director for

approval.

Sean O’Kelly said that the paper set out the plan regarding how the Trust planned to

respond to the “Francis Report” in two ways:



1) It would review the report and its recommendations and conclusions in detail

and derive an action plan from these; and,

2) It would review the report more generally and conduct a number of

opportunities where staff could reflect on it and explain any themes and ideas

arising from the report.

The requirement was for the Trust to produce a detailed action plan by the end of

the year, but completion was expected before this time.

Work would be led by Sean O’Kelly, Helen Morgan and the Trust’s Clinical Chairs.

A Core group would oversee this initial phase of work and groups were due to meet

on Wednesday 01 May to initiate process.

Comments:

Emma Woollett said that useful sessions had been held to review how the

Board could take responsibility, not just in light of the “Francis Report”, but also

due to changes in constitution and structure. Robert Woolley confirmed that the

Trust Secretary was currently engaging with other acute providers across the south

west to share governance lessons and any pertinent information regarding this would

be taken into account by the Francis Report Core Group.

Guy Orpen asked how the “patient voice” would be brought in to the response

to the report. Sean O’Kelly said that this would have to be considered carefully as

there were many pre-existing mechanisms for patient experience. Another

recommendation was specifically regarding the ‘patient voice’, so this work stream,

in particular would inform thinking in this regard. Deborah Lee added that in

preparing the annual report, the Trust examined how it approached patient

experience and gathering patient insight from the previous year. Of note, as well as

building on more routine survey approaches, UH Bristol almost doubled the number

of specific focus group type experiences. Deborah considered this one of the most

powerful ways in which the Trust could investigate what it was like to be patient at

this Trust.

Lisa Gardner asked if listening to staff would be part of designing our response

to the “Francis Report”. Helen Morgan confirmed that all nurses had access to the

report and Sean O’Kelly added that there had been considerable editorial comment

regarding the report in medical literature, so it was in the general discourse for

medical staff. Robert Woolley said that more staff ‘listening events’ were intended

and he was interested in whether the Board challenged itself further and commenced

reporting of staff satisfaction at Trust Board, in addition to the Workforce report.

Robert was interested to research and follow a practice in Europe where the spread

of patient safety culture was monitored within hospitals.

There being no further questions or discussions, the Board resolved to approve the

Timetable for Responding to the Mid Staffordshire NHS Foundation Trust Public

Inquiry Report (the “Francis Report”).

8. Research & Innovation Strategy Progress Report

The Board received this report by the Medical Director to note.

The Director of Research at North Bristol NHS Trust and University Hospitals

Bristol NHS Foundation Trust, David Wynick, joined the meeting and introduced

his presentation to the Board.

David had been Joint Director for North Bristol NHS Trust and UH Bristol for three



years, and he reported that the “quantum” had changed the whole research landscape

and the buy in and involvement of research active trusts like ours.

Highlights of David’s presentation:

It was important to note that patients treated in a research active environment

responded considerably better than those who had not, and there was evidence to

prove this, even when resources were under great pressure.

Research Funding from the Department of Health (DoH) to the National

Institute for Health Research (NIHR) had stayed constant in recent years despite

cuts in other Government departments; as such, changes were being seen in care and

outcomes from research.

A considerable amount had been achieved regarding Research & Innovation at

UH Bristol in the time since the Trust Board signed off the Research & Innovation

Strategy in December 2010. Within a month of this a major review had commenced

and by the summer of 2011 the whole department had been restructured. By

September 2011 detailed operational delivery plans had been completed.

The vision of Research & Innovation at the Trust was to improve patient health

through excellence, with a focus on three key areas:

1. To recruit patients into clinical trials;

2. To increase income through commercial and non-commercial research

and develop grant income; and,

3. To develop a “research-savvy” workforce to underpin this work.

The function had been mirrored with the structure and the department reorganised to

align with the three major work streams.

Funding was now better balanced than before; the Trust received stable

funding from the Comprehensive Local Research Network, NIHR grants were rising

rapidly and commercial research had risen. As a consequence of these grants

research capability funding had also increased. In total the Trust’s current grants

matched any of the other large research-active trusts outside the “golden triangle”

(Oxford, Cambridge and London). David felt that it would be possible for UH

Bristol to be one of the top research trusts outside of these in two to five years.

