COUNCIL OF GOVERNORS’...

COUNCIL OF GOVERNORS’ MEETING (open to trust members, members of the public and the press)

DATE: Tuesday 3rd July 2018

TIME: 1800 to 2000 (approx.)

VENUE: The Atrium, Royal Free Hospital

Distribution

CHAIR: Dominic Dodd Chairman of the council of governors and the trust board

COUNCIL MEMBER (S): See list of all governors overleaf

IN ATTENDANCE: David Sloman Group chief executive Caroline Clarke Chief finance officer and deputy group chief executive Emma Kearney Group director of corporate affairs and communications Wanda Goldwag Non-executive director Jenny Owen Non-executive director Mary Basterfield Non-executive director Stephen Ainger Non-executive director James Tugendhat Non-executive director Duncan Gordon-Smith Trust secretary Matt Keirle Membership and governance manager (minutes)

APOLOGIES RECEIVED: Anthony Schapira Non-executive director

COPY FOR INFO: Non-executive directors

Contact for apologies or any enquires concerning this meeting should be made via:

Matt Keirle, membership and governance manager Direct dial: 020 7794 0500 ext 82116 or Email: [email protected]

Governor name Constituency

Staff-elected governors

Dr Banwari Agarwal (apologies) Wale Bakare Dr Nicholas Macartney Marva Sammy Dr George Verghese Dr Tony Wolff

Patient-elected governors

Peter Atkin Frances Blunden Dr Stephen Cameron (apologies) Linda Davies Judy Dewinter Sneha Bedi David Myers

Public-elected governors

Dr Effiong Akpan Dr Anthony Isaacs (apologies) Dr Richard Stock Maria Higson Lata Mistry Jude Bayly Professor Paul Ciclitira (apologies)

Appointed governors

Cllr Abi Wood Prof Hans Stauss Cllr William Wyatt-Lowe Cllr Peter Zinkin (apologies)

London Borough of Camden University College London

Hertfordshire County Council London Borough of Barnet

1

Council of governors meeting

Agenda

3 July 2018

Atrium, Royal Free Hospital (Open to trust members, members of the public and the press)

Item Lead Paper Page

no.

Timings

(approx.)

Administrative items

2018/22 Chairman’s introduction and apologies

ffabsence

D Dodd (verbal) -

18.00-

18.05

(5 mins)

2018/23 Governors’ register of interests D Dodd 1 1

2018/24 Approve minutes of previous meeting: 18

April 2018

D Dodd

2 6

2018/25 Review of matters arising and action log D Dodd 3 15

2018/26 PWC – annual audit letter PWC 4 19

18.05-

18.15

(10mins)

Updates on the performance of the trust

2018/27 Chairman’s report to council (including item

re: lead governor review) D Dodd 5 40

18.15-

18.35

(20 mins)

2018/28 Chief executive’s report to council D

Sloman 6 42

2018/29

Lead governor’s report J

Dewinter 7 49

18.35-

18.55

(20 mins)

2018/30 Quality committee feedback

• GSIC – feedback from Frances

Blunden

ALL

(verbal) -

18.55-

19.10

(15 mins)

2018/31 Questions & answers ALL

(verbal) -

19.10-

19.20

(10 mins)

Updates for the Council

2018/32 To note any specific issues escalated by

governors from their attendance at major

trust programme boards or ‘go see visits’

ALL

(verbal) - 19.20-

19.25

(5 mins)

2018/33 To note any feedback from attendance at

recent conferences or other event.

ALL (verbal) -

2

Item Lead Paper Page

no.

Timings

(approx.)

Any Other Business

2018/34 To note any other urgent business D Dodd (verbal)- 19.25-

19.30

(5 mins) 2018/35 Questions from members of the public D Dodd (verbal) -

Part 2 – confidential meeting

2018/36 Nomination committee recommendation D Dodd 8 51 19.30-

19.45

(15 mins)

2018/37 Nominations committee briefing – long

tenure appointments for non-executive

directors and chair

Jenny

Owen

9 53 19.45-

20.00

(15 mins)

2018/38 AOB & Close D Dodd 20.00

For information

2018/39 Non-executive directors’ report to the

council 10

58

2018/40 Council of governors’ forward planner

2018/19 11

70

2018/41 Governors’ briefing pack (circulated by

email) 12 -

2018/42 Confirm date and venue of next council of

governors meeting:

Date: 13 November 2018

Time: 6pm-8pm

Venue : Atrium, Royal Free Hospital

(verbal) -

2018/43 Close

Declaration of interests –governors are requested to highlight any changes to the register of interests at each council of governor meeting held in public 1

Paper 1

COUNCIL OF GOVERNORS DECLARATION OF RELEVANT AND MATERIAL INTERESTS

Last reviewed by council of governors: 18 April 2018 For review on: 3 July 2018

Directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies)

Ownership or part-ownership of private companies, business or consultancies likely or possibly seeking to do business with the NHS

Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS

A position of authority in a charity or voluntary organisation in the field of health and social care

Any connection with a voluntary or other organisation contracting for NHS services

Research funding/grants that may be received by an individual or their department

Interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the Trust must be declared)

Date of entry

09/10/14 Mr P ATKIN Atkin Associates Limited Media Ambitions (Enterprises) Limited Giant Media International Limited Consultant in Jaffe Porter Crossick Solicitors

26/11/15 Ms J BAYLY Nil Nil Nil Panel member at the Nursing and Midwifery Council

Nil Nil Nil

26/11/15 Ms F BLUNDEN Nil Nil Nil Nil Member of Diabetes UK

Member of Royal College of Physicians Patient Carer Network

NIL Nil

31/10/17 Mr D BEDFORD Nil Nil Nil Nil Nil Nil Nil

1


Paper 1








Date of entry

26/11/15

Updated:

17/10/17

Dr S CAMERON Nucleus Holdings Ltd ArticulateScience Ltd ArticulateScience LLC (USA) Chrysalis Medical Communications Ltd Chrysalis Medical Communications, Inc. (USA) ClinicalThinking Ltd ClinicalThinking, Inc. (USA) Cognito Medical Communications Ltd Health Interactions Ltd Health Interactions, Inc. (USA) Health Interactions Asia Pacific Pte Ltd (Singapore) Health Interactions (Shanghai) Consultancy Co. Ltd (China) International Medical Press Ltd Institute for Medical and Nursing Education, Inc. (USA) MedicalExpressions Ltd MedicalExpressions, Inc. (USA) MediTech Media Holdings Ltd MediTech Media Ltd MediTech Media, Ltd (USA) Nucleus Central Ltd Nucleus Central, Inc. (USA) NucleusX, Inc. (USA) The Nucleus Group Holdings, Inc. (USA) Nucleus Holdings Asia Pacific Pte Ltd (Singapore) The Nucleus Group (Shanghai) Consultancy Co. Ltd (China) ScientificPathways Ltd

ScientificPathways, Inc. (USA) SciMentum Ltd SciMentum, Inc. (USA) SynaptikDigital Ltd Nucleus Global Ltd (Dormant Company) NucleusX Ltd (Dormant Company) DSPS Properties Ltd

International Medical Press Limited (Owner)

2


Paper 1








Date of entry

31/10/17 Miss L MISTRY Nil Nil Nil Nil Nil Nil Nil

31/10/17 Dr E AKPAN Nil Nil Nil Nil Nil Nil Nil

17/06/16 Mrs L DAVIES Partner in Davies Communications

Nil Nil Chair of Governors of New End Primary School

Nil Nil Nil

26/11/15 Mrs J DEWINTER Director of J Rock Investments, a private investment company

Nil Nil Chairman of Myeloma UK, a national cancer charity based in Edinburgh Charity number SC 026116

Trustee RFL charity

Patient representative on the UCL ECMC Board (Experimental Cancer Medicine Centre)

Nil Nil

01/11/17 Dr D DANIELS Director of D and T Associates

Owner of D and T Associates

Nil Nil Nil Nil Nil

14/10/14 Dr A ISAACS Nil Nil Nil Nil Nil Nil Nil

01/11/17 Dr N MACARTNEY Nil Nil Nil Nil Nil Nil Nil

02/11/17 Dr B AGARWAL Nil Nil Nil Nil Nil Research grant funding as co-applicant through Horizon 2020 – EU research framework programme for research and innovation

Nil

06/11/17 Ms M HIGSON Nil Nil Nil Member of the Camden Council Health and Social Care Committee

Nil Nil Nil

3


Paper 1








Date of entry

06/08/16 Cllr D MCGOWAN Director of Arta Architectural Ltd

Nil Nil Nil Nil Nil Nil

31/10/17 Dr G VERGHESE Director of Verghese Orthopaedics; Director of North London Orthopaedic Clinic LLP

Nil Nil Nil Nil Nil Nil

08/01/18 Dr P CICLITIRA Nil Nil Nil Trustee of Clinical Research Trust

Nil Nil Nil

08/11/17 Mrs M SAMMY Nil Nil Nil Nil Nil Nil Nil

08/11/17 Mr W BAKARE Nil Nil Nil Nil Nil Nil Nil

15/08/16 Dr D MYERS Director, Radnor Lodge Investments Ltd

Partner, Wizzard Creative Services;

Nil President & Treasurer, Royal Free Hospital Kidney Patients Association; Chair of the Royal Free Organ Donation Charity

Nil Nil Nil

15/11/14

Updated: 07/09/16

Prof.H STAUSS Nil Consultant to Cell Medica and has shares with this company

Nil Programme Director for UCL Partner Academic Health Science Centre; Director Institute of Immunity and Transplantation; Co-Director UCL Division of Infection and Immunity

Nil A recipient of research grants from government and charitable funding bodies

Funded research collaboration with Cell Medica, which includes options for Cell Medica to UCL’s IP

Nil

19/01/16 Dr R STOCK Director and shareholder of EmanexLtd. Exhaust’in Ltd. Marathon Warehouse Distribution Ltd

Nil Nil Wife is a Barnet councillor who sits on their Health and Wellbeing Board

GP Haringey

Nil Nil

4


Paper 1








Date of entry

03/12/14 Mr T WOLFF Nil Nil Nil Nil Nil Nil Nil

22/01/15 Cllr W WYATT-LOWE Nil Trading partnership “Wyatt-Lowe Associates”

Nil Trustee (and Treasurer) of the charity “Adeyfield Neighbourhood Association”; Vice chair of Hertfordshire County Council; Trustee of Age UK

Surgery Patients Participation group; Dacorum (Borough) Patients Group; Dacorum Borough Council Health; Committee Hertfordshire Public Health Cabinet Panel.

Nil Nil

06/11/17 Miss S BEDI Nil Nil Nil Nil Nil Nil Nil

09/10/15 Cllr P ZINKIN Governor at Birkbeck, University of London

Shareholder in Balfour Beatty plc

Nil Nil Councillor at London Borough of Barnet

Nil Investor in a number of unit trusts

16/06/17 Cllr A WOOD Nil Nil Nil National Childbirth Trust

Councillor at London Borough of Camden

Nil Nil

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Paper 2

Minutes of the council of governors’ meeting held in public on Tuesday 18 April 2018 at 6.00 pm in the Sir William

Wells Atrium, Royal Free Hospital

Present:Mr Dominic DoddDr Effiong Akpan Mr Peter Atkin Mr Wale Bakare Ms Jude Bayly Mr David Bedford Ms Sneha Bedhi Mrs Frances Blunden Dr Stephen Cameron Prof Paul Ciclitira Ms Linda Davies Mrs Judy Dewinter Ms Maria Higson Dr A Isaacs Dr Nicholas Macartney Ms Lata Mistry Mr David Myers Ms Marva Sammy Prof Hans Stauss Dr Richard Stock Dr George Verghese Dr Tony Wolff Cllr Abi Wood Cllr William Wyatt-Lowe Cllr Peter Zinkin

chairman elected public governor elected patient governor elected staff governor elected public governor elected patient governor elected patient governor deputy lead governor and elected patient governor elected patient governor elected public governor elected patient governor lead governor and elected patient governor elected public governor elected public governor elected staff governor elected public governor elected patient governor elected staff governor appointed governor elected public governor elected staff governor +elected staff governor appointed governor appointed governor appointed governor

In attendance:Mr Stephen Ainger Ms Mary Basterfield Dr Duncan Gordon-Smith Ms Emma Kearney Ms Akta Raja Prof Anthony Schapira Sir David Sloman Dr Chris Streather Mr James Tugendhat Ms A Macdonald

non-executive director non-executive director trust secretary group director of corporate affairs and communications non-executive director non-executive director group chief executive group chief medical officer non-executive director board secretary (minutes)

Action

2018/01 CHAIRMAN’S INTRODUCTION AND APOLOGIES FOR ABSENCE

The chairman welcomed those present and attendees.

