Annual General Meeting Thursday 8 September 2016

1. Annual General Meeting Thursday 8 September 2016

2. Welcome Professor Steve Barnett, Chairman

3. Agenda Professor Steve Barnett (Chairman) Don Richards (Chief Financial Officer) Lisa Emery (Chief Information Officer) Paul da Gama (Director of HR & OD) Tracey Carter (Chief Nurse and DIPC) Michael van der Watt (Medical Director) Katie Fisher (Chief Executive) Professor Steve Barnett (Chairman) Overview of the Trust Our Finances Our Quality Improvement Plan Our People & Well-led Getting the basics right Patient Focus, Infrastructure & Governance What we still need to do & key messages Your Questions

4. Our Board of Directors

5. Our sites and services Watford General Hospital Serving over 500,000 people 136,000 emergency attendances 450,000 outpatient attendances 39,000 planned and 52,000 emergency admissions 5,000 deliveries/year 4,200 staff 350 volunteers • inpatient emergency and intensive care • elective care for higher risk patients • outpatient and diagnostic services • C.600 beds and nine theatres • women's and children's services Hemel Hempstead Hospital • 24 hours/7 day a week urgent care centre • diagnostic services, incl. MRI and pathology • outpatient services • stroke rehabilitation ward • endoscopy and bowel cancer screening #OurImprovementJourney St Albans City Hospital • inpatient care - low risk and day-cases • outpatient and diagnostic services • 40 beds and six theatres • minor Injuries Unit, 9am – 8pm 7 days a week

6. Our Vision • the very best care for every patient, every day • Our aims are to: • deliver the best quality care for our patients • be a great place to work and learn • improve our financial sustainability • develop a strategy for the future • Our values: • Commitment, Care, Quality #OurImprovementJourney

7. Some of our proudest achievements • 15th lowest mortality rate nationally based on HSMR figures (Hospital Standardised Mortality Ratio) in the UK – great news for patient safety • 50% reduction in deaths following hip fracture since 2013 • 99.04% of our patients received harm-free care, a figure above the national average of 97.9% • no grade 4 pressure ulcers, an 80% reduction in grade 3 • 50% reduction in cardiac arrest rates in our hospitals • middle management nursing vacancy rate fell from 32.4% to 6.8% (March 2016) • significant improvements in medical and nurse training and education • caring rated ‘outstanding’ across most of paediatrics with staff rated ‘caring, compassionate and kind’ in 2015 Care Quality Commission inspection • innovative delirium recovery programme – methods now adopted by other hospitals #OurImprovementJourney

8. Our finances Looking back and moving on Don Richards, Chief Financial Officer

9. The financial highlights… In 2015/16 we: delivered a deficit of £41.2m against a revised plan of £41.7m increased spending on frontline clinical staff by £12.8m saved an impressive £12.3m - and will work hard to keep this momentum going spent £16.6m on capital projects including £8.2m back log maintenance bought Shrodells building – now used to provide care to elderly patients invested in IT – Wifi and technology to track medical records and manage bookings delivered services without the level of loans we have had in prior years we paid our commissioners contract penalties of £4.7m and £1.7m fines for under-achievement against CQUINs (Commissioning for Quality and Innovation) #OurImprovementJourney

10. 2015/16 2014/15 Income from patient care activities 275.0 287.6 Other operating income 24.8 25.7 Income 299.8 313.3 Operating expenses (336.8) (323.5) Operating surplus / (deficit) (336.8) (323.5) Other gains and (losses) 0.0 0.6 Dividends and interest (4.1) (4.2) Reported NHS financial surplus / (deficit) (41.2) (13.8) 2015/16 income & expenditure 400 350 300 250 200 150 100 50 0 (50) Income Expenditure Net deficit We spent more than we earned – in line with our agreed plan 4% reduction in income. £12m Provider Deficit Funding included in 2014/15, not received in 2015/16. Income reduced by contract penalties (see below). Costs rose by 4% #OurImprovementJourney The plan agreed with the NHS TDA (now NHSI) was to end the year with no more than a £41.7m deficit. Therefore the plan was achieved. Also the outturn included £4.7m of contract penalties and £1.7m shortfall on CQUIN payments (£6.4m total)