Looking at performance, metrics had been re-cast, largely to deal with the three

areas judged upon from a national point of view. ‘Performance Initiating Research’

was the time it took someone to submit a valid application to start a study, to the

time the first patient was recruited. Of note, the national benchmark set by the

Department of Health for this was seventy days. Following data collection at UH

Bristol, the number of studies that met this benchmark were 9% a year ago, but first

quarter data showed an increase in the figure to 29%. This was positive, but 71%

were still not meeting the benchmark. If areas were removed where delays were due

to outside forces or a rare cancer study, for example, more than half the studies

reached the benchmark and the figure was rising. The Trust was aiming for the

figure of exclusions to be 70% within a year.

The process for recruiting patients to clinical trials would be reviewed, as 2011

had been a poor year and a major driver to reorganising the department. As a

consequence of the changes, recruitment to trials jumped by almost 30% and 2012

had seen the best year of recruitment.

At present, the total grant income of all active grants was over £25m and a



further increase was expected. If the Collaboration for Leadership in Applied Health

Research and Care (CLAHRC) application was awarded another £9m of funding

would exist.

Of positive note, Professor John Sparrow at the Bristol Eye Hospital had just

been awarded a prestigious NIHR programme grant over five years to look at

various research aspects of cataracts.

David highlighted some areas of importance regarding change and challenge within

Research & Innovation over the next year:

1. The Western Comprehensive Local Research Network was one of over a

hundred comprehensive and topic-specific networks. The Department of

Health had decided to focus down all networks into just fifteen, which

mapped into the Academic Health Science Network geography. In the

west, UH Bristol were bidding to host the local Comprehensive Clinical

Research Network and it would be known whether this was successful by

the end of summer.

2. The Trust was in a strong position to bid for £9m through the new NIHR

CLAHRC scheme on 13 May. There was confidence in the application

and interviews were being held in July for an expected outcome by the

end of summer, for commencement in January 2014. This would have

major synergies with Bristol Health Partners and the £9m of new funding

would mean could do more with Bristol Health Partners.

Two particular areas of importance were highlighted within the Trust:

1. With the advent of closure of the Old Building, there were plans to merge

the two Clinical Trial units in both Medicine and Surgery, which would

mean greater efficiencies.

2. Space in the BRI was due to be converted into a Research unit, for

completion by autumn 2013. This would provide greater capacity, and

further studies and grants could be undertaken.

The larger picture for Bristol was Bristol Health Partners and the West of England

Academic Health Science Network. Bristol Health Partners had gone from strength

to strength since its launch in May 2012 and the recent TedMed Conference was “a

huge success”. There were now twelve health integration teams and 3 more had

recently been accredited. Of these, five were hosted by UH Bristol and at least

another six were in development and were noted to map effectively into the

CLAHRC.

Comments:

Responding to a question from Paul May regarding whether Research &

Innovation looked at the entire process of the continuum of work contracts for

consultants through to the delivery of research, David Wynick confirmed that a

consultant was offered a mentor from the moment they were appointed to a research

position. Anyone with an area of interest in research would be assisted in setting up

a research profile and if necessary, would be provided with ‘pump priming funds’ to

buy their time for research activity. Once they were busy recruiting into clinical

studies, they would be assigned a research PA of activity to allow them to continue

this work. As Bristol’s reputation had risen over recent years, the quality of

applicants was rising and there was now a university or academic partner on each

consultant appointment panel to ensure research was a priority.



Kelvin Blake asked what work was being undertaken to engage the nursing

contingent to ensure they submitted research projects. David said that this was one

of the major drivers for UH Bristol. With University of West of England (UWE)

funding the Professor of Nursing Research, Margaret Fletcher, planned to focus on

this bigger agenda and conduct research.

Guy Orpen requested more information regarding what form grant outputs

would take. David said that the NIHR would find it more difficult than the

university would find in its research assessment exercise, but if the Trust thought

about what its impacts were such as alterations in clinical care, pathway, and

redesign, and ensuring postcode lotteries in terms of peoples’ variability in care,

these stories and outcomes were less tangible and it would be more difficult to say

how well the Trust had done by its patients. This was an on-going issue but David

felt sure that looking at what BHP and CLARHC had achieved in three to five years,

it was likely that the Trust would have provided better care and outcomes and

reduced morbidity than it would have otherwise. This would be easier to do once the

Health Integration Team was up and running. Guy added that he thought some

evidence might engage people in thinking that research was valuable in patient

outcomes. David agreed with this, saying that the Trust’s Hospital Standardised

Mortality Ratios were good, but it was difficult to link this directly to research.