Apologies were received from:

Dr Banwari Agarwal elected staff governor Dr David Daniels elected public governor Ms Wanda Goldwag non-executive director Ms Jenny Owen non-executive director

6

2

2018/02 GOVERNORS’ REGISTER OF INTERESTS

The governors’ register of interests as produced was confirmed as an accurate record.

Governors were also reminded of their ongoing obligation to keep the trust secretary informed of any future changes in their interests.

All

2018/03 MINUTES OF THE MEETING HELD ON 23 JANUARY 2018

The minutes from the council of governors meeting held on 23 January 2018 were approved as a true and accurate record.

2018/04 REVIEW OF MATTERS ARISING AND ACTION LOG

The log of actions and matters arising from the meeting was received and noted.

The following comments were made:

2017/121 Flu vaccination

At the last meeting the question had been raised of whether 70% flu vaccination (the trust’s current target) was adequate to block exponential transmission rates. The group chief executive reported that he had obtained advice from a professor of infectious diseases and international Health. This was that the trust was best advised to adopt national guidelines (as it had done) and that the reality was that the average influenza vaccine uptake for healthcare workers was around 60% and a trust achieving 70% would be doing well (RFL achieved 72%). He could not see the rationale for moving away from national recommendations until this was consistently being achieved.

2018/05 CHAIRMAN’S REPORT TO THE COUNCIL

The chairman noted that the board would be considering group and hospital priorities and objectives at its meeting the following week. He referred to the discussion at the joint board and council meeting when one of the issues raised had been bandwidth. The remuneration committee would be looking at this in more detail and he would report back to the council of governors in due course.

It was noted that a number of questions had been submitted at the joint meeting which there had not been time to respond to at the meeting. These would be dealt with separately.

The chairman congratulated Mrs Dewinter, Ms Davies and Dr Cameron on their re-election, noting in particular the number of votes cast for Mrs Dewinter. He noted that the terms of appointment were under review as they needed to be aligned with those of the remainder of the council, but avoiding the ‘cliff edge’ effect. The trust secretary would be making recommendations to the chairman on this.

Dr Isaacs, public elected governor, noted that it had previously been suggested that the public and patient constituencies should be merged and asked what the current position was. The chairman responded that this

Trust secretary

7

3

was not being pursued at this stage but would be returned to in the future.

Finally, the chairman highlighted the appointment of Vineeta Manchanda as an associate non-executive director as part of NHSI’s Next Director scheme.

The chairman’s report was received and noted.

2018/06 CHIEF EXECUTIVE’S REPORT TO THE COUNCIL

The chief executive highlighted the following points from his report:

The Royal Free emergency department (ED) was almost completed, having been redeveloped over a four year period but remaining open throughout. At the end of May the clinical decision unit would transfer into a new 30 bedded unit, which would also include other assessment beds. This unit would open in two phases.

The Chase Farm redevelopment remained on time and on budget and it was expected that the new hospital would be fully open by September.

The Institute of Immunity and Transplantation (Pears Building) had commenced. The group chief executive reminded governors that this was being funded and managed by the Royal Free Charity, which was currently putting new relationship management arrangements in place. He also noted that it was important to remember that this development was as much about cutting edge science as about a building project. The trust would be working closely with the Charity on the project. The group director of corporate affairs and communications reported that a joint stakeholder engagement post was being put in place and there would a regular newsletter, drop in sessions plus the construction working group, which included stakeholder representatives.

The chief executive’s report was received and noted.

2018/07 QUESTIONS AND ANSWERS

Ms Higson, elected public governor, asked about the Pears programme board which had not met for some time. Ms Mistry, elected public governor asked when the Pears meetings would take place. The group chief executive responded that the previous governance arrangements had been linked to the planning process and needed to be revised given that the project had moved into the construction stage. This was currently being worked on and would include consideration of where the three governors assigned to the project could add most value.

Mrs Blunden, deputy lead governor and elected patient governor, congratulated the trust on the transformation of the Royal Free ED. She then raised the issue of the limited parking at Chase Farm Hospital for people with disabilities or undergoing chemotherapy or radiotherapy. She also asked about the back up plan if the digital systems did not work.

The group chief executive undertook to check what protected parking was available and how this compared with demand.

Trust Secretary

Trust secretary

8

4

Regarding the digital hospital he responded that there was a series of gateways which would have to be achieved prior to the go live decision point in August. The digital solution would not go ahead unless there was absolute confidence in its success. In every major programme it was likely that something would go wrong so it was important to try and anticipate risks and put mitigations in place. Training was clearly key to the success of the project and there was a dilemma between starting too soon and staff forgetting what they had learned and leaving it too late. The team would also be looking at disaster recovery arrangements.

He added that the Cerner system being implemented at Chase Farm and then at Barnet Hospital would be the most modern system currently in the NHS and would give Healthcare Information and Management Systems Society (HIMMS) level 6 immediately. HIMSS tracked healthcare organisations' progress towards achieving a paperless patient record environment with a measure from 0 (worst) to 7 (best). All being well Chase Farm would move to level 7 six months after the system went live.

Ms Sammy, staff elected governor, asked why the new system was not being piloted first. The group chief executive responded that the experts had advised the trust to undertake a total implementation on both sites rather than a phased approach, as there were risks inherent in two systems running at the same time.

Dr Isaacs, public elected governor asked about wholly owned subsidiaries, in particular the implications for staff currently employed in those departments and for future staff. He also asked about plans to roll out this model.

The group chief executive responded that no decision had yet been made with respect to a subsidiary for property services and consultation was currently taking place with affected staff and the trade unions. The chairman added that the group services and investment committee was overseeing this matter and that the reasons for considering a property services company were related to staff turnover and retention issues and the lack of parity with the private sector on tax treatment.

Dr Macartney, staff elected governor, asked whether any other hospitals were using the electronic patient record or was RFL a forerunner.

The group chief executive responded that a trust in Cambridge had recently implemented a system called EPIC that gave HIMSS 6+ but the Chase Farm system would be the most advanced Cerner system in the NHS. However it was being used successfully elsewhere in the world.

Mr Myers, patient elected governor, asked if GPs would have access.

The chief executive responded that the system would not link to GPs currently, but a system to provide a bridge between the two systems was currently being developed.

Ms Bayly, public elected governor, noted that there had only been 4 responses in the family and friends test (FFT) for the antenatal department at the Royal Free Hospital. She also asked information about trends could be included. The group chief executive said that the low number of

Trust secretary

9

5

antenatal responses was being looked into and undertook to provide information about FFT over time in his next report.

A question was asked about the high number of negative sentiments in press mentions in February and the group chief executive undertook to provide more information on whether the data was correct and if so what was behind this.

Ms Bedi, patient elected governor, asked whether staffing levels were sufficient. The group chief executive referred to the monthly nursing and midwifery staffing report reviewed by the hospital and group executive teams which compared planned and actual staffing and identified where the nurse to patient ratio was below 1:8 on a day shift, or 1:11 on a night shift. This occurred very infrequently and no harm had been reported. He added that all staff were asked to report any safety issues on the Datix system and that the trust’s ambition was to have high reporting but with low harm, as this was how emerging problems could be identified and tackled. The trust had seen a higher than desired number of never events and had a workshop with clinical staff, NHS Improvement and the Care Quality Commission to ensure transparency and that the lessons were being learned.

Finally, he referred to the guardians of safe working for junior doctors and that there was a reporting system for junior doctors who had safety concerns.

Prof Schapira, non-executive director, added that the clinical standards and innovation committee reviewed clinical standards, in conjunction with the newly formed local hospital committees. Mortality rates were well below the expected standard, the trust participated in national audits and the number of serious incidents and infection rates gave no cause for concern.

Ms Bayly, public elected governor, noted that North Central London CCGs had allocated money for perinatal mental health and a consultant had been appointed. However there were no clinic slots or appointments at Barnet Hospital. The group chief executive undertook to look into this.

Trust secretary

Trust secretary

2018/08 LOCAL MEMBERS’ COUNCILS : WHAT WILL THEY LOOK LIKE, HOW WILL THEY FUNCTION AND HOW SHOULD THEY EVOLVE

The trust secretary introduced this item which was designed to encourage discussion on how best the council of governors could engage with the membership in the context of a devolved hospital structure. It had previously been agreed to establish local members’ councils (LMCs) and the objectives for these were detailed in the report. The report also listed a number of risks. Finally he drew the council’s attention to the questions posed in the report.

The chairman noted that there were different engagement opportunities depending on the hospital but that currently more governors were allocated to the Royal Free and that allocation of governors between the sites needed to be evened out. He added that the proposal was to make a careful and slow start and then build on that.

Mrs Blunden referred to the LMC membership and asked whether there was

10

6

a maximum number of members. She suggested that the focus should be on the function of the hospitals, rather than geography.

Dr Isaacs suggested that public engagement was not an end in itself and it was important to understand why people wanted to engage. He thought this was primarily to improve the quality of clinical services. The chairman noted that the report set out the primary objective of LMCs in terms of engagement and that engagement would be through the methods described in the report.

The chairman confirmed that the annual members’ meeting and medicine for members would continue to be organised at group level but it was proposed to replicate these at local hospital level. He emphasised that there was no proposal to delegate any decision making from the council of governors to the LMCs.

Dr Akpan, public elected governor, asked if the trust knew how the local people wanted to be engaged. The chairman responded that there was a little data but the current evidence base was not good enough. The trust had some information about how representative the membership was of the population the trust served.

Mrs Blunden suggested that it might be necessary to think about more innovative ways to get people involved, for example open days and health workshops.

Mr Myers suggested that communication needed to be added as one of the standards for LMCs listed in paragraph 3.1.

The chairman suggested that it would be important to learn by doing.

Summarising the discussion, the chairman listed the following key actions:

• There was a need to balance out the LMC membership – governors were asked to contact the chairman or trust secretary if they were happy to move from the RFH LMC to the CFH LMC

• Communications needed to be added to paragraph 3.1

• LMC should be established and then reviewed after a couple of rounds of meetings.

Governors

Trust secretary

Trust secretary

2018/09 LEAD GOVERNOR APPOINTMENT

The council of governors unanimously re-elected Mrs Dewinter as lead governor and Mrs Blunden as deputy lead governor for two year appointments, with an annual validation.

Mrs Dewinter thanked the council of governors for the confidence they had shown in her and thanked Mrs Blunden for her support.

2018/10 QUALITY ACCOUNT; GOVERNORS’ FINAL STATEMENT

The group chief medical officer was in attendance for this item. He highlighted the change that had been made on page 30, amending the reference to involvement with stakeholders to “ improve patient engagement

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7

to enable patients as partners”. He noted that patient involvement was a real priority with the trust and was featuring much more in pathway redesign.

Dr Cameron, patient elected governor, suggested that the table on page 35 of the report did not make sense.

He stated that the NHS target for eliminating Hepatitis C as a major health concern was 2025 not 2030 as stated in the report.

Dr Macartney asked whether a target of reducing the number of never events from nine to four was sufficient to reach zero in 2019/20. The group chief executive clarified that this was a tolerance not a target as the actual target was zero. The group chief medical officer added that a reduction to four was challenging but achievable.

Dr Macartney then raised the issue of swab counts at the Royal Free Hospital and the group chief executive asked him to pursue this through the management line.

Ms Bayly highlighted the safety huddles and the reduction of in utero transfers as two example of excellence.

Mrs Blunden commented that the report contained many examples of excellence and innovation and it would be helpful to draw these out for wider circulation.

The group chief medical officer thanked the council of governors for their very helpful comments.

The council approved the attached statement for inclusion in the quality account 2017/18.

2018/11 LEAD GOVERNOR’S REPORT

Mrs Dewinter highlighted the following points:

• Ms Owen, vice chair, would be attending the next informal governors’ meeting

• Colleagues should sign the code of conduct if they had not already done so

• Governors had asked if it would be possible to speed up the publication on the website of the medicine for members films

The lead governor’s report was noted by the council.

Governors

Membership

manager

2018/12 QUALITY COMMITTEE FEEDBACK AND REVIEW

The chairman commented on the role of governors at board committees, which was to report back to the council of governors on the following questions: where had the NEDs been focusing their challenge, where did the governors feel they should be focusing and could they be more effective. They were not there to be another non-executive director and,

12

8

although they could contribute to the committee at the discretion of the committee chair, it was important to keep the balance of the interplay between the executive directors and non-executive directors. The committee chair would advise on confidentiality and the extent to which the subject matter could be reported back to the council of governors.

The chairman then invited Mrs Dewinter to report back from the quality improvement and leadership committee.

Mrs Dewinter reported that Ms Owen, as the committee chair, had highlighted that progress was too slow on patient involvement and had asked for a detailed report on how this could be improved. She had also asked for an audit of patient engagement. She had provided strong challenge to the executive on this.