11. inpatient activity 45,000 40,000 Inpatient - 35,000 Elective Inpatient - Non 30,000 A&E activity Elective 115,000 25,000 110,000 20,000 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 105,000 A&E outpatient activity 100,000 380,000 95,000 360,000 90,000 340,000 FY10 FY11 FY12 FY13 FY14 FY15 FY16 320,000 Outpatient 300,000 280,000 260,000 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 How many patients did we treat? • a continued rise (6%) in emergency admissions. • elective admissions were back to their highest levels after a small decline in 2014/15, although we continue to admit more emergency patients than elective. #OurImprovementJourney

12. NHSE specialist commissioning 5.5% Other operating Non - NHS income clinical 10.3% revenue 0.9% NHS clinical revenue (Other) 6.2% NHS clinical revenue (HVCCG), 77.2% Over three-quarters of our income is paid by Herts Valleys CCG An increasing proportion of income from CCGs is for emergency care Commas need removing ‘Other income’ no longer includes GUM services (approx 1.3% of 14/15 total) #OurImprovementJourney

13. Agency costs rose last year in response to increased demand, while recruitment improves • agency costs rose to £37m, permanent staff costs rose by 4% and bank staff costs remained flat • although agency costs rose by 36% this was much less than the 142% increase in 2014/15 • prior year increases in the agency market have been stimulated by: • concerns over safe staffing levels • resultant shortage in trained staff • agency cost caps, limits on agency pay rates and targets for departments will support a significant reduction in agency costs for 2016/17. #OurImprovementJourney

14. Assets, liabilities and borrowing • our fixed assets (land and buildings) worth £171m • in-year deficit and the agreed capital programme the Trust had to borrow the following amounts from the Department of Health: • £32m to support recurrent spending • £7m to maintain creditor balances/pay suppliers • £11m to support our capital programme • we have appointed new internal and external auditors • more details are in our annual report, online or copies here tonight. #OurImprovementJourney

15. The financial highlights • In 2016/17 we will: • expect that contract penalties will not be levied by our commissioners • will see more benefit from our five-year contract to improve IT infrastructure • invest in new MRI/CT (Watford) • continue to spend less on agency staffing • complete the endoscopy expansion (Watford) • make a case for significant investment in our estate • install high voltage generators to back up power supply (Watford)

16. Our Quality Improvement Plan (QIP) Lisa Emery, Chief Information Officer

17. Our Response – Delivering our Quality Strategy CQC review findings for the Trust Are services safe? Are services effective? Are services caring? Are services responsive? Are services well-led? Inadequate Requires improvement Requires improvement Requires improvement Inadequate WHHT Quality Improvement Plan Themes Getting the basics right Patient focus Infrastructure Governance, risk management and decision-making Our people #OurImprovementJourney Changing the culture of the organisation and embedding the change

18. Key areas of concern in 2015 #OurImprovementJourney

19. - Our People - Well-led Paul da Gama, Director of Human Resources & Organisational Development

20. Our People • The CQC said • we MUST: • Ensure the right staffing levels • Provide appropriate staff training, supervision and appraisal • Improve our organisational culture • What have we done? • workforce strategy agreed • Staffing • major recruitment campaign (UK and overseas) • more than 400 new nurses and midwives since Sept 2015 • monthly agency spend reduced by £1m+ • 30+ new consultants appointed, now only a handful of vacancies Agency spend #OurImprovementJourney £s Culture and Development • new values launched • learning strategy in development • extended mentoring for student nurses • new programmes for our medical and nursing staff