Garry Williams, a Patient Governor who was present, asked if Research &

Innovation would work with external providers of the NHS. David confirmed that

this would definitely be the case as BHP would bring together all health research

and partners across Bristol. He provided an example of this, saying that this week a

full application for the Health Integration Team had shortlisted cataract surgery.

50% of this surgery was completed by independent sector providers and

traditionally, they had not input into research due to their commercial models, but

David was delighted to see that a chief executive of an independent provider was

keen to do just that, and as such he could see a scenario that if solid evidence was

generated over the next five years to show a pathway or treatment regime worked, it

would attract interaction with non-NHS agencies. Guy Orpen added that a key

partner in BHP was Bristol City Council, which was a central player in healthcare

delivery.

Referring to the “postcode lotteries” David mentioned, Anne Skinner, a Patient

Governor who was present, requested clarity regarding assistance for local people

outside of Bristol, in places such as Weston and North Somerset. David responded

that BHP was starting in Bristol, and if CLARHC was achieved, it would expand to

Bath. Overarching BHP and CLARHC was the AHSN, which had a major remit in

bringing together all of these activities and minimising postcode lotteries across the

whole geographical boundary. Each area had its own AHSN, and they would work

together over time to share best practice and even out variation.

Robert Woolley asked if the Board had any expectation to see a report

regarding Research & Innovation regularly. Guy Orpen said that he was interested

in how Research & Innovation delivered transformation and outcomes and also

suggested that it was likely to couple in to the Trust’s ability to compete effectively

in the provision of Specialised Services. Finally, it would relate to delivering

education.

The Board agreed it would like to see an update report on a quarterly basis.




Research & innovation Strategy Progress Report.

Delivering Best Value

9. Finance Report

The Board received and considered this report on the activity of the Finance

Committee for review. The most recent meeting was held on Friday 26 April 2013.

a. Overview – Director of Finance and Information

Paul Mapson highlighted the following main headlines from the report:

The end of year position was still subject to audit, but of a headline surplus of

£6.6m, of which £865k was called a ‘reversal of an impairment’, which was a

technical item. Therefore, the real management reported surplus position was £68k

higher than the original plan of £5.7m. Paul anticipated this remaining the same

following audit.

CRES equated to 82% of the plan and impact of this and performance had

played in to next year’s position.

It was decided at year end to change the way in which income was billed. In

the past there were always estimates for March activity and these were adjusted in

the new financial year. A view was taken that given the scale of change in the

system, expecting new bodies to pick up estimated variances and pay bills in the

new year was risky, so the estimate was fixed at a slightly higher level.

A couple of adverse variances were seen in the divisions in March. Of most

concern was the Division of Medicine, where the variance shown was £268k, which

was after a significant amount of winter funding was applied. The scale of actual

deterioration was well in excess of £0.5m, which was entirely due to the cost of

coping with emergency pressures. The major concern was the impossibility to

sustain this if it continued. The Division of Surgery, Head & Neck had deteriorated

by £0.5m but it was thought this was due to the valuation of supplies, with some

improvement anticipated.

The risk rating was 3.1, potentially.

Capital had slipped further than planned and as a consequence a report had

been taken to the Finance Committee suggesting a slightly different approach was

taken to capital planning.

The cash balance at end of year was £35m, which was satisfactory. Debtors

rose slightly but these were mainly short-term debtors. Payment performance was

seen to have improved towards the end of the year.

Surplus had been achieved for the tenth year. The long-term plan culminated in

the next two or three years, with major capital redevelopments. It was essential that

the Trust did not go into financial deficit when buildings were opened.