Mrs Dewinter suggested that bullying and harassment remained an area requiring future development and that a more innovative approach might be needed as the things that had been tried had not made very much difference.

Regarding the patient partner programme a cultural change was needed so that partnership became an expectation and second nature.

2018/13 SPECIFIC ISSUES ESCALATED BY GOVERNORS FROM THEIR ATTENDANCE AT BOARD QUALITY SUB-COMMITEES, MAJOR TRUST PROJECT MEETINGS OR ‘GO SEE’ VISITS

No issues were raised.

2018/14 TO NOTE ANY FEEDBACK FROM ATTENDANCE AT RECENT CONFERENCES OR EVENTS

No issues were raised.ADMINISTRATIVE ITEMSANY OTHER BUSINESS

2018/15 ANY OTHER URGENT BUSINESS

Organ donation committee

Mr Myers noted that living donations offered the best prospect for patients requiring organ donation and that consultants needed to have paid time to promote this. The group chief medical officer undertook to pursue this and provide a response.

Group chief medical officer

2018/16 QUESTIONS FROM MEMBERS OF THE PUBLIC

There were no questions. FOR INFORMATION

2018/17 NON-EXECUTIVE DIRECTORS’ REPORT TO THE COUNCIL

The report was received and noted.

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2018/18 COUNCIL OF GOVERNORS’ FORWARD PLANNER 2018/19

The council of governors’ forward planner was received and noted.

2018/19 GOVERNORS’ BRIEFING PACK

It was noted that the governor briefing pack had been circulated separately.

2018/20 DATE OF NEXT MEETINGIt was confirmed that the next meeting would be held on at 6.00 pm on Wednesday 3 July 2018 at the Royal Free Hospital.

There being no further business the chairman declared the meeting closed at 8.00 pm.

Signed as an accurate record:

………………………………………… Date: 3 July 2018Dominic Dodd Chairman

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Paper 3

1

COUNCIL OF GOVERNORS’ ACTION TRACKER

Actions as at 3 July 2018

Date of

meeting

Minute No. Action agreed Accountable

Lead

Target due

date

Action taken/Commentary Status

18/4/18 2018/05 Trust secretary to make recommendations

to chairman about the terms of appointment

for the three newly elected governors

Trust Sec 3/7/18 Will be item on July CoG agenda Closed

18/4/18 Governor representation in Pears

governance structure

Trust Sec 3/7/18 Steering group membership includes

Sneha Bedi, patient governor, and

academic sub group membership

includes Lata Mistry

Closed

18/4/18 2018/07 Chief executive to investigate what

protected parking there will be for patients

in the new CFH

Trust Sec 3/7/18 Email sent to Natalie Forrest.

Response to be included in the chief

executive’s report for July CoG

Closed

18/4/18 2018/07 Provide FFT trend information Trust Sec 3/7/18 This has been requested from Hayley

White and will be included in the

briefing pack for July CoG

Closed

18/4/18 2018/07 High number of negative sentiments in

February press mentins

Trust Sec 3/7/18 The large volume of negative press coverage was predominantly due to the widely reported story of surgeon Sudip Sarker, who was jailed for six years for lying about his qualifications in order to land a job. He had worked at RFH and we had provided him with references before he went to the Whittington and then on to Worcestershire Acute Hospitals NHS Trust

Closed

15

Paper 3

2


Date of

meeting


Lead

Target due

date


18/4/18 2018/07 Ms Bayly, public elected governor, noted that North Central London CCGs had allocated money for perinatal mental health and a consultant had been appointed. However there were no clinic slots or appointments at Barnet Hospital. The group chief executive undertook to look into this.

Trust Sec 3/7/18 Information requested from Ruth Ouzia. Response to be included in the chief executive’s report for July CoG

Closed

18/4/18 2018/08 • There was a need to balance out

the LMC membership – governors

were asked to contact the chairman

or trust secretary if they were happy

to move from the RFH LMC to the

CFH LMC

• Communications needed to be

added to paragraph 3.1

• LMC should be established and

then reviewed after a couple of

rounds of meetings

Governors

Trust Sec

Trust Sec

16

Paper 3

3


Date of

meeting


Lead

Target due

date


18/4/18 2018/11 Colleagues should sign the code of conduct

if they had not already done so

Governors had asked if it would be possible

to speed up the publication on the website

of the medicine for members films

Governors

Memberhip

manager

3/7/18

3/7/18

The majority of governors have now provided signed codes of conduct. Those who have not are being followed up individiaully.

Closed

18/4/18 2018/15 Mr Myers noted that living donations offered

the best prospect for patients requiring

organ donation and that consultants needed

to have paid time to promote this. The

group chief medical officer undertook to

pursue this and provide a response.

Group chief

medical officer

3/7/18 Chris asked to provide info In progress

23/1/18 2017/121 CoG to be updated as to whether 70% flu

vaccination coverage (the target to which

the trust is working) is likely to be sufficient

to block exponential transmission rates.

Trust Sec April CoG Advice is being sought of clinicians Closed

22/11/17 2017/104 A&E go-see to be arranged in 2018 Jo Hopkins First half

2018

Currently under review by comms Completed

22/11/17 2017/104 A&E tour to be arranged for governors Membership

Sec

First half

2018

Membership sec in discussions with

Sarah Dobbing

In progress

22/11/17 2017/108 Direct communication by Trust Sec with line

managers of staff governors to ensure that

all are aware of the time commitments of

the governor role and the flexibility afforded

to staff governors.

Trust Sec May 2018 Line managers contact details have

been requested before a

communication is sent.

Completed

17

Paper 3

4


Date of

meeting


Lead

Target due

date


15 Nov 16 2016/110 Lead governor report

Communications seminar for governors Trust

secretary/head

of external

relations

First half

of 2018

UPDATE APRIL – postponed until

after finalisation of the trust social

media policy

UPDATE JUNE – requested update

In progress

18 May 16 2016/40 (i) Lead governor role description –Review of trust constitution The planned future review of the trust’s

constitution should give consideration to the

incorporation of an amendment to remove

the current restriction that only elected

patient or public governors are entitled to

stand as either lead governor or deputy

lead governor.

Trust secretary 2018 UPDATE APRIL 2018: To be

considered at NomCom in May.

In progress

30 Sept 15 2015/52 Raising concerns

Annual review of process of governors

raising concerns

Trust secretary July 2018 UPDATE 11/04/18: A paper will be

included in the papers for the July CoG

meeting following the first LMC

meetings in May.

UPDATE 29/0618: The paper will be

produced after the first round of LMC’s

in July.

Work in

progress

18

pwc.co.uk

Royal Free London NHS Foundation Trust Annual Audit Letter

Year ended 31 March 2018

Government & Public Sector

June 2018

19

http://www.pwc.co.uk/

PricewaterhouseCoopers LLP, 1 Embankment Place, London WC2N 6RH

T: +44 (0) 20 7583 5000, F: +44 (0) 20 7212 4652, www.pwc.co.uk

PricewaterhouseCoopers LLP is a limited liability partnership registered in England with registered number OC303525. The registered office of PricewaterhouseCoopers LLP is 1 Embankment Place, London WC2N 6RH.PricewaterhouseCoopers LLP is authorised and regulated by the Financial Conduct Authority for designated investment business.

Report to the Council of Governors

Dear Ladies and Gentlemen,

We are pleased to present our Annual Audit Letter summarising the results of our audit for the year ended 31 March 2018. We look forward to presenting it to the Council of Governors of Royal Free London NHS Foundation Trust.

Yours faithfully

PricewaterhouseCoopers LLP

The Council of Governors Royal Free London NHS Foundation Trust Pond Street London NW3 2QG June 2018

Reports and letters prepared by external auditors and addressed to governors, directors or officers are prepared for the sole use of the NHS Foundation Trust and no responsibility is taken by auditors to any governor, director or officer in their individual capacity, or to any third party.

20

http://www.pwc.co.uk/

Royal Free London NHS Foundation Trust

Annual Audit Letter PwC Contents

1. Introduction 1

2. Audit findings 2

Appendices 5

Appendix 1: Summary of uncorrected misstatements 6

Appendix 2: ‘Enhanced auditor reporting’ relating to our work on ‘Value for

Money’ 7

Appendix 3: Summary of recommendations (financial statements audit) 10

Appendix 4: Summary of recommendations (Quality Report) 13

Contents

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Annual Audit Letter PwC 1

The purpose of this document This letter provides the Council of Governors of Royal Free London NHS Foundation Trust (“the Trust”) with a high level summary of the results of our audit for the year ended 31 March 2018, in a form that is accessible for you and other interested stakeholders.

We have already reported the detailed findings from our audit work to the Audit Committee in the following reports:

audit opinion on the financial statements for the year ended 31 March 2018;

report to those charged with governance (ISA (UK) 260);

limited assurance opinion on the Trust’s Quality Report for the year ended 31 March 2018; and

the ‘Governors Report’ (long form report) setting out the findings arising from our work on the Quality Report for the year ended 31 March 2018.

Scope of work We performed our audit in accordance with the International Standards on Auditing (UK) (“ISAs UK”) and the Comptroller and Auditor General’s Code of Audit Practice (“the Code”), which was issued in April 2015. Our reports and audit letters are prepared in accordance with the ISAs (UK) and the Code and all associated Audit Guidance Notes issued by the National Audit Office and relevant requirements of the NHS Act 2006.

The Board of Directors is responsible for preparing and publishing the Trust’s financial statements, including the Annual Governance Statement. The Board of Directors is also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in the use of the Trust’s resources. As auditors we need to:

form an opinion on the financial statements;

review the Trust’s Annual Governance Statement;

form a conclusion on the arrangements in place to secure economy, efficiency and effectiveness in the use of the Trust’s resources; and

perform procedures on the Trust’s Quality Report, including: – provide an opinion on the content of the Trust’s Quality Report and

the consistency of the document with a number of information sources specified by NHS Improvement;

– provide an opinion on two performance indicators included within the Trust’s Quality Report, as specified by NHS Improvement; and

– provide a summary of findings arising from our work on one performance indicator selected by the Governors.

We carried out our audit work in line with our 2017/18 Audit Plan that we issued in November 2017.

1. Introduction

22



Financial statements We completed our audit work over the financial statements during May 2018 and issued an unqualified audit opinion on the financial statements on 25 May 2018 with the inclusion of a material uncertainty in relation to going concern paragraph. The Directors included additional disclosures within the Annual Report and within the accounting policies note to the financial statements in respect of going concern. We included in our audit report a material uncertainty paragraph which draws the readers’ attention to the disclosures in the financial statements. Note – such a paragraph is not a qualification of the audit opinion. We have identified details of misstatements for reporting to the Audit Committee as part of our audit and these are set out in Appendix 1 of this report. We also raised a number of control recommendations, which are summarised in Appendix 3.

Value for Money Under the Code of Audit Practice, we must satisfy ourselves, by examination of the financial statements and otherwise, that you have made proper arrangements for securing economy, efficiency and effectiveness in your use of the Foundation Trust’s resources. As part of our audit we are required to conclude on whether the Trust had in place, for the year ended 31 March 2018, proper arrangements to secure economy, efficiency and effectiveness in its use resources. We issued a modified conclusion on 25 May 2018 in respect of Value for Money for the following reasons:

The Trust are in breach of their licence and under enforcement notice for financial performance reasons. At the time of signing our audit opinion this enforcement notice was still in place.

The Trust reported a deficit of £24.6m in 2017/18 which included the recognition of the sale of Parcel B for £47.6m and the receipt of STF funding which totalled £22.5m.

As noted in Board papers, the Trust needs to achieve £45.5m of savings in 2018/19 to achieve its plan. Based on our review of Trust Board papers, £44.2m of cost savings were achieved in 2017/18. It is also noted from a review of the Trust Board papers that the Trust’s reference costs are below 100. This compares favourably to other peer trusts as shown on the NHS Improvement reference costs index - https://improvement.nhs.uk/resources/reference-costs/.

The Trust have a significant underlying deficit, albeit have made steady progress to reduce this in 2017/18 with the financial plans for 2018/19 showing it to decrease further. The Trust is currently in year one of a four year financial improvement plan and have made progress against this plan.

In 2017/18 the Trust have drawn down £43m against their agreed loan facilities with the Department of Health. The cash position in 2018/19 will be reliant on further loans from the Department of Health which the Trust believe will need to be in the region of £57m. The Trust’s cash forecast shows that it will need to draw down from the DH working capital facility in 2018/19 to meet creditor payments. The Trust is forecast to hold approximately £117m in total borrowings at the end of 2018/19.

2. Audit findings

23


We are also required to disclose, either in our auditor’s report on the financial statements or in this letter, ‘enhanced auditor reporting’ information about the scope of our work relating to the Value for Money work that we perform. This is included in Appendix 2.