21. The CQC said we MUST: • Ensure staff are able to attend and carry out mandatory training • Ensure that all staff are effectively supported with formal supervision and appraisals • Enable all staff to access appropriate developmental training opportunities as required Well-led What have we done? Mandatory Training • improved access to mandatory training – compliance now 90% • mandatory training completed in the first week of employment Appraisals • appraisal documentation now focused on our vision and aims • appraisal rates are now at 93.2% (medical appraisal rate 100%) Leadership and Engagement • moving towards clinically-led organisation – underpinned by leadership development programme for senior clinicians • revamped induction and reconnect sessions for new starters • monthly Schwartz rounds – proving very popular • success with revalidation (NMC and GMC) #OurImprovementJourney

22. Getting the basics right Tracey Carter, Chief Nurse & Director of Infection Prevention and Control

23. The CQC said we MUST: • Ensure that medicines are stored securely • Comply with the Mental Capacity Act • Look after patient data better • Improve record keeping • Improve security Getting the basics right What have we done? Getting the Basics Right • lockable notes trolleys and new medicines storage • missed dosages down from 8.3% in October 2014 to 5% in May 2016 • new care plans to better manage pain and other needs • improved security – including CCTV • 15 steps programme Safeguarding • over 90% safeguarding mandatory training uptake • enhanced training to help staff support patients with mental health illnesses and/or loss of capacity • pocket guides to make legislation easier to learn #OurImprovementJourney Patient experience • ‘hello my name is” in support of national campaign • noise at night project to help our patients sleep more soundly • patient experience & carers’ strategy • our quality account gives more detail on all of the above and more!

24. The CQC said we MUST: • Ensure security systems within maternity are maintained at all times • The CQC noted: • Significant concerns re leadership, culture, team working, staff morale and high midwifery vacancies • Concerns about governance arrangements • Concerns relating to bed allocation for elective patients; vulnerable adults and harder to reach service users Maternity What have we done? Leadership and Staffing • fully substantive leadership team including new roles • more clarity on consultant job plans with explicit lead roles and responsibilities • midwifery vacancy reduction from 44 in April to 13.5 in July 2016 • key roles providing education and student support • Governance • restructured risk management processes • weekly clinical Incident review panel • new quality metrics (dashboard) developed and regularly reviewed • daily incident review at the daily patient safety meeting #OurImprovementJourney • Patient Experience • ‘I Want Great Care’ feedback used to improve patient experience • 3 x daily consultant labour ward rounds and min. 98 hours cover • staggered fasting and arrival times for elective patients • increased interaction with parents and local community • improved information for parents

25. - Patient Focus - Infrastructure - Governance Michael van der Watt, Medical Director

26. The CQC said we MUST: • Ensure effective Emergency Department triage • Train doctors to manage safe transfers from critical care • Keep outpatient cancellations and waits to a minimum What have we done? Clinical effectiveness Patient focus • improved ED waiting times to see a doctor or senior nurse • frailty service to assess emergency patients and reduce admissions • 100% of ITU doctors trained in critical care transfer • ‘hospital at night’ – multi-disciplinary support for acutely unwell patients • now in top 50% in national stroke audit (previously bottom 6%) • end of life care strategy approved and being embedded • NEWS JUST IN – figures released today show we’re one of 15 UK trusts with a statistically lower than expected mortality rate for broken hips Outpatients #OurImprovementJourney • new phone system – call waiting down from 19 to 5 mins, abandoned calls down 50% to 5% • respiratory - 18 week compliance up from 65% to 97% and new specialty one stop clinics developed • reduction in short notice cancellations

27. The CQC said we MUST: • Ensure all premises and facilities are safe and secure • Ensure all premises fit for purpose • Ensure all equipment is checked and maintained Infrastructure What have we done? • Safety & risk management • completed self-assessment across sites • strengthened H&S risk assessment assurance • theatre 4 at St Albans reopened after major refurbishment • improvements to mortuary environment • Buildings • major backlog maintenance programme (£8m+) • refurbished inpatient areas including special care baby unit and relocation of pre-op assessment • new accommodation for cardiology, respiratory and vascular lab – due to complete this year • some improvements in ophthalmology but more to be done #OurImprovementJourney • Equipment • improved internal audit assurance • IT upgrade launched (but some technical and performance difficulties)