Service Level Agreements (SLAs) had been agreed with commissioners, which

covered specialist, local and regional commissioners in one contract. Significant

benefit had been gained from the contract, including tariff changes and renegotiating

terms regarding payment of readmissions marginal tariffs, so it was likely that 1.5%

had been taken back from a 4% reduction in the tariff, as set nationally. This

equated to about £7m, which would be provided to divisions to reduce their

underlying deficits. Assuming the negotiation held true, it would provide the Trust

with a good starting position in the next financial year.



John Savage said that the Board should acknowledge that ten years of consistent

financial control was a considerable achievement.

b. Finance Committee Chair’s Report

The Chair of the Committee, Lisa Gardner, presented a verbal report on the meeting

of the Finance Committee of 26 April 2013.

Lisa stated that it was important to note that the divisions did well, if the

Division of Surgery, Head & Neck was removed from the equation. £17m of £21m

of CRES funds had already been identified and risk assessed, which was good

progress.

More information been received from Plymouth Hospitals NHS Trust, which

was being analysed to see where differences were, always ensuring quality was

maintained.

Changes to Accounting Policies were also reviewed in the Committee and an

extraordinary Audit Committee meeting was also held to approve these, due to the

timing of the release of the Monitor financial reporting document. There were no

major changes.

A paper and presentation was received regarding Monitor’s approved costing

guidance and the Trust’s approach, which required further work before bringing it to

the Board Development Seminar on 17 May.

A Monitor assessment and regulatory system financial performance Quarter 4

was included in papers and the Finance Committee had to commit and recommend

to the Board that it would still maintain a Finance Risk Register of 3, which it

anticipated and agreed.

The main focus at present was regarding the new financial year and how to

work differently and ensure divisional targets were more realistic and achievable.

c. Board Review

Kelvin Blake gave his opinion that despite hearing of pressure areas and

overspend, the Trust had actually achieved results at year end. Robert Woolley said

that UH Bristol demonstrated that it was able to consistently achieve a level of

savings without the risk of harming patients. The position Paul described in terms of

getting savings target to a realistic level for the year gave confidence of achievement

and continued to drive the message regarding Transforming Care. Ultimately, the

Trust had a declining resource pool and it either provided services to standards

insisted on as a minimum or cease to provide them. Paul Mapson added that a

contract had been negotiated at high level which gave UH Bristol the ability to earn

a significant amount of money in delivery of services. If it delivered activity in

specialist areas particularly, it would then go a long way to making the plan

deliverable.

Emma Woollett highlighted the importance of conveying a message that the

Trust must not use activity to mask an inability to control costs.

John Moore asked if Earnings Before Interest, Taxes, Depreciation, and

Amortization (EBITDA - operating surplus before financing items) increased or

decreased this year? Paul Mapson confirmed that it was lower and the surplus being

below EBITDA this year was one of the mechanisms used to mitigate overspend in

certain divisions.




the Finance Report.

Renewing Our Hospitals

10. Quarterly Capital Projects Status Report

The Board received this report by the Director of Strategic Development to note.

Deborah Lee said that four major capital schemes were being progressed across the

Trust’s campus.

Referring to the Bristol Haematology & Oncology Centre (BHOC), Deborah stated

that the Trust had not communicated as well as it could previously with patients

when making changes, and Governors had been particularly instrumental in helping

Deborah’s team to understand how it could have undertaken these challenges

differently. This time, patients were notified about the disruption and given advice

regarding parking, and some focus groups were undertaken with patients to gauge

their opinions, which assisted in this.

The paper outlined the following two risks:

1. The transfer of Specialist Children’s Services from Frenchay. The policy

direction regarding Specialised Services had changed with the introduction of the

National Commissioning Board, and two of the assumptions made regarding aspects

of care had changed, which were:

a. Specialist Spinal Surgery on Children, where the assumption at the time

was that the care would only be delivered in specialist centres. The Trust

therefore assumed that work undertaken elsewhere in the region would come

to the Bristol Royal Hospital for Children. This policy had not emerged, so it

was prudent to assume that there was an element of risk regarding the

assumption. UH Bristol would continue to work with other providers in the

region to understand what best care looked like for the most complex children;

b. When the original plan was cast for the provision of Paediatric

Neurosurgical Services, it was thought that Wales would be unlikely to sustain

specialist elements of the service and that around 200 operations would be

transfer from South Wales to Bristol. Since that time Wales had changed their

policy direction with the aim of maintaining local neurosurgical and the

Trust’s plans were now being revised to reflect this. The clinical view was that

in the next two years the risks regarding clinically sustainable services in

Wales for specialist neurosurgery would re-emerge, but at present a

contingency plan was required as from next April the envisaged flow would

not materialise. There were opportunities to mitigate the cost base, which the

Trust would take.

