49Thmeeting of the Board of Directors

49thMeeting of the Board of Directors

Thursday 1st July 2010

3.30pmBoardroom, Pinewood House

Board of Directors

Dave MellishChair

Archie HerronVice Chair & Non Executive Director

Anne TaylorNon-Executive Director

Sally JacobsonNon Executive Director

James KellockNon Executive Director

Paul WardNon-Executive Director

Seyi ClementNon-Executive Director

Stephen FirnChief Executive

Helen SmithDeputy Chief Executive & Director of Service Delivery

Ify OkochaMedical Director

Richard PageDirector of Finance

Simon HartDirector of HR and Organisational Development

Wilf BardsleyDirector of Nursing and Governance

Directors

Trevor EldridgeDirector of Greenwich Mental Health Services

Sian ThereseDirector Bexley Community Health Services

John EnserDirector of Bexley Mental Health Service and Forensic and Prison Services

Rachel EvansDirector of Estates and Facilities

Iain DimondDirector of Bromley Mental Health Services

Keith MillerDirector of Psychological Therapies

In attendance

Susan OwenRisk Manager (Minutes)

Item /

Action

DM welcomed Seyi Clement to the meeting as the new Non Executive Director, and officially welcomed Sian Therese.

1. /

Apologies for absence

Stephen Whitmore, Director of CAMHS and ALD / Noted
2. / Minutes of the Board of Directors Meeting 3rd June 2010
DM asked the Board if they were happy with the length of the minutes. As Board meetings are not held in public, it may be helpful to have the detail for publication.
The minutes were agreed as an accurate record of the meeting. / Agreed
3. / Matters arising
There were no matters arising. / Noted
4. / Chief Executive Update
Bexley Community Health Services
The transfer of Bexley Community Health Services was confirmed as of today. This is a significant achievement as we are one of the first trusts to have fully integrated services.
Greenwich Community Health Services
This will be a different process to Bexley. It has become clear thatmore documentation will be required and given that we have only got nine months it is going to be a challenge. In addition to the processes we followed for Bexley – due diligence, business case, Monitor approval etc – the SHA have indicated that they want to see a modernisation and organisational development plan which shows how the transfer of the services will not just benefit the local service but will contribute to the changes in the wider health economy and help the NHS deliver savings and improve quality. We will need to keep GPs and Local Authorities on board throughout the process. The Board will drive this process and a project plan and risk register will be in place.
SF – If we have not completed the transfer by then, hosting arrangements will be put into place.
PW – We will need to renew and review GP engagement
SF –HS has drafted a plan which will be shared with the Board.
DM – It is a real structural weakness in the current system that the organisations that are making decisions now won’t exist in a year’s time.I support the view that this needs to move forward as quickly and as efficiently as possible. / Noted
5. / Annual Members Meeting 2010
DM reported that the Annual Members Meeting will be held on Wednesday, 29th September at the O2. A key part of this will be the “market place” involving all directorates. The nomination process for the Recognition Awards has started – nominations can be on a team or individual basis for any outstanding activities linked to quality and patient experience. / Noted
6. / Revised Operating Framework
SF presented this item. Process targets will be removed or reduced and the focus will shift to outcome targets. Commissioners are asked to give priority to military veterans receiving appropriate treatment – we will need to keep this under review. There will be more detail on reconfiguration in the White Paper; this has been delayed and the estimated date for publication is 16 July. A Picture of Health was designed to deliver £17M a year savings for South London Healthcare which is critical to reduce debt. In terms of financial efficiencies, the ceiling for management costs in PCTs and SHAs will be two thirds of 2009/10 so savings are required. Payments system will seek to reward performance and be tough on poor quality. Hospitals will be responsible for patients for 30 days after discharge. If a patient is readmitted, there will be no further payments to the hospital for any treatment. The aim is to create more joined up working between hospital and community health services. We will need to look closely at what this means for Oxleas.
JK – Is it realistic to think that that ceilings on management costs might be imposed on foundation trusts?
RP – There is a possibility. This will more likely affect PCTs, SHAs and Quangos.
PW –There may be a squeeze on organisations to reduce what might be determined as non-essential expenditure.
SH – London Strategic Health Authorityhad the highest increase in management costs so there has been a particular focus on London.
PW – It does feel there is an inconsistency in terms of how the health economy will manage if initiatives such as A Picture of Health are put on hold. / Noted
7. / Director of Service Delivery Report
The Trust was not successful with the Belmarsh Bid, but we have not yet had formal feedback. Much work was put into this and the outcome should not been seen as a reflection on the quality of the bid. Our final score was 66.5 and Harmony – the successful bidder – was 68.06, so this was very close.
DM – For the minutes, the Board commends the quality of the bid and the proposed models and also thanks JE and colleagues forthe amount of work put into it
SJ – Were there just two bidders?
