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Agenda and minutes

Venue: Board Rooms, Trust HQ, Great Western Hospital, Swindon. View directions

Contact: Carole Nicholl  01793 605171

No. Item


Apologies for Absence and Chairman's Welcome


The Chair welcomed all to the Great Western Hospitals NHS Foundation Trust Board meeting held in public and explained this meeting was being held virtually due to the Coronavirus Pandemic. Whilst under normal circumstances the public were able to attend the Trust’s Board meeting held in public Government social isolation requirements constituted ‘special reasons’ to avoid face to face gatherings as permitted by legislation, therefore under these circumstances the public were unable to attend. 


Roger Stroud, Lead Governor, and Pauline Cooke, Deputy Lead Governor had been invited as observers in order to retain the effective relationship between the Board and Council of Governors during these unprecedented times.  Roger assured the Trust Board that the Council of Governors were pragmatic and accepted the Trust’s approach to meetings in these challenging times.


Apologies were received as outlined above.



Declarations of Interest

Members are reminded of their obligation to declare any interest they may have in any issue arising at the meeting, which might conflict with the business of the Trust.


There were no declarations of interest.


Minutes pdf icon PDF 396 KB

Liam Coleman, Chairman

·         9 April 2020 (public minutes)


The minutes of the meeting of the Board held on 9 April 2020 were adopted and signed as a correct record.



Outstanding actions of the Board (public) pdf icon PDF 487 KB


The Board received and considered the outstanding action list and the following noted:-


338/19  :  Quality Report :  Review of Quality Policies, Procedures and Structures – It was confirmed that this was underway.  Closed.


282/19  :  Chief Executive’s Report  :  Primary Care  -  It was noted that the review was underway however the final report would wait until feedback had been received from the CQC Inspections.

Action  :  KM



Questions from the public to the Board relating to the work of the Trust pdf icon PDF 248 KB


The Board received and reviewed one question which related to carers involvement.




that there was no further action required.



Chairman's Report, Feedback from the Council of Governors

Liam Coleman, Chairman


The Board received a verbal update which included:-


Virtual Meetings  -  The Lead Governors had been invited to the meeting in order to maintain a degree of scrutiny outside the Board, ask questions and to give assurance to the governor group on how the Board was running during this period of national emergency.  The situation would be kept under review and in line with government guidelines.


Rosemarie Phillips  -  It was with great sadness to hear that one our longest and most esteemed Governors, Rosemarie Phillips, had passed away.  Rosemarie was cared for by our Palliative Care team in her final days and her family have praised the kindness and compassion of those who cared for her following a short illness.

As a passionate advocate for people with sensory loss, since 2013 Rosemarie's role as Governor saw her influence many improvements for those with poor eyesight and hearing.  Alongside her role as Governor, Rosemarie volunteered in the Eye Clinic and was well known and respected in the local community as an advocate for improving accessibility.


Rosemarie's family shared the following words:


“Please don't mourn her, don't send flowers; celebrate her life.”


I know Rosemarie's fellow Governors, members of the Board and all those who worked closely with her, will be deeply saddened by this news and send our condolences to her family at this sad time.


Governors  -  The Trust welcomed a new Governor, Judith Furse representing Swindon Constituency who replaced William Evans.


Wiltshire Health & Care   -  A successful virtual recruitment process had been undertaken  for the position of Chair, Wiltshire Health & Care. Dr Stephen Ladyman had been appointed and would take up his position on 1 June 2020.


Kevin McNamara, Chief Executive gave verbal headlines from a recent Wiltshire Health & Care Board meeting and confirmed that the contract to provide adult community services in Wiltshire had been extended to run until 2023, and, that the organisation had entered the new financial year with a small surplus, with some elements of capitalisation undertaken at year end.


Julie Soutter, Non-Executive Director asked if the Board would know the outcome of the audit with regards to Wiltshire Health & Care’s capitalisation.  Kevin McNamara, Chief Executive replied that any material capitalisation would be reported to the Board.


Charitable Funds  -  Discussions are underway on how to adapt to fund raising in a virtual world.  In that context there was a run taking place today within the hospital grounds where members of staff were running to raise funds.




to note the verbal update.



Chief Executive's Report pdf icon PDF 387 KB

Kevin McNamara, Chief Executive


The Board received and reviewed a report from the Chief Executive which focussed on the Coronavirus.  The following was highlighted:-


·         The response to coronavirus had been extremely fast-paced, with the normal pace of change within our organisation significantly accelerated.

·         Our staff continued to go above and beyond to respond to this unprecedented challenge and the Board thanked them for everything they have done to care for patients.

·         The Trust remained open for all patients that required urgent or emergency care.

·         The South West continued to have the lowest case rate per head of population, and the lowest number of people in hospital, of all regions.

·         The Trust continued to plan for increased numbers, and potential future waves of Coronavirus.

·         There had been some positive gains which included stranded patient flow, however also potential risks around the cancer and stroke patients outside the hospital.

·         Sadly at the time of writing there had been a total of 80 deaths as a result of COVID-19, together with 1 member of staff and one volunteer. 

·         Staff risk assessments were being carried out to reduce risk of infection to our staff.

·         Planning was underway to move into Phase2 to look at how safely we can reintroduce services while living and working alongside COVID-19 for the foreseeable future.


Andy Copestake, Non-Executive Director asked if the numbers of Freedom to Speak Up cases had increased due to