Annual Governance Statement The aim of the Annual Governance Statement (“AGS”) is to give a sense of how successfully the Foundation Trust has coped with the challenges it faced, drawing on evidence on governance, risk management and controls. We reviewed the AGS and considered whether it complied with relevant guidance and whether it was misleading or inconsistent with what we know about the Foundation Trust. We found no areas of concern to report in this context.

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Quality Report We were required by NHS Improvement to review the content of the 2017/18 Quality Report, test three performance indicators and produce two reports:

1. Limited assurance report: This report is a formal document that requires us to conclude whether anything has come to our attention that would lead us to believe that:

The Quality Report does not incorporate the matters required to be reported on as specified in the FT ARM and the “Detailed requirements for quality reports for foundation trusts 2017/18”;

The Quality Report is not consistent in all material aspects with source documents specified by NHS Improvement; and

The specified indicators have not been prepared in all material respects in accordance with the criteria set out in the FT ARM and the “Detailed requirements for external assurance for quality reports for foundation trusts 2017/18”.

We have issued an unqualified limited assurance report in respect of the content and consistency (defined by NHSI’s “Detailed requirements for quality reports 2017/18”) of the quality report.

With regards to our work on the mandated performance indicators, our limited assurance report is qualified as follows:

We have issued an adverse conclusion in respect of issues identified through sample testing of the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways; and

A disclaimer of conclusion has been included within our limited assurance report in respect of issues identified through sample testing of the percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge.

2. Governors report: A private report on the outcome of our work that is made available to the Trust’s Governors and to NHS Improvement. This includes the

findings in respect of the local indicator selected for testing which was the maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers. We identified one difference in the sample we selected for testing.

We identified a number of recommendations as a result of our testing over the quality report indicators. These are shown in Appendix 4.

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Appendices

26


We found the following misstatements during the audit that have not been corrected by management. Both management and the Audit Committee were satisfied that these misstatements remained uncorrected as they did not have a material impact on the financial statements.

No Description of misstatement Income statement Balance sheet

F = factual, J = judgemental, P = projected Dr (£’000) Cr (£’000) Dr (£’000) Cr (£’000)

1 Overstatement of accruals (projected) – errors noted in accruals testing. Known misstatement £84,940

Projected misstatement, £1,080,620 - 84,940 84,940 -

2 Potential overstatement of income and trade receivables (judgemental)

(reflecting largest commissioners debtors of £9.5m less provisions of £7.2m) 2,300,000 - - 2,300,000

3 Overstatement of provisions (factual) – during our testing we noted that there was insufficient

evidence to support provisions for redundancy being reflected in the financial statements. - 1,077,588 1,077,588 -

Total uncorrected misstatements 2,300,000 1,162,528 1,162,528 2,300,000

Appendix 1: Summary of uncorrected misstatements

27


Appendix 2: ‘Enhanced auditor reporting’ relating to our work on ‘Value for Money’

We are required to provide ‘Enhanced auditor reporting’ in relation to the work supporting our conclusion on whether the Trust had in place, for the year ended 31 March 2018, proper arrangements to secure economy, efficiency and effectiveness in its use of resources. As permitted by Application Guidance Note 7 ‘Auditor reporting’, issued by the NAO on 21 December 2017, we have elected to include this reporting in this letter.

The scope of our audit The scope of our work is determined by the requirements outlined in Application Guidance Note 3 ‘Auditor’s work on Value for Money (VFM) arrangements’ (AGN 03) issued by the NAO on 9 November 2015

As part of designing our work on VFM, we considered materiality and assessed the risks of the Foundation Trust not having put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

AGN 03 requirements us to use the following evaluation criterion to form our opinion:

“In all significant respects, the audited body had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people”

In order to help us consider this overall evaluation criterion, the NAO have outlined the following sub-criteria which are intended to guide our work and reach an overall judgement;

informed decision making;

sustainable resource deployment; and

working with partners and other third parties.

These criteria are not separate and we are not required to reach a distinct judgement against each one.

28


Key audit matters Key audit matters are those matters that, in the auditors’ professional judgement, were of most significance in forming the conclusion on whether the Trust had in place proper arrangements to secure economy, efficiency and effectiveness in its use resources and include the most significant assessed risks of failing to put in place proper arrangements identified by the auditors, including those which had the greatest effect on:

the overall audit strategy;

the allocation of resources in our work; and

and directing the efforts of the engagement team.

These matters, and any comments we make on the results of our procedures thereon, were addressed in the context of our work on arrangements to secure value for money as a whole, and in forming our conclusion thereon, and we do not provide a separate opinion on these matters. This is not a complete list of all risks we identified.

Key audit matter How our audit addressed the Key audit matter

Enforcement Notice

On 23 November 2017 NHS Improvement issued enforcement action to Royal Free due to

breaches of the Trust’s licence for:

Financial performance in 2016/17 which included a significant variance against the

planned deficit (excluding STF);

A significant underlying deficit in 2016/17 supported by a plan submitted for 2017/18

with showing a variance of £57m to the control total (being a £33m deficit, excluding

STF); and

The lack of a robust plan to deliver the 2017/18 plan or to address the underlying deficit

in the longer term.

At the time of signing our audit opinion the enforcement notice is still in place and has been

taken into account in reaching our conclusion.

We consider the results of regulatory inspections and any enforcement action taken by regulators

in our assessment of value for money as it impacts our value for money conclusion specifically in

regards to ‘sustainable resource deployment’ as described above.

We obtained and read the Trust’s enforcement notice from the NHS

Improvement website.

We confirmed with the Trust that the enforcement notice was still in place at

the time of signing our audit opinion.

We obtained and read reports from the Care Quality Commission following

inspections they had carried out at the Trust.

Deficit position of the Trust

The Trust have reported a deficit of £24.6m in 2017/18. The Trust met its control total in

2017/18, achieving cost savings of £44m as set out in the Board papers, and the financial position

We read Board papers presented during 2017/18 that discuss the financial

position and performance of the Trust.

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Key audit matter How our audit addressed the Key audit matter

was improved through the recognition of the sale of Parcel B for £47.6m and the receipt of STF

funding which totalled £22.5m.

The Trust has submitted its annual plan for 2018/19 which reports a planned deficit of £66m

(before impairment). The planned deficit includes costs savings of 4.4% of total operating

expenditure.

We consider the financial performance of the Trust in the current year as well as the cumulative

performance to establish whether proper arrangements have been put in place regarding

‘sustainable resource deployment’.

We confirmed the receipt of the cash for the sale of Parcel B and the receipt of

STF funding through confirmation from NHS Improvement.

We obtained and read the Trust’s annual plan for 2018/19. We understood the

control total set for 2018/19 and the savings targets that the Trust needed to

achieve, as well as the borrowing requirements, to support the achievement of

that total.

Cash position of the Trust

In 2017/18 the Trust have drawn down £43m against their agreed loan facilities with the

Department of Health and Social Care.

The cash position in 2018/19 will be reliant on further loans from the Department of Health and

Social Care which the Trust believe will need to be in the region of £57m. The Trust have

mitigation plans in place if cash is needed which include managing the working capital position

to a more favourable position for the Trust and the potential disposal of assets.

The Trust’s cash forecast shows that it will need to draw down from the Department of Health working capital facility in 2018/19 to meet creditor payments. The Trust is forecast to hold approximately £117m in total borrowings at the end of 2018/19.

We performed an analysis of the cash flow forecasts that the Trust have

prepared for 2018/19 to ascertain the borrowing requirements needed to

support their working capital position.

We read the going concern paper the Trust produced and considered its

accuracy in light of the audit work performed for the 2017/18 financial

statements audit.

We read the current loan agreements from the Department of Health and

confirmed the receipt of the loans in 2017/18 to cash received and to a central

statement from the Department of Health.

How we tailored the scope of our work We tailored the scope of our work to ensure that we performed enough work to be able to report on whether the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its Use of Resources.

30


Deficiency Recommendation Management’s response

Fixed Asset Register maintenance and barcoding

We have followed up on the control deficiency / weakness (CD/W) raised in prior year

(see below) with the Fixed Assets Accountant, who explained that The Trust have taken

up the barcoding suggestion, but the planned implementation is going to be limited to

the new hospital (Chase Farm), which is due to become operational in the next financial

year. The barcoding system may then be applied in Royal Free if it is successfully

implemented in Chase Farm.

We have picked a donated asset recorded by Medical Clinic team during our

walkthrough and confirmed that the asset was accounted for in the fixed assets register.

We note that there may be valid reasons as to why an asset cannot have a barcode

attached, such as the sterilisation of assets before being stored in the hospital. The Fixed

Asset team is aware of this issue, and will take this into consideration when

implementing the barcoding system.

As the Trust do not have any compensating control in place to ensure completeness of

their fixed asset register, the control weakness is raised again for FY 17/18.

We recommend that management

carry out the implementation of

barcoding system of Chase Farm

Hospital as planned.

We recommend that the Fixed Asset

team should also carry out sample

checks of the assets held at Royal Free

Hospital against the fixed asset

register on a timely basis.

Agreed this will be investigated with the

Medical Electronic Department who have

commissioned a new system for Chase Farm

(Roy Smith - July 2018)

Finance staff will continue to periodically

verify assets held on the fixed asset register

to those on site via a physical inspection. Due

to the number of assets this will be on a

sample basis. A programme will be in place

to ensure that all material assets are verified

every 18 months.

(Lubna Dharssi - July 2018)

Overpayments to employees leaving the Trust

During our walkthrough with the payroll team, we have found that there is an issue with

regard to overpayments of ex-employees due to late termination forms authorised by

line managers. The payroll system could not be updated until an authorised

termination form was received, and this led to overpayments to employees after they left

the Trust.

There is a risk that the Trust are unaware of how much overpayment has been made

We recommend that the Trust enforce

a threshold period during which

leavers forms need to be authorised.

We recommend that the Trust

investigate the total amount of

overpayment to leavers, with input

from SBS, and initiate debt recovery

Agreed. Managers will be reminded to

adhere to the Trust deadlines.

SBS Payroll now provide a weekly list of all

overpayment together with reasons which

are analysed by senior Finance and HR

managers. In addition this is being

Appendix 3: Summary of recommendations (financial statements audit)

31



since outsourcing the payroll service to SBS, and being unable to recover it, posing a further constrain to the tight level of operating cash flow.

process in line with its normal policy.

Timely update and request of issuing

invoice against employees being

overpaid should be agreed between

the Trust and SBS.

reconciled to invoices raised and progress of

recovery monitored.

(Lubna Dharssi - June 2018)

Supplier invoices recognition

The engagement team obtained multiple supplier invoices as support for the accruals

balances at year-end. These were invoices which Finance had accrued for based on

estimates, however, as at 31/03/2018, it was noted that some of these invoices has been

received, therefore actuals could have been used.

Specifically, there were two invoices which were dated 30/01/2018 and 27/02/2018,

which were processed in the AP ledger on 06/02/2018 and 07/03/2018 respectively,

however had not yet been matched to purchase orders / delivery.

There is a risk that at year-end the accruals balance is higher than it should be and that

accounts payable is lower than it should be.

There is also a higher risk that invoices will be paid late as it has taken so long for them

to be posted to the system.

We recommend that departments are

instructed to receipt any goods

received in a timely manner, and

match invoices to orders, to ensure

the appropriate and accurate

recording of supplier invoices in the

ledger.

As part of the PCOS implementation training

on receipting is being refreshed and will be

more through than previously. In the

meantime budget holders will be directly

reminded to process goods receipts and any

non adherence will be escalated as necessary.

As a mitigation AP actively chase end users

where accounts are on stop.

(Lubna Dharssi - June 2018)

Errors noted in journal postings

The engagement team have tested a total of 25 journals, for which it was noted several of

the journals identified were correction journals, where the original posting was

incorrectly posted to the wrong general ledger accounts.

Although it most instances these were identified by the management accountants a part

of the month end close down process (mitigating control) it has been identified as an

inefficiency.

We recommend that users responsible

for posting journals are adequately

informed on the correct treatment,

before making incorrect postings

which could go unidentified.

Agreed. Finance will investigate the number

of journals to identify the source of errors

and agree a plan to correct coding at source.

This will be part of the project plan to

upgrade the EFIN ledger.

(Mashud Sikdar – September 2018)

Aged bank reconciling items

The engagement team have tested the bank reconciliations for all bank accounts at

31/03/2018.

Finance identify and clear out

reconciling items on a timelier basis.

The amount in question is immaterial.

Treasury have identified the differences and

will be resolving by the end of the quarter.

(Gabriele Orsini - June 2018)

32



It was noted that the reconciling items included aged amounts, dating back to July 2017.

Hence, there is risk that the ledger is not accurate. It has been noted that these amounts

are not significant, however the control point has been raised for best practice.