JE – There may have been a third
SJ – When we get feedback could we think about sending someone not involved in the bid?
JE – We are not expecting feedback immediately
SF – We had really helpful feedback after the Croydon bid so after the cooling off period I think we should request feedback.
HS – The National Dementia Strategy has been noted as one of the two areas for prioritisation in the Revised Operating Framework. There are no national requirements but there is an expectation that we work with other agencies and publish progress. Much work has been done on the Dementia Strategy within the trust and there has been substantial investment from Commissioners. We have received £360K from Greenwich PCT for the older persons’ liaison service of which £100K will go to the dementia service and memory clinic and £412K from Bexley.
DM – Nothing from Bromley?
HS – We have been asked to use some of our NICEfor a memory clinic.
TE – Regarding the IAPT service, both Keith Miller and I have been working closely with NHS Greenwich and we are confident that we will be able to resolve the waiting list issue over the coming months. Trainee therapists will qualify in the Autumn and we have a strategy to increase the number of group sessions. It is important that this service is successful. We are attending monitoring meetings with NHS Greenwich. / Agreed
8. / Key Performance Indicators Exception Report May 2010
The number of Monitor targets has increased from 4 to 8. There are two targets which are a cause for concern. We need to achieve a minimum of 95% of people on CPA are reviewed at least once every 12 months. We are just slightly below target at 93.7% but we will above that target by next month.
SC – Can you explain what that means?
HS – We had previously looked at clients who had not had a review and subtracted this from the total caseload. We are now able to identify clients who have actively had a review. We have found that there is a gap in terms of looking at those two figures which has caused us to drop slightly below 95%. With the old method, the figure was about 97%.
SC – You are confident that we will be able to achieve the target by next month?
HS – Yes. The Business Analytics Team identifies individuals who have not had a review and this is followed up on an individual basis.
There is a new target this year around meeting the Early Intervention in Psychosis targets we agreed in our Standards Contract. We need to be on trajectory to meet the overall year end target. There are no concerns in Bexley and Bromley so we should meet the target. Greenwichis lower, but there has been additional recruitment into that service so we are confident that by year end we will meet the year end trajectory.
TE –We have achieved the targets for the first two years so there is no reason why we will not achieve this year.
HS – The final target for the Board to note is self-certification with improving access to healthcare for people with a learning disability. Our current score is 17 out of 24 and there is an action plan in place to achieve 24 of out 24. Monitor has yet to let us know the details of the trarget.
We have made improvements in acute bed usage this month. In all of our three boroughs, working age adult our occupancy has dropped. Bexley is at 87%, Bromley just below 100% and Greenwich at 103%. This is the lowest it has been in Greenwich for some years and the number of sleepovers has reduced also. Bed occupancy in older adults services is also low.
JK – On page 21 (outpatient activity) we are told that in May 2010, Bexley offered 53 appointments, which is half or third of what we have seen in previous months.
HS – It could have been the impact of the Change Programme which was implemented in Bexley and Bromley in April. We will look into that.
AH – The targets for indicators 7 and 8 have not yet been stated. Are you confident it is not going to be an uphill struggle when we are told the targets?
HS – We have conducted informal benchmarking with other trusts in London and we are not widely adrift compared to these.
AH – All of the targets relate to mental health, are targets and KPIs going to be introduced for integrated trusts.
HS – Not Monitor targets.
DM – I am delighted with our plans to improve data quality. We must be assured about the quality of our data before we invest in a Business Information System.
Given the constraints being placed on local authority and social services, have we got a mitigation plan if there is a lack of support from Social Services when planning discharge.
HS – We are very alert to that and we have had a number of discussions about some quite innovative responses. / Noted
9. / Quarter 1 Monitor declaration – Standards and Targets
Each quarter Monitor requires the Board to self-certify whether we are on track to meet all the targets. The following exceptions were discussed.
Item 2 - CPA review for all clients on CPA at least annually. Confident we are on track to reach target
Item 5 - Meeting over 95% of our commitment to serve new psychosis by early intervention teams. Fully confident that we will reach 100% in each of the boroughs by the end of the year
Item 7 - Patient outcome data submitted though MHMDS. Monitor have not said what the target is but all our evidence shows we are doing as well or better than other trusts.
Item 8 - Self certification against compliance with requirements regarding access to healthcare for people with a learning disability. We are confident we will achieve 24 out of 24 by year end.
It was recommend that the Trust confirms to Monitor that all healthcare targets and indicators have been met for Quarter 1 of 2010/11 and that sufficient plans are in place to ensure that they will continue to be met. / Agreed