2. Deborah Lee advised that the recently completed capacity refresh had

indicated that the proposed future bed base for the BRI may be insufficient to meet

the predicted demand in light of both local and national changes to activity and

length of stay. Deborah Lee advised that the Trust Management Executive was now

recommending a higher bed base than currently assumed, though this was still a

reduction over the current number of beds. Options for providing additional beds

were being worked up and would be presented to the Board at its May meeting.

Comments:

Responding to a question from John Savage regarding the Old Building,

Deborah Lee confirmed that the plans were still consistent with the



decommissioning of the building. Deborah and Paul Mapson were working closely

to manage long term financial planning in this respect.


Quarterly Capital Projects Status Report.

Corporate Governance

11. Corporate Risk Register

The Board received and reviewed the report by the Chief Executive.

Robert Woolley said that the Corporate Risk Register had been reviewed following

appointment of the Trust Risk Manager, Lee Mercer, who had changed the format of

the document and improved its legibility.

Work continued on the way that corporate risks were managed, logged, reported and

then extracted for the Board.

Of note, Risk 759 had been escalated to the Corporate Risk Register since its last

presentation to the Board in January 2013. The cover paper also outlined the risks

which had been deescalated, which provided evidence of the Trust’s continued

attention to risk management and pursuing the high rated risks, particularly those

with a patient safety implication.

Three risks had a high residual rating:

1. Hospital Acquired Infections;

2. Emergency patients, particularly patients queuing in corridors;

3. Obsolete radiotherapy hard and software.

Deborah Lee reported positive performance in the following two areas:

1. Lack of trauma theatre capacity; following transfer of Surgery, Head & Neck

in March, performance for patients accessing theatre within 36 hours was at about

30% – 50%. As at the first few weeks of April, performance had now achieved 80%.

2. A focussed action plan was being led by the divisions regarding Endoscopy,

however positively the backlog of 900 patients had now reduced to 200.

Comments:

Emma Woollett emphasised the continued concerns regarding maternity

staffing and endoscopy service capacity, which had been included on the register for

some time. Robert Woolley said that both risks had been carefully reviewed in light

of significant assessment and recruitment.

Referring to healthcare infections, Emma then highlighted her concern

regarding the description of controls, some of which did not have a number of

actions to justify the assessment of low risk. Robert Woolley responded that this

was a reporting position to date and the Trust know that the action regarding MRSA

had not been sufficient enough this year to keep UH Bristol near the contractual

target or within the Monitor threshold. The Trust’s controls regarding MRSA in

particular, had been of low effect. The rigour of the plan would be assessed in the

current year, but the issue now was that the targets were substantially lower and

actually ‘zero’ for MRSA and the risks were still high.

John Moore highlighted the risks regarding the information management

system, as it was not said to be watertight. John asked if the Trust Management

Executive had discussed risks in detail regarding this and record keeping. Robert



Woolley confirmed that this was monitored against related outcomes for the Care

Quality Commission and the Information Governance Toolkit. Risks were not

considered as ‘high’, but were fully on the Trust’s agenda and encompassed a

number of areas of work.


the Corporate Risk Register.

12. Board Assurance Framework Report (including Strategic, Corporate & Compliance Objectives Status Reports)

The Board received and reviewed the report by the Chief Executive.

Robert Woolley introduced the report and said that it concluded a review of the

Trust’s performance against the 2012/13 milestones in its 3-year action plan.

UH Bristol had achieved 80% of its own objectives, for conclusion in the year. A

small number were amber rated and were therefore automatically carried over into

the new financial year; three objectives had a red residual risk rating. There were

issues with the Monitor green rating, which was not surprising, given that the Trust

was recently red rated.

Non-delivery of Cash Releasing Efficiency Savings had been fully evident to Board.

The Trust awaited results of the Care Quality Commission’s follow-up review of

performance in the Paediatric Cardiac Surgery Service and in maternity staffing,

following a visit on Friday 26 April. Informal results were positive, but a formal

response was required before the risk was cleared.