Inconsistencies in floor area assumptions

We noted some minor inconsistencies in respect of the retained estate buildings at

Barnet (mortuary and post grad centre) and crèche at Chase Farm. We believe these

minor area inconsistencies do not have a material impact on the financial

statements. These should be reviewed, checked for current accuracy and shared with

the trust valuers (Montagu Evans) going forward.

In some instances the sq.m adopted in the valuation are based on prior year information

and do not agree to the more accurate area calculations derived from CAD drawings

which are now available.

Floor area assumptions used by the valuers) are not completely accurate resulting in

potentially higher or lower values although this is not expected to be material as

buildings have not changed since initial inputs, however the technology available to

measure the assets has, which has resulted in minor variations.

Estates review area calculations and

measurements on the retained and

peripheral buildings at Chase Farm

and Barnet in advance of next asset

valuation and provide the valuers

with updated area calculations.

We note your comments and agree to carry

out the review in line with your

recommendation in advance of the next asset

valuation.

(Andrew Panniker – March 2019)

33


Appendix 4: Summary of recommendations (Quality Report)

Observation Recommendation

Review of the content requirements

1. A number of the requirements of the FT ARM had not been met within the initial draft of the Quality Report. These included:

Wording issues in the statements of assurance from the Board in Part 2 of the Quality Report.

Performance information to be completed in the core indicator section within Part 2 and the performance against NHS Improvement’s oversight documents in Part 3 of the Quality Report.

The Trust updated for these in the subsequent versions of the Quality Report.

Ensure the requirements of the FT ARM are communicated to the person responsible for compiling the Quality Report. Ensure the requirements of the FT ARM are reviewed and incorporated into the Quality Report. Where the exact wording of sentences and/or paragraphs are mandated, ensure that these are appropriately highlighted within the document to avoid inadvertent modification.

Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways

2. Incorrect inclusion in the indicator

The clock starts when any care professional or service permitted by an English NHS commissioner to make such referrals, refers to a consultant-led service. Inclusion ends following a verified clock stop when first definitive treatment is received. However, for three cases sampled it was noted they did not meet the definition for inclusion in the indicator:

One case sampled was for non-consultant led Direct Access services; and

For a further two cases sampled the verified clock stop was recorded before the end of the sampled month meaning the pathways should not be included as incomplete.

In light of the issues noted, Management should review the controls in place designed to ensure that only referrals for consultant led service feed in to the indicator and consider revisions as necessary in order to prevent future errors.

This could include increased training of hospital staff. This should reduce the number of pathways requiring corrections through the validation process.

A new logic rollout (Phase 3) to address the issues identified from the Phase 1 and 2 roll-outs.

These two approaches should be adhered to, allowing their implementation to be analysed through future testing of 2018-19 pathways.

34


3. Incorrect exclusion from the indicator

The clock starts when any care professional or service permitted by an English NHS commissioner to make such referrals, refers to a consultant-led service. Inclusion ends following a verified clock stop when first definitive treatment is received. However, for one case sampled it was noted they did were incorrectly excluded from the indicator:

For one case sampled the pathway was prematurely terminated, and therefore excluded from the indicator, due to changes resulting from the update of the patient records system in August 2017.

In light of the issues noted, Management should review the controls in place designed to ensure that cases are correctly excluded from the indicator and consider revisions as necessary in order to prevent future errors.

This could include increased training of hospital staff. This should reduce the number of pathways requiring corrections through the validation process.

A new logic rollout (Phase 3) to address the issues identified from the Phase 1 and 2 roll-outs.

These two approaches should be adhered to, allowing their implementation to be analysed through future testing of 2018-19 pathways.

4. Incorrect inclusion in the indicator outside of our sample

For one patient we sampled the December 2017 reporting, where the individual was correctly included in the Denominator of the indicator (the case was a breach).

We noticed, however, that treatment was received on 31 January 2018. Therefore, it should have been excluded from the January 2018 indicator but was incorrectly included as a breach. This was due to due to changes resulting from the update of the patient records system in August 2017.

As for finding 1.

Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge

5. Insufficient documentation on Cerner and FirstNet

From discussions with Management and from our review of individual case records for the majority of cases making up the indicator the Trust’s clinical staff enter details directly onto the two relevant systems (Cerner and FirstNet). As such the data on the systems is considered the definitive source of information for the calculation of the indicator. Comparison between two systems only represents valid audit evidence where a controls based approach to obtaining evidence can be adopted. However, given the weaknesses in the control environment outlined in the following paragraphs a control based approach would not provide sufficient evidence. As such, we were unable to obtain the evidence we needed to reach a conclusion on this indicator.

Should the below issues be addressed a controls based approach could be followed. If not Management may wish to consider the retention of evidence external to the systems to support the arrival and admission / transfer / discharge times.

6. Non-adherence to national guidance for clock starts for ambulance arrivals at Royal Free Hospital

Until 27 November 2018 the Royal Free Hospital did not record any information with regards to ambulance arrival times and the clock start always occurred at the point of registration irrespective of whether the patient was a walk in or an ambulance arrival. This was inconsistent with the approach at Barnet and Chase Farm Hospitals. At the

This should be addressed by the new practices adopted by Royal Free Hospital.

35


latter, clock starts occurred at handover or 15 minutes after arrival, which is in line with the national guidance.

7. Non-adherence to national guidance for recording registration times for non-ambulance cases

In 2017/18 the original start and end of registration times recorded in Cerner previously have been replaced by a single registration time. The Trust confirmed that this represents the end of registration. In line with our guidance from 2016/17 the Trust should use the start of registration as such there are likely to be additional breaches caused by cases which are currently recorded as near the 4 hour mark (3h50m or more) in line with our prior year findings. As the start of registration is no longer recorded we cannot restate these figures.

The Trust should clarify the appropriateness of using the manually input arrival date and time field with the Department of Health and ensure that future reporting appropriately reflects the guidance received.

The Trust should aim to use the automated ‘visit’ field as the standard clock start time, only adding a manual override in circumstances such as delayed ambulance handover or urgent triage being performed in advance of patient registration at reception.

8. Differences in the number of attendances per Cerner versus the indicator definition

The indicator should be presented as the arithmetic average of the four quarterly outturns for the period. However, through testing performed, it was found that the attendance records on Cerner cannot be directly reconciled to the Trust’s calculated indicator as this is computed the Trust’s breaches database. The breaches database holds aggregate attendance figures but does not have individual case details. It was noted that our indicator numerator was 3,701 lower than the Trust’s total, and the denominator was 2,648 lower than the Trust’s total which is primarily as a result of the inclusion of planned attendances that should be excluded from the indicator. Currently there is no mechanism of distinguishing between the types of attendances on the breaches database to enable direct reconciliation between the two.

Management should ensure that the number of attendances per Cerner can be directly reconciled to the amounts held in the breaches database. In order to do this management should consider if there is a mechanism to distinguish between planned and unplanned attendance numbers logged in the breaches database.

9. Failure to correctly record the clock start or stop times

For 1/15 of the initial samples the clock start per Cerner was not the earlier of patient handover time or after 15 minutes of arrival time per the national guidance (it was 21 minutes later). For 1/15 of the supplementary sample there was no check out time recorded on Cerner. Check out time was 00:02 per the CAS card, whereas the Cerner-based listing recorded a clock stop 22:45. This changed the status of this case from non-breach to breach.

Management should reinforce the need to update records on Cerner to ensure data is correct and that the data entered reflects national guidance.

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers

10. Patient’s sent for treatment at UCLH have an incorrect clock stop date on Infoflex

For three out of 15 cases reviewed the patient was sent for treatment at UCLH the original Infoflex clock stop date was not updated for the final agreed date of first

In discussion with Management it has been noted that for FY19 more patients who have had cross-Trust pathways will have clock stops validated with the second Trust. Together this control and the reconciliation ensure that cross-Trust

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definitive treatment as defined by UCLH. Although the Infoflex clock stop date was not up-to-date per the explanations in testing template, the explanations also confirmed justifiable reasons why different clock stop dates were provided on OpenExeter by UCLH.

Because these pathways concluded at a Trust outside Royal Free, the OpenExeter submission made by that Trust (UCLH) will supersede Royal Free's clock stop. As such no incorrect clock stop has been included in national reporting for the indicator despite the disparity on Royal Free's Infoflex system

OpenExeter discrepancies with Infoflex records are identified and validated in a timely manner.

11. Infoflex/Cerner Reconciliation Issue

A reconciliation is performed from Infoflex to CERNER (EPR)/patient notes twice weekly by the Cancer validation team. Access databases queries are run to identify any cases for which the relevant fields are not identical in both Infoflex and CERNER based on NHS number. This usually occurs when a patient DNA and the Cerner clock stop date needs to be updated as a result. Such cases are chased up by the team for confirmation by consultants. Orin Stephens confirmed that these reconciliations are performed twice weekly but are not retained after reconciling items are resolved. This represents a control design weakness, as it is not possible to prove that prior reconciliations were conducted.

This issue was also flagged in the prior year, although changes have not been made in the intervening period due to misunderstanding the nature of the weakness.

In discussion with Management it was agreed that this control will be documented going forward, although it may be documented on a less frequent basis than twice weekly due to the constant monitoring of pathways via alternative mitigating controls (see 'Processes and Controls' tab, final box). These mitigating controls increase the likelihood that any Infoflex/Cerner interface discrepancy would be identified.

12. Infoflex/Open Exeter Reconciliation Issue

There is also an Open Exeter to Infoflex reconciliation performed by the Senior Information Analyst, which corrects any anomalies caused by submissions by other Trusts not matching in clock start or stop dates (split-pathway patients between Trusts). Examples of these anomalies can be seen in the three differences, as they predate the control (introduced early 2018).

The March 2018 reconciliation was inspected on Microsoft Access, confirming that under 10 differences were returned. The Trust confirmed that these had been investigated. However, the 3/15 differences seen during sample indicate that there are still discrepancies between Open Exeter and the local Infoflex system which are not being investigated.

In discussion with Management it has been noted that for FY19 more patients who have had cross-Trust pathways will have clock stops validated with the second Trust. Together this control and the reconciliation ensure that cross-Trust OpenExeter discrepancies with Infoflex records are identified and validated in a timely manner.

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In the event that, pursuant to a request which you have received under the Freedom of Information Act 2000 (as the same may be amended or re-enacted from time to time) or any subordinate legislation made thereunder (collectively, the “Legislation”), you are required to disclose any information contained in this report, we ask that you notify us promptly and consult with us prior to disclosing such information. You agree to pay due regard to any representations which we may make in connection with such disclosure and to apply any relevant exemptions which may exist under the Legislation to such information. If, following consultation with us, you disclose any such information, please ensure that any disclaimer which we have included or may subsequently wish to include in the information is reproduced in full in any copies disclosed.

© 2018 PricewaterhouseCoopers LLP. All rights reserved. In this document, “PwC” refers to PricewaterhouseCoopers LLP (a limited liability partnership in the United Kingdom), which is a member firm of PricewaterhouseCoopers International Limited, each member firm of which is a separate legal entity. Please see www.pwc.com/structure for further details161103-141803-AK-OS

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CHAIRMAN’S REPORT

Executive summary

The chairman’s report containing items of interest/relevance to the council.

Action required

The council is asked to note the report. There will be an opportunity for questions at the meeting on 3 July 2018.

Report From D Dodd, group chairman Author(s) Duncan Gordon-Smith, trust secretary Date 28 June 2018

Report to Date of meeting Attachment number

Council of Governors 3 July 2018 Paper 5

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CHAIRMAN’S REPORT

A BOARD AND COUNCIL MATTERS

ANNUAL MEMBERS’ MEETING

The annual members’ meeting takes place on on 18 July in the Sir William Wells atrium at the Royal Free Hospital.

This is an opportunity for patient, public and staff members to hear about the trust’s achievements over the last year, some of the latest developments and our plans for the year ahead. There will also be the opportunity to put questions to members of the council of governors, who have been elected to represent members’ interests, and the trust board.

Doors will open at 5pm when there will be a range of display stands showcasing the trust’s achievements and plans for the future. Light refreshments will also be available.

LOCAL MEMBERSHIP COMMITTEES

The first round of hospital LMC meetings are scheduled for July.

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CHIEF EXECUTIVE’S REPORT

Executive summary

This is a chief executive’s report containing items of interest / relevance to the council.

Action required

The council is asked to note the report. There will be an opportunity for questions at the meeting on 3 July 2018.

Report From D Sloman, group chief executive Author(s) Duncan Gordon-Smith, trust secretary Date 28 June 2018

Report to Date of meeting Attachment number

Council of Governors 3 July 2018 Paper 6

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CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

A TRUST DEVELOPMENTS

CHASE FARM HOSPITAL REDEVELOPMENT UPDATE

The redevelopment of Chase Farm Hospital remains on budget and the handover of the new hospital is scheduled for 12 July 2018. This is dependent on the building passing mechanical and electrical (M&E) safety tests in advance of this date.