10. / Finance Report
RP presented the Finance Report. This is the first time since we have been a Foundation Trust that we score a Monitor rating below 3 and a deficit that has moved away from the plan. The main reason is the unachieved savings plans which should improve.The savings plan includes income generation which accounts for why we are £102K below plan. There is still some expenditure to be allocated. Pay expenditure is underspent by £100K. Unusually, non-pay is also underspent. There has been some underspend for costs per case and Un-contracted Emergency Admissions - normally we have pressure in those areas. On the balance sheet, there has been an increase in debtors (receivables) because Greenwich PCT have underpaid.
AH – Minor point of accuracy - should interest receivable be £60,000, not £50,000? How far are we away from 2.49 rating?
RP – We are a long way from that
DM – But we have come down very quickly,
RP – We had planned at 3.6 but we were always very close
AH – Page 9 shows that almost two thirds of the wards are over budget on nursing.
RP – There is variation between 15% under to nearly 20% over and these are taken up with each directorate.
JE – In the Bracton, a significant proportion of that will have beenon additional staff to carry out observations. We will get additional income from these beds. It will look over plan at present, but we will get the additional income negotiated in the contract.
SC – Will the additional income feature elsewhere in the reports?
RP – Yes, we don’t have variable budgets.
DM – The comments on the three borough based service directorates mention cost pressures due to nursing at a time when we have low bed occupancy.
ID – In Bromley, the two areas which are overspending is Cator Ward which is the Dementia Ward, where we have had significant levels of 1:1 observation. The other one is Ivy Willis House where there are some historical issues about establishment. Now that Ivy Willis has merged with Banbury House we can resolve these.
AH – I think the broader question is whether we are able to use these figures for nursing pay expenditure as a justification for the summary or are there other factors such as payments coming in later?
RP – The bottom line Income and Expenditure position and the EBITDA is fixed appropriately and we do not use variable budgetary changes. The problem is that the bottom line is not looking as healthy and that is different from previous reports.
AH – When the bottom line is healthywe can accept these variables, but when the bottom line starts to look worrying, then we need to look further because we could be missing a bigger problem.
SF – We have got to getclear as to where we focus our efforts because staffing is £100K underspent which means we will be £600K underspent at the end of the year even if we continue with these figures. Staffing should be something we have more control over so we may need to aim for being more than £600K underspent. The difference this year is that CREs are higher as we have to make more efficiencies and we are relying on a greater extent to income generation which we have not been able to achieve. As an Executive, this is making us look at the detail and being clear about what is manageable and how we focus our efforts.
DM - I think that would be really useful for the Board, as we enter these times of economic constraints, to really focus in on where we are overspending. There is a £105K overspend on medical staff, £92K overspend on nursing and £95K overspend on administrative and clerical staff, which has gone up by 40% in a month. We could reduce the overspend by £300K if we managed that.
PW – I think the responsibility for this lies with the Board. I would argue for us to be able to spend some time as a Board really focusing on what our main priorities are.
DM – There is a huge adverse movement in Bromley from £6,000 to £148,000. At the end of last financial year we were reassured as a Board that the Bromley Change Programme would resolve the financial problems in Bromley.
ID – We did deliver on the CREs from last year. Aproportion of CREs have been implemented and the money should have moved over. I am not sure that this has happened yet. I would expect there to be an improvement next month.
DM – In terms of bank expenditure it is the third lowest we have spent on bank in the 12 month period. For agency expenditure, it is the second highest in 12 months and the first four highest are all in five months of this year. Have we lost focus on this?
SH – One of the reasons for the increase in nursing agency use is the issues that John’s raised in Bracton around observations. There is also the perennial issue in Bromley that most of our bank staff live in Greenwich and Thamesmead and donot want to travel to Bromley. We are undertaking a bulk recruitment of 50 to 100 healthcare assistants over next few weeks to address this.
SF – We can’t accept unexplained variations. As an Executive we need to understand the detail. I spent yesterday in CAMHS services was told they are employing more agency staff because they expect the grants for some of their services to end this year. Rather than employing someone substantively they are using agency staff as, by March, the post may not exist and this will avoid redundancies. These are good reasons but we need to make sure we understand those variations.
AH – Is it possible to get a breakdown on spend on administrative and clerical staff as we do for nursing?
DM – We will address administrative and clerical agency staff at the next Performance Committee and there will be actions taken as a result of that.
AT – Would we use bank and agency staff to cover holidays?