28. The CQC said we MUST: • Ensure effective risk management at all levels • Ensure better incident reporting, investigation and learning to drive improvement Governance What have we done? • Understanding risk • root and branch review and rebuild of risk management processes – all risks actively managed and regularly reviewed • trust-wide awareness campaign on identifying and handling risk • risk management training for all new staff at induction • corporate risk register - moved from more than 180 risks scored at 15+ in April 2015, to 21 at July 2016 • Improved incident management and complaints process • new serious incident policy and process with timeframes • historic complaints cleared, improved practices in place but more to do • divisions report learning from complaints and incidents plus Trust-wide learning events • Use of data to drive improvement: • strengthened ward to Board assurance • detailed workforce, safety and quality dashboards and ward scorecards • divisions using improved information to drive service delivery & planning #OurImprovementJourney

29. What we still need to do Katie Fisher, Chief Executive

30. What we still need to do • Workforce - recruit, retain, engage • good progress but more to do • Culture • clinical leadership - ongoing journey • investment in service line triumvirates • Emergency care pathway • a key risk - emergency care improvement programme to improve internal processes and actively working with partners to address system issues including DToC • Elective pathway • resilience across all service lines in dashboard performance • cancer • referral to treatment (RTT) • Estates and IT infrastructure • significant legacy issues and shortfall in capital • work commenced on medium and long term plans – significant investment will be required • Financial deficit • underlying deficit in 2015/16 £41.2m • £18m CIP programme – £12m identified Clinical and financial sustainability #OurImprovementJourney

31. Long term plans • Your Care, Your Future • fundamental system wide redesign of care pathways and service models to improve outcomes and integrate care • recognises importance of high quality, sustainable acute hospital services and need to improve estate and IM&T infrastructure • providers to take a key leadership role, commitment to strengthen joint working and work together to drive system value • Our clinical strategy • final draft approved at September Trust Board • sets out the Trust’s vision and priorities (aligns with Your Care, Your Future) • some specialties have well developed local strategies in place; need to support and empower all teams to develop • Sustainability • financial and clinical sustainability go hand in hand • need to drive out variation in care to deliver optimum value • estates and IM&T enablers - SOC being developed and IM&T strategy being updated • explore potential benefits of joining the proposed Royal Free Hospital group Your Care, Your Future Clinical Strategy #OurImprovementJourney

32. Our key messages • patients saying we are improving • staff wanting to come and work here • trust board fully recruited - clear ownership for the delivery and quality of the improvement journey • clear diagnosis of the challenges with plans to address • longer term options being developed for infrastructure, service resilience, financial viability and organisational form • evidence of significant cultural change, now needs to be sustained • patient safety at the heart of everything we do • A team that has taken responsibility and is full of optimism for the future #OurImprovementJourney

33. Thank you to… Professor Steve Barnett, Chairman League of Friends and Norman and Mavis Tyrwhitt who pledged £148,000 Dr Ian Frankel and Dr Michelle Jacob and their 40 colleagues for their contributions to the Cremation Fund Dr Samuel Afolami, DrKatarzynaPiotrowska, Fiona Loud (Chair) and Debbie Walford (Specialist Nurse Organ Donation) for the organ donation fund To the people who completed challenges for us including the Boys & Girls Nursery, the team from the Warrior Adrenaline Race, the Vitality British 10k London Run - Lisa Emery and her colleagues from IT and Finance and the Special Care Baby Unit team who completed the Three Peaks Challenge And thanks to all of the following who raised money for us: Philip Costard, Lisa Davies, Lauren Davis, Paul Hakim, Fleur Harvey, Michael Jefferys, Sarah Lansdell, Gemma Nash, Martin Sheehy, Emily Adams, Suzanne Boon and Dani Cox

34. Your questions…