Comments:

Referring to page 148 of the meeting pack and the pause in improvements to

Fire Safety in the Trust, Paul May asked if there was any risk to patients. Robert

Woolley reported that “huge strides” had been made in fire safety compliance, so he

doubted there was any significant risk. James Rimmer reassured Paul that Fire

Safety did not pose a risk and had actually been deescalated from the Corporate

Risk Register.


the Board Assurance Framework Report.

13. Quarter 4 Compliance Framework Monitoring & Declaration Report (including Quarterly Financials)

The Board received and considered this report by the Chief Executive for approval.

Robert Woolley explained that the Board had to declare to Monitor its retrospective

appraisal of compliance for Quarter 4, when the Trust was amber red for

Governance. It also took into account the prospective performance for Quarter 1.

The Trust Board was asked to note potential risks in Quarter 1, particularly

regarding the Accident & Emergency 4 Hour target, Referral to Treatment Times

(largely as a result of transfer of Head & Neck and Ear & Throat services from

North Bristol NHS Trust), and Infection control and risks regarding screening.

The Board was asked to make a declaration of amber red compliance for

retrospective Quarter 4 and prospective Quarter 1, based on the Trust’s performance

for the quarter so far.

The Finance Risk Rating (FRR) was at 3 for the quarter.

Comments:



In response to a query by Emma Woollett regarding Quarter 2, James Rimmer

stated that the Trust was expecting improvements to targets, due to the

establishment of action plans. He continued, saying that improvements in Referral to

Treatment Time would were more likely be seen at the end of Quarter 2.


Quarter 4 Compliance Framework Monitoring & Declaration Report (including

Quarterly Financials).

14. Risk Management Strategy

The Board received and considered this report by the Chief Executive for approval.

Robert Woolley explained that the Strategy had been referred to the Trust Risk

Manager for review, and the Board were asked to approve this revised statement.

The Board were asked to approve the strategy based on the following aspects:

1. The Statement of Objectives, which was included at page 188 of the pack;

2. The Board Statement of Risk Appetite.

Comments:

Referring to table 8.2a on page 189 of the pack, John Moore asked if all

foundation trusts were adopting this methodology and how they might rate

themselves by utilising this approach. Robert Woolley was not aware that all trusts

were moving to this approach, which was based on ‘best practice’. For clarity,

Deborah Lee added that, the score chart overleaf regarding the assessment of risk

materialising, was entirely independent of this table and there was no read across.

Each de-escalated risk was considered by the Trust Management Executive each

month. Robert Woolley explained that the Risk Management Group received and

reviewed divisional risk registers on a rolling basis and any risks were interrogated

at the meeting and also at departmental level.

Responding to a query from Paul May regarding the first bullet point of Item 7

– Risk Management Objectives, and the acceptance of levels of risk, Robert

Woolley said that the indicator was consistent in the approach the Board had taken.

If the South West Pay Terms and Conditions Consortium was reviewed, for

example, the Board was prepared to take steps which staff could regard as

provocative or creating uncertainty or discomfort; by the same token, the Board was

not prepared to compromise on safety or quality of service so in the current climate,

this made sense.

Referring to finance, Guy Orpen said he was aware that the Trust had taken out

loans and made investments in business, which was indicative of an appetite for

taking certain types of risks regarding confidence in future performance. Guy asked

if it was worth considering having two different sorts of financial appetite, such as

investment versus appetite for performance. Robert Woolley said that there was a

read across between business and finance and in line with what Guy described and

the Trust had prepared to invest in taking a degree of risk, but the risk regarding

investment was tempered by UH Bristol’s concern that it was conducted affordably.

If approved, the Risk Management Policy and Procedures would be revised, and

there would be a plan for implementation, which would include training of relevant

staff at each level of organisation, to deliver the strategy as the Board intended.


revised Risk Management Strategy.



Information and Other

15. Any Other Business

There was no other business.

16. Date of Next Meeting

Public Meeting of the Trust Board of Directors, Friday 31 May 2013 from 10:30

– 12:30 in the Conference Room, Trust Headquarters, Marlborough Street, Bristol,

BS1 3NU.

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