It is planned that the first patients will be seen in the new hospital on 30 July 2018, in outpatients. A detailed timetable of sequential moves has been agreed, whereby all other services will move during July, August and September. The communications team is implementing a plan to communicate key dates to stakeholder groups. Letters are being sent to patients whose next appointment will be in the new hospital. Works to roads and landscaping will be completed in 2019, after which an official opening ceremony will take place.

The trust project team continues to support staff in preparing to move into the new hospital. Designated move managers have been identified in each department, and teams have been provided with move checklists and plans setting out when they will receive training for new information management and technology (IM&T) systems. Significant clinical engagement is underway to sign off the new IM&T systems and oversee the transition to a digital paperless hospital at Chase Farm. This work will realise efficiencies, making a major contribution to the trust’s financial strategy. Staff consultations are underway to agree shift patterns in the new hospital, and effect the changes required to move into the new hospital.

ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT REDEVELOPMENT UPDATE

The Royal Free Emergency Department redevelopment was undertaken under two contracts. The first has provided a new dedicated paediatric emergency department and waiting area, new staff facilities and office accommodation and a new ambulatory care unit.

Contract 2 started on 26 September 2016 and comprised three main phases. The first phase of the construction works delivered Part 1 of majors, a new reception desk, and the rapid assessment and treatment area including new London Ambulance Service handover facilities. Phase 2 which provides a new imaging facility (including two x-ray rooms and one CT suite) and a six bedded resuscitation unit was completed in November 2017. Works are now completed on the largest phase which completes the majors’ facility and delivers a new 30 bedded adult assessment unit (AAU). These facilities went live on 17 May 2018 as planned. The remaining works are underway and allow for some minor changes to allow temporary rooms to convert into their final usage. The project has made good progress and the clinical and project teams are working closely to maintain clinical operations at all times.

THE PEARS BUILDING

The demolition of the car park is now complete and work is starting on the piling for the Pears Building, which will house the UCL Institute of Immunity and Transplantation. During the demolition work there were some concerns about dust voiced by local residents and the neighbouring school, despite measures being taken to minimise this. It is expected that any dust issues will now recede.

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Discussions are underway with design companies and local schools as part of a project to provide some informative and attractive artwork on the extensive area of hoardings. It is hoped to have these in place in the autumn.

The construction working group, which includes local residents, representatives of the school and St Stephen's Church, Camden councillors and officers, held a meeting on 26 June. The terms of reference have been broadened and processes changed to allow community input into the meeting agendas. On 28 June there was a "drop-in" in the Peter Samuel Hall, open to all, which provided information about the building and the research programme, as well as an opportunity to ask questions.

B REGULATION

INFORMATON COMMISSIONER’S OFFICE (ICO) UNDERTAKINGS

The trust has now met all the requirements of the undertakings agreed with the Information Commissioner. The final stage of this was the publication of the report of the audit carried out by Linklaters LLP into the use of the Streams app (designed to deliver improved care to patients with acute kidney injury (AKI)), which took place on 12 June 2018.

The audit concluded that RFL’s use of Streams is lawful and complies with data protection laws. While the audit identified areas in which further improvement could be made, it contains the following important conclusions:

• DeepMind only uses patient information for the purpose of providing Streams. It does so under the direction of RFL and in strictly controlled conditions. DeepMind is not permitted to use patient information for any other purpose.

• Streams does not use artificial intelligence. Instead, it implements a simple decision tree used across the whole of the NHS.

• The audit revealed nothing that casts doubt on the safety and security of the patient information used in Streams. The audit confirmed appropriate systems and controls are in place to protect patient information.

Streams is a secure instant alert app which delivers improved care for patients by getting the right data to the right clinician at the right time. Similar to a breaking news alert on a mobile phone, the technology notifies nurses and doctors immediately when test results show a patient is at risk of becoming seriously ill, and provides all the clinical information they need to take action.

Each year, many thousands of people in UK hospitals die from preventable conditions like AKI, because the warning signs are not picked up and acted on in time. AKI is estimated to cause 40,000 deaths and cost the NHS over £1 billion every year.

Streams integrates different types of data and test results from a range of existing IT systems used by the Royal Free Hospital. Because patient information is displayed in one place – on a mobile application – it reduces the administrative burden on staff and means they can dedicate more time to delivering direct patient care.

The Streams app was built in close collaboration between experts at DeepMind and clinicians at the Royal Free London. It was introduced in January 2017 and is already helping to provide better, safer and faster care to our patients. Nurses report it is saving

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them around two hours each day – time which would previously have been spent looking through paper patient notes.

C BOARD AND COUNCIL MATTERS

PROTECTED PATIENTS PARKING AT CHASE FARM HOSPITAL

A question was raised at the council meeting on 18 April about protected patient parking at the CFH site.

The trust follows the DoH Health Technical Memorandum (HTM) 07 -03 guidance on all matters relating to car parking management. This includes adopting the best practice guidelines for reduced parking fees and concessions for frequent site users.

The current concessions will remain in place for the new hospital parking arrangements;

• Patients attending for treatment on a regular basis are able to secure a weekly permit at £12 per week.

• For patients who have long term treatment plans in place (four weeks plus) their parking is free of charge.

Both of the schemes highlighted above are in the trust car parking policy and the concessions are offered by the clinic/ward at time of treatment.

In addition to this, all drop off bays have 20 minutes grace on the CFH site. All other car parking on the new CFH site will be focused around the multi-storey car park and adjacent surface grade car park extension 135 spaces. It is anticipated that sufficient car parking will be available.

PERINATAL MENTAL HEALTH SERVICE

A question was raised at the council meeting on 18 April about perinatal mental health and why there were no clinical appointments at Barnet hospital.

Our perinatal mental health service was launched in October 2017. The perinatal team have clinics across our sites including on our Barnet site. Our Barnet obstetric lead was appointed in February 2018 and implemented her clinics on the Barnet site in May 2018 alongside midwives. From August 2018 a consultant psychiatrist will be will be running her clinic at the same time as our obstetric and midwife leads on the Barnet site. The perinatal mental health team also clinics at our Chase farm and our Edgware sites.

FRIENDS AND FAMILY TEST (FFT)

At the council meeting on 18 April there was a request to provide further trend analysis of FFT data. The analysis covers the period June 2017 to May 2018 and shows trends for inpatients, A&E, outpatients and maternity. The report has been included in the governors’ briefing pack.

D LOCAL NEWS AND DEVELOPMENTS

PRIME MINISTER’S VISIT TO THE ROYAL FREE HOSPITAL

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The prime minister announced the government’s vision for the future of the NHS at a visit to the Royal Free Hospital on 18 June. She was joined by health and social care secretary Jeremy Hunt, chancellor Philip Hammond and the chief executive of the NHS Simon Stevens, and the speech was attended by some of the most senior leaders in the NHS, and staff from across the Royal Free London. The prime minister chose the Royal Free London to speak about how the government intended to “secure the future of the NHS: now and for generations to come”.

Ahead of her speech to a packed auditorium, the prime minister visited the Royal Free Hospital’s children’s ward to speak to staff, patients and parents. She also heard about the progress of the Royal Free London group which was established in July 2017.

COMMUNICATIONS BOARD REPORT: MAY 2018

Media coverage

The trust was mentioned in 236 stories. In addition, we were featured in BBC News coverage about a kidney transplant at the Royal Free Hospital. This had nine million viewers. BBC News at 6 and 10 on 29 May, showed kidney donor Prafula Shah’s operation taking place at the Royal Free Hospital, conducted by Mr Colin Forman. Meanwhile her niece, Shakti, who has chronic kidney disease, was in a nearby theatre at the hospital, receiving another person’s kidney (part of the ‘paired donation’ sharing scheme). Prafula’s experience was part of a wider story about the shortage of BME donors.

The table below shows the sentiment of press mentions in May:

May Royal Free Hospital

Barnet Hospital Chase Farm Hospital

Total

Positive 48 2 0 50Neutral 101 43 2 146Negative 40 0 0 40Total 189 45 2 236

Digital Communications

Total number of Facebook followers: 5646 (+ 97) Number of Posts: 37, reaching 82k people Total number of Twitter followers: 15,522 (+151) Number of Tweets: 97, reaching 207k people.

Our top tweet was a social share of the No Hospital is an Island video on YouTube which showcases our clinical practice groups. The film can be seen here https://www.youtube.com/watch?v=VlyuamewFGY.

Internal communications

Digital transformation: as part of our activity to engage staff with the roll out of the new electronic patient record (EPR), we were delighted that the special week-long future state validation event saw 400 attendees, with 80% saying that they were confident with the new system. Future comms includes a suite of ‘The face of EPR’ posters and banners, a new Freenet hub and a newsletter.

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Dementia Action Week: we celebrated Dementia Action Week by asking staff to take action to make positive changes for people affected by dementia. As part of this, we promoted the launch of the pioneering radio session, the ‘Sundown Sessions’ – developed by Royal Free Radio and Danielle Wilde, trust dementia lead. The show is ground-breaking in its use of hospital radio and volunteers as a clinical intervention.

GDPR: we helped raised staff awareness around the changes to the General Data Protection Regulation by creating Freenet, screensaver and chief executive’s briefings content. We also supported the update of our public-facing information, including the website and the messaging around each hospital, updating and distributing the trust’s ‘How we use and share information’ leaflet.

E NATIONAL NEWS AND DEVELOPMENTS

FIVE YEAR FUNDING SETTLEMENT FOR THE NHS

During her visit to the Royal Free Hospital, the prime minister announced a new five year funding settlement for the NHS, giving real terms growth of more than 3% for the next five years. She has also tasked the NHS with producing a 10-year plan to improve performance, specifically on cancer and mental health care, and unpick barriers to progress. The main points are summarised below.

Government reveals more money for the NHS

• The government has announced a major new package of funding for the NHS covering the five financial years from 2019-20.

• The average annual uplift is 3.4 per cent per year above inflation – based on Office for Budget Responsibility projections.

• The funding is frontloaded, meaning the annual rates of growth are: 3.6%; 3.6%; 3.1%; 3.1%; 3.4%.

• This will equate to £20.5bn more revenue in real terms compared with 2018-19. • A further £1.25bn has been found to deal with an increase in pensions costs

associated with the new Agenda for Change pay deal. • The funding is for the NHS England commissioning budget only. This means it does

not include capital funding, public health, health education, or social care. • In an appearance in front of the Public Accounts Committee, the NHS chief executive

said there was an explicit commitment from the government that the adult social care budget would be set to not put further pressure on the NHS.

• The NHS chief executive also told the Public Accounts Committee that the extra money does include funding for an increase in Agenda for Change salaries from next year.

A 10 year plan

• In return for the increase in funding, the NHS has been tasked to develop a 10-year plan, via an “assembly” convened by national leaders. The prime minister has emphasised that this should have strong clinical input.

• The 10-year plan, which will likely be delivered by the autumn budget, should set out how the service intends to deliver major improvements in mental health and cancer care.

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• Ministers may be considering legislative reform: the prime minister described the number of contracts held between NHS organisations as a “problem”, and said she wanted the service to suggest ways of breaking down any barriers that might hold up progress, including in the regulatory framework.

• The prime minister set out five priorities for the NHS: Putting the patient at the heart of how care is organised; a workforce empowered to deliver the NHS of the future; harnessing the power of innovation; a focus on prevention; and “true parity of care” between mental and physical health.

• The prime minister said she would like to see the 10-year plan set out ambitious “clinically defined access standards” for mental health.

• Finally, she said clinicians should confirm the NHS is focused on the right performance targets for both physical and mental health – indicating that ministers may be willing to reconsider key performance standards.

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Paper 7 Lead governor report – 3 July 2018

Governor inbox

Governors’ informal meeting The informal meeting on 3 July will focus on how we can effectively discharge our role, following recent discussion with some governors.

The next informal meeting is on 13 November in the board room, 2nd floor executive offices at the Royal Free Hospital, between 4.00pm and 5.45pm. James Tugendhat will attend part of the meeting and will be joined by associate NED Vineeta Manchanda.

Medicine for members’ events

Our last event, ‘Cutting edge research at the Pears Building’, was very well received. It focused specifically on the work of the Institute of Immunity and Transplantation (IIT) and included speakers and patients relating to two areas of work at the IIT.

A programme is being finalised for the remainder of the year and will include events on the following services: child and adolescent eating disorders, infectious diseases, diabetes and an area of work of the charity, possibly the support hubs.

If you would like to put forward any suggestions of topics for future medicine for members events, please let Matt or Duncan know. These events are hosted by us and are an important opportunity to engage with our members and the public, so please do your best to be involved by attending and offering to chair.

External meetings

On 24 May, Frances Blunden attended the NHS Providers annual governor focus conference, which brings together governors from all types of NHS provider from across the country. Presentations included: an overview of the national policy agenda and the key issues currently facing the NHS; governors and public engagement in the development of system-wide plans for transformation; and a look at ways of strengthening the legitimacy of governor elections by improving the number of candidates standing and turnout in council of governor elections. Finally, following a review of how far the NHS has come in its 70 years, there was a look to the future and consideration how recent developments may impact on our future healthcare system. Copies of the presentation and notes from the sessions can be found on the NHS Providers' website.

In addition to the conference presentations, there was a governor showcase featuring work that governors from several trusts have undertaken. Copies of the presentations and posters can be found here. NHS Providers also launched its latest governor briefing on sustainability and transformation partnerships, No trust is an island which can be found here.

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Jenny Owen

I would like to thank Jenny for her outstanding contribution as a NED and as chair of PSEC and QIL over the past seven years. Throughout that time Jenny has brought a particular focus on ensuring that patients are at the forefront of all the trust’s work. We wish her well in her plans for the future.

Meetings attended by lead governor

• QIL committee meeting • Nominations Committee meetings • Recently elected governors who requested guidance around their role. • Dominic Dodd and Emma Kearney for my regular monthly 1:1 meetings. • Chris Streather meeting at the National Amyloidosis Centre • Wanda Goldwag 1:1 meeting • Debbie Sanders 1:1 meeting• Introductory meeting with Libby McManus in her new role as Chief Transformation Officer• Introductory meeting with Vineeta Manchanda, Associate NED• Weekly with our trust secretary and membership officer to review the week ahead and any

outstanding items.• Monthly RFL Trust board meetings• Monthly Well Led Review meetings• John Connolly re CPG work to plan for potential Medicine for Members event

Judy Dewinter, Lead Governor 26 June 2018

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Paper 8

Nominations Committee Recommendation Non-executive director appointment

1. The terms of both Stephen Ainger and Jenny Owen come to an end in 2018:

1.1. Stephen Ainger’s term ends on 31 October 2018. That will be the end of his second term by which time he will have been a NED at the trust for just over 6 years serving two full terms;

1.2. Jenny Owen’s term ends on 31 August 2018. That will be the end of her third term – two appointments of three years followed by an exceptional reappointment for a single year approved by CoG in 2017.

2. Jenny Owen has indicated that should would not wish to be reappointed. Stephen Ainger has indicated that he would wish to be reappointed for a term that would take him beyond 6 years.

3. NomCom has considered the composition of the NED cohort and is of the view that it would be appropriate to recommend to CoG that, initially, it seeks, through an open competitive process, to appoint one additional NED. NomCom noted the greater experience of those newer NEDs in the cohort at this juncture and that the force of the continuity argument is therefore not as strong as when NomCom last considered the issue of reappointments in 2017.

4. In recommending that CoG approves a search for one rather than two NEDs (a nominal reduction of one NED post), NomCom was mindful of the following:

4.1. proposals under consideration to reduce the number of NED chaired board committees from four to three thereby reducing one draw on NED capacity;

4.2. this approach would not preclude seeking a second appointment should that be appropriate in the future;

4.3. there is the potential for closer working with NMUH in the future under a single board and that could bring into play consideration of NMUH NED appointments to a single board;

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4.4. each NED appointment is associated with a cost and the trust should look to take a proportionate approach in those circumstances.

5. In terms of the person specification, NomCom identified that the following skills / experience should be sought:

5.1. significant experience of work as a non-executive director;

5.2. detailed knowledge and/or experience of out of hospital care and the relationship between health and social care, which is a skillset that Jenny Owen brings to the board; and

5.3. the potential to take on the role of senior independent director.

6. CoG is asked to approve the initiation by NomCom of a competitive process for the appointment of a single NED position.

June 2018

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Paper 9

Nominations Committee Briefing Long Tenure Appointments for Non-Executive Directors and the Chair

1. Background

1.1. In 2017, the council of governors (CoG) approved an amendment to the trust’s constitution, which allows the nominations committee to make more than one recommendation for the reappointment of a non-executive director or chair.

1.2. The rationale behind the change to the constitution was to remove a restriction that resulted in a lack of flexibility for CoG around the appointment of NEDs and the chair and its ability to have regard to all the circumstances of the trust at any given time.

1.3. Previously, it was only open for the nominations committee to make one such recommendation. This meant that if a NED or the chair was to have their term extended beyond a second term – usually 6 years in total, an open competitive process would have to be carried out. It remains open to CoG to refuse any recommendation made by the nominations committee (NomCom) regardless of whether it be the first or any subsequent recommendation.

1.4. The constitution provides that the ‘…Chairman, shall be appointed by the Council of Governors for terms of office not exceeding three (3) years’. It further provides that ‘any term beyond six (6) years (whether consecutive or not) for a Non-Executive Director, including the Chairman, should be subject to particularly rigorous review’.

1.5. The rationale behind that provision is that where a NED serves more than 6 years, they could be seen to be less independent from the executive than the role requires.

1.6. Paragraph B.1.1 of the NHS FT Code of Governance expands upon the test for independence for NEDs (including the chair):

‘whether the director is independent in character and judgement and whether there are relationships or circumstances which are likely to affect, or could appear to affect, the director’s judgement’

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‘circumstances which may appear relevant to its determination, including if the director:

has been an employee of the NHS foundation trust within the last five years;

has, or has had within the last three years, a material business relationship with the NHS foundation trust either directly, or as a partner, shareholder, director or senior employee of a body that has such a relationship with the NHS foundation trust;

has received or receives additional remuneration from the NHS foundation trust apart from a director’s fee, participates in the NHS foundation trust’s performance-related pay scheme, or is a member of the NHS foundation trust’s pension scheme;

has close family ties with any of the NHS foundation trust’s advisers, directors

or senior employees;

holds cross-directorships or has significant links with other directors through involvement in other companies or bodies;

has served on the board of the NHS foundation trust for more than six years from the date of their first appointment; or

is an appointed representative of the NHS foundation trust’s university medical or dental school’

1.7. Paragraph 7.1 of the code goes on to state:

…Any term beyond six years (eg, two three-year terms) for a non-executive director should be subject to particularly rigorous review, and should take into account the need for progressive refreshing of the board. Non-executive directors may, in exceptional circumstances, serve longer than six years (eg, two three-year terms following authorisation of the NHS foundation trust) but this should be subject to annual re-appointment. Serving more than six years could be relevant to the determination of a non-executive’s independence.

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1.8. Both the chair and Jenny Owen were reappointed beyond 6 years following recommendations from the nominations committee under the amended constitutional provision.

1.9. During debate at CoG, some concerns were expressed about the safeguards in place to ensure that the trust maintains in place a cohort of NEDs that is sufficiently independent to carry out its role effectively. The chairman undertook to take this issue back to the nominations committee for consideration.

2. Issues identified by NomCom

2.1. Should there be an absolute limit on NED terms?

2.1.1. Previous experience suggests that building a hard stop into a process can be problematic and the comply or explain provisions of the NHS Foundation Trust Code of Governance mean that there is no absolute bar to multiple reappointment. However, it is clear that there must be cogent arguments for such steps.

2.1.2. In the case of reappointment of NEDs, the safeguard is that CoG may disagree with a recommendation from NomCom and vote it down. If this becomes a realistic possibility, as it should be if there is provision for it, this means that recommendations in future should be brought to CoG in good time to allow a plan B to be initiated if required.

2.2. Should there be a flex permitted on terms beyond 6 years? – i.e. should the full range of terms 1/2/3 years be under consideration or should it be limited to a single year with consideration of reappointment annually?

2.2.1. The code states that terms beyond 6 years should be subject to ‘annual reappointment’.

2.2.2. From a practical perspective, if reappointment decisions are to be made with sufficient time for alternative plans to be enacted and the trust were limited to one year appointments, one would be looking to consider reappointment almost as soon as the NED had been reappointed. This is administratively unattractive and is also likely to be highly unattractive to the sort of individuals that the trust has been able to attract to its NED cohort in recent times.

2.2.3. In these circumstances an alternative proposal might be that the trust retains the ability to reappoint for more than one year beyond 6 years but

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that each subsequent year of reappointment is subject to rigorous annual review – see below - following which CoG could decide to remove the NED.

2.3. Should there be an annual check for long tenures and if so what should this look like?

2.3.1. If CoG accepts the proposal above, rigorous annual review is a requirement of the process. Recently, NomCom has identified and carried out the following discrete elements for such a review:

• Securing the input of governors and executive directors as to the independence of the NED in question (part of a standard appraisal process).

• Securing the input of individuals external to the trust as to the performance and independence of the NED in question.

• A face to face meeting of the of the NED in question with NomCom, which informs a formal assessment to be presented to CoG.

2.4. What is input of CoG into a ‘particularly rigorous’ review?

2.4.1. It is proposed that ‘particularly rigorous’ review encompasses the elements set out in 2.3 above- cf annual checks - and that CoG receives a formal report from NomCom accordingly.

3. Decision for CoG

3.1. CoG1 is asked to select one of the following options, as identified by NomCom, around the appointment of the chair and NEDs:

3.1.1. OPTION 1: introduce a hard stop on reappointments at a given length of tenure under the constitution2.

3.1.2. OPTION 2: adopt a formal set of standards around reappointments, including a confirmation of independence on an annual basis beyond 6 years, but do not seek a constitutional change.

1 The chairman will recuse himself from debate.

2 Any change to the constitution requires approval by both CoG and the board.

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3.1.3. OPTION 3: incorporate standards into the constitution including a confirmation of independence on an annual basis.

3.2. Approve the essential elements of a ‘rigorous’ annual review for terms beyond 6 years:

3.2.1. Securing the input of governors and executive directors as to the independence of the NED / chair in question (part of a standard appraisal process).

3.2.2. Securing the input of individuals external to the trust as to the performance and independence of the NED / chair in question.

3.2.3. A face to face meeting of the of the NED in question with NomCom, which informs a formal assessment to be presented to CoG. A focus of such a meeting to be the independence of the NED / chair from the executive.

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Non-executive directors’ report – July 2018

OVERVIEW

The purpose of this report is to provide a regular update from the NEDs on their activities and on any matters to they wish to bring the council’s attention.

This will give the council a regular opportunity to ask questions of the non-executive directors on the focus and progress of their work in holding the executive team to account for the performance of the trust.

BOARD COMMITTEE MEETINGS SINCE LAST COUNCIL MEETING

A central means by which non-executive directors seek assurance from executive team on trust performance is via the committees of the board, most of which are chaired by non-executive directors.

Reports from these meetings will be appended in the monthly briefing pack for governors’ reference on the dates shown below.

TRUST BOARD SUB COMMITTEE REPORTS INCLUDED IN GOVERNOR BRIEFING PACK:

• Audit committee 18 March 2018 • Quality improvement and leadership committee 26 March & 27 April 2018 • Clinical standards and innovation committee 9 April 2018 • Group services and investment committee 10 May 2018 • Population health and pathways committee 24 April 2018

PROGRAMME BOARD MINUTES INCLUDED IN GOVERNOR BRIEFING PACK:

• Chase Farm Hospital redevelopment (requested) TBC • Pears programme board (requested) TBC

PERFORMANCE REPORTS INCLUDED IN GOVERNOR BRIEFING PACK:

• Finance performance report (public) May 2018 • Trust performance report (public) May 2018

58

2

Board committee

Non-executive directors

Governor observers

Board committee dates

Meeting minutes circulated in briefing pack for CoG as dated

Clinical standards and innovation

(Bi-monthly)

Anthony Schapira (chair)

Mary Basterfield

Peter Atkin Stephen Cameron Banwari Agarwal

9 April 2018

14 May 2018

16 July 2018

3 July 2018

13 November 2018

13 November 2018

Audit

(5 x a year)

Mary Basterfield (chair)

Stephen Ainger Akta Raja Wanda Goldwag

N/A 18 March 2018

18 May 2018

3 July 2018

13 November 2018

Quality improvement and leadership

(Bi-monthly)

Jenny Owen (chair)

Anthony Schapira Stephen Ainger

Sneha Bedi Judy Dewinter Marva Sammy

26 March 2018

27 April 2018

3 July 2018

13 November 2018

Population health and pathways

(Bi-monthly)

James Tugendhat Dominic Dodd

Jude Bayly Anthony Isaacs Tony Wolff Abi Wood

24 April 2018 3 July 2018

Group services and investment

(Monthly)

Wanda Goldwag (chair)

Stephen Ainger Akta Raja

Peter Zinkin Frances Blunden Effiong Akpan

10 May 2018

14 June 2018

5 July 2018

3 July 2018

13 November 2018

13 November 2018

RemunerationCommittee

(Quarterly)

Dominic Dodd (chair)All NEDS

N/A N/A N/A

Programme Boards & work streams

Executive lead & Non-executive

Governor observers

Meeting dates

Meeting minutes circulated in briefing pack for CoG as dated

Chase Farm Rebuild

(Monthly)

David Sloman Stephen Ainger

Richard Stock Lata Mistry George Verghese

11 May 2018

15 June 2018

xx

Pears Building

(Monthly)

David Sloman Anthony Schapira

Sneha Bedi Judy Dewinter Lata Mistry

TBC TBC

59

3

PROGRAMME OF GO SEE VISITS

A new programme of ‘Go-see’ visits by non-executive directors is taking place. Visits are to the previous go see areas, but quality improvement (QI) projects have been integrated into the programme.

Governors are invited to accompany the non-executive director when each visit is confirmed. Current dates are below:

Go see area Date NED and governorICU, nursing – reduce turnover 11 May 2018 Mary Basterfield

Wale Bakare Therapies area plus QI project. 5 June 2018 Stephen Ainger

Governor TBC Neonatal care standards (QI area)

8 June 2018 Mary Basterfield Frances Blunden

Blood glucose control diabetes & endocrinology (QI project)

28 June 2018 Akta Raja George Verghese

Post operative observations (QI area)

10 July 2018 Stephen Ainger TBC

Paediatrics deteriorating child (QI area)

13 July 2018 Mary Basterfield Sneha Bedi

Medicine, Microbiology – reduce UTI’s (QI area)

23 July 2018 Jenny Owen Judy Dewinter

A briefing is provided prior to each go-see and there is also the opportunity to be involved in the feedback process after visits.

60

4

NON EXECUTIVE DIRECTORS’ ACTIVITIES SINCE LAST COUNCIL MEETING – July 2018

Dominic

Dodd

Trust Board Board

Committees

Council of Governors Other Internal External

Stakeholders

April2018

NED board pre-meet

Trust Board parts 1 & 2 (chair)

Remuneration committee (chair)

Population health and pathways committee

1:1 with new Governors

Council of Governors (chair)

Lead governor

Well Led Steering Group

CEO, Royal Free hospital plus Go See visit

Leader and CEO, Camden Council

RFL/NMUH Joint Steering Committee

Chair, Chelsea & Westminster NHS FT

Chair, UCLH

UCL Partners Board

UCL Partners remuneration committee

Chair, UCL Partners

Chair, NHS Improvement

Director of Policy, Kings Fund

King’s Fund Audit committee

Co-chair, NHS Equality and Diversity Council May2018

NED board pre-meet


Group services & investment committee

Nominations committee (chair)

Lead governor

Non exec appraisal meetings (all NEDs)


CEO, Barnet hospital plus Go See visit

Academic Trust Liaison committee

Chair, Guy’s & St Thomas’ NHS FT

Deputy CEO, NHS Improvement

King’s Fund Board

Kings Fund investment committee

Medical Director, NHS England

61

5

June2018

NED board pre-meet


Remuneration committee (chair)

Group services & investment committee

Nominations Committee (chair)

Lead governor


Academic Trust Liaison committee

President & Provost, UCL

RFL / West Herts Programme Board

NHS Improvement Chairs Advisory Board

Chair and CEO, Care Quality Commission

UCL Partners Audit & Risk committee

Deputy CEO, NHS Improvement

Prime Minister, Chancellor, Secretary of State for Health & Social Care, CEO NHS England

62

6

Stephen Ainger

TrustBoard

Board Committees / Programme boards

Council of Governors

Other Internal ExternalStakeholders

April 2018 • NED pre-meet

• Trust board Parts 1 & 2

• Group services and investment committee

• Council of Governors meeting

May 2018 • NED pre-meet



• Audit committee • Quality improvement and

leadership committee

• Extraordinary Land Opportunities Programme Board

June 2018 • NED pre-meet



• Land Opportunities Programme Board.

63

7

Mary Basterfield

Trust Board Board

Committees

Council of

Governors

Other Internal External

Stakeholders



• Clinical standards and innovation committee




• Clinical standards

and innovation

committee

• Audit committee

(chair)



64

8

Wanda

Goldwag

Trust Board Board

Committees

Council of

Governors


Stakeholders



• Group services and investment committee (chair)




• Board seminar at Chase Farm Hospital


• Audit committee




65

9

Jenny Owen

TrustBoard

Board Committees / Programme

boards

Council of Governors Other Internal ExternalStakeholders



• Quality improvement and leadership (chair)

• Well led steering group

• Remuneration committee


• End of life meeting




• Committee review with chairman and group chief nurse

• Go See 10N • Dominic Dodd 1:1 • James Tugendhat 1:1



• Quality improvement and leadership (chair)



• Meeting with Debbie Saunders • Mentoring session

66

10

Akta Raja Trust Board Board Committees Council of

Governors


Stakeholders





• Council of governors meeting




• Audit committee





67

11

Anthony Schapira

Trust Board Board

Committees

Council of Governors Other Internal External

Stakeholders



• Clinical standards and innovation committee (chair)

• Quality improvement and leadership committee

• Renumeration committee

Council of

Governors



• Clinical standards and innovation committee (chair)

• Academic Trust Liaison Committee (chair)

June 2018 • NED pre-meet • Trust Board

Parts 1 & 2

• Renumeration committee

• Quality improvement and leadership committee

• Academic Trust Liaison Committee (chair)

68

12

James

Tugendhat

Trust Board Board

Committees

Council of

Governors


Stakeholders



• Population health and pathways committee (chair)







69

Meeting / Activity Governors

Involved

Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-18 May-18

Council of governors

meeting

All 23 January 2018

Atrium @ 6pm

18 April 2018

CoG Atrium 6-

8pm

3 July 2018 CoG

Atrium 6-8pm

Paper re

governor

complaint

handling

13 November

2018 CoG Atrium

6-8pm

January CoG April CoG

Joint council of governors &

board meeting

All 20 March 2018,

RFH Atrium @

6pm

Annual members meeting All July AMM

Medicine for members

event

All 22 February 2018

Atrium, 6-

7.45pm. Organ

donation opt out

debate.

DeepMind,

Streams and the

Royal Free TBC

19 April 2018

Atrium, 6-

7.45pm. Stem

Cell Therapies at

the Free - the IIT

Treatment of

diabetes at the

Free TBC

Preventative

medicine &

population

health TBC

Dementia TBC

Governor Specific Seminars PWC - auditors &

the RFL accounts

6-8pm date and

venue TBC

Comms @ RFL 31

May 6-8pm.

Boardroom,

executive offices,

2nd floor, RFH

Induction All 9 January 2018

6pm-8pm Peter

Samuel Hall: The

RFL in context - a

vanguard in the

provision of 21st

century care

16 January 2018

6.30pm-8pm

Atrium: Roles &

responsibilities

of a governor at

RFL

18 January 2018

6pm-8pm Palm

Boardroom

Barnet Hospital:

Foundation

Trusts and how

they function

28 February 2018

6pm-8pm Peter

Samuel Hall:

Challenges facing

RFL and how RFL

is seeking to

address those

challenges

Nominations committee JD, AW, PA, HS 23 January 2018

meeting room 1

AB house @

10am

Membership engagement

group (Debbie Sanders,

Chair)

WB, MH

Chase Farm Hospital local

engagement group (Akta

Raja, Chair)

NM, DMc, LM,

GV PLUS

PUBLIC/PT BY

POSTCODE

Barnet Hospital local

engagement group(NED

tba, Chair)

MS, RS, TW,

WWL, PZ PLUS

PUBLIC/PT BY

POSTCODE

Paper 11

70

Royal Free Hospital

(Stephen Ainger, Chair)

BA, WB, FB, SC,

MH, AI, DM, AW

PLUS PUBLIC/PT

BY POSTCODE

Quality improvement and

leadership committee

(Jenny Owen, Chair)

SB, JD, MS 22 January 2018,

RFH Boardroom

@ 10am

26 March 2018,

ABH Boardroom

@ 10am

21 May 2018 @

10am

23 July 2018 @

10am

24 September

2018 @ 10am

19 November

2018 @ 10am

28 January 2019

@ 10am

25 March 2019

@ 10am

Clinical standards and

innovation committee (Prof

Schapira, Chair)

BA, PA, SC 15 January 2018,

RFH Boardroom

@ 9.30am

19 March 2018,

ABH Boardroom

@ 10am

14 May 2018 @

10am

16 July 2018 @

10am

17 September

2018 @ 10am

12 November

2018 @ 10am

21 January 2019

@ 10am

18 March 2019

@ 10am

Group services and

investment committee

(Wanda Goldwag, Chair)

EA, FB, PZ 11 January 2018,

ABH Boardroom

@ 9am

8 February 2018,

ABH Boardroom

@ 9am

8 March 2018,

ABH Boardroom

@ 9am

12 April 2018,

ABH Boardroom

@ 9am

10 May 2018,

ABH Boardroom

@ 2pm

14 June 2018,

ABH Boardroom

@ 1pm

5 July 2018, ABH

Boardroom @

10am

13 September

2018, ABH

Boardroom @

1pm

11 October 2018,

ABH Boardroom

@ 1pm

8 November

2018, ABH

Boardroom @

1pm

6 December

2018, ABH

Boardroom @

2pm

10 January 2019,

ABH Boardroom

@ 1pm

14 February

2019, ABH

Boardroom @

1pm

14 March 2019

ABH Boardroom

@ 1pm

Population health and

pathways committee

(James Tugendhat, Chair)

JB, AI, TW, AW TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY TBA BI MONTHLY

Pears progamme board

(Chris Streather, Chair)

SB, JD, LM 2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

Chase Farm programme

board (David Sloman, Chair)

LM, RS, GV 19 January 2018,

ABH Boardroom

2.30pm-4pm

28/02/2018, ABH

Boardroom 3pm-

4.30pm

16 March 2018,

ABH Boardroom

1.30pm-3pm

13 April 2018,

ABH Boardroom

11am-12.30pm

11 May 2018,

ABH Boardroom

12.30pm-2pm

15 June 2018,

ABH Boardroom

11.30am-3pm

20 July 2018,

ABH Boardroom

11am-12.30pm

17 Aug 2018,

ABH Boardroom

2.30pm-4pm

14 Sept 2018,

ABH Boardroom

12.30pm-2pm

12 Oct 2018, ABH

Boardroom

12.30pm-2pm

16 Nov 2018,

ABH Boardroom

12.30pm-2pm

14 Dec 2018,

ABH Boardroom

11.30pm-1pm

2019 dates TBA 2019 dates TBA 2019 dates TBA 2019 dates TBA 2019 dates TBA

Revalidation advisory group

(Jane Hawdon, Chair)

TBC

Maggie's programme board FB, JD 2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

2018/19 dates

TBA

Organ donation committee

(Chair, David Myers)

DM, MS

LGBT champion LD

BME champion JB 1 March 2018,

Clock Tower

Boardroom,

Chase Farm

Hospital, 11am-

12noon

11 April 2018,

Palm

Boardroom,

Barnet Hospital,

10am-11am

12 September

2018, Palm

Boardroom,

Barnet Hospital,

10am-11am

15 November

2018, Clock

Tower

Boardroom,

venue TBC, 11am-

12noon

Disability champion LM

Governor by-elections By elections for 3

patient

governors

NED terms expiring N/A Jenny Owen end

of term

Stephen Ainger

end of term

Quality accounts All Progress update

on priorities and

governors choice

of indicator for

testing

Invite to

governors to

attend quality

account team

event on

02/02/2018

showcasing

clinical

excellence and

quality account

consultation

Send copies of

the draft quality

account to

governors for

consultation to

inform the final

statement

Final statement

from governors

for publication in

the quality

account

Copy of the final

quality account

for information

Progress update

on quality

priorities

Progress update

on priorities and

governors choice

of indicator for

testing

Invite to

governors to

attend quality

account team

event

showcasing

clinical

excellence and

quality account

consultation

Send copies of

the draft quality

account to

governors for

consultation to

inform the final

statement

Final statement

from governors

for publication in

the quality

account

Key

Anthony Isaacs AI

Abi Wood AW

Banwari Agarwal BA

David Bedford DB

David Daniels DDa

Donald McGowan DMc

David Myers DM

Paper 11

71

Effiong Akpan EA

Frances Blunden FB

George Verghese GV

Hans Stauss HS

Jude Bayly JB

Judy Dewinter JD

Linda Davies LD

Lata Mistry LM

Maria Higson MH

Marva Sammy MS

Nicholas Macartney NM

Peter Atkin PA

Paul Ciclitira PC

Peter Zinkin PZ

Richard Stock RS

Sneha Bedi SB

Stephen Cameron SC

Tony Wolff TW

Wale Bakare WB

William Wyatt-Lowe WWL

Paper 11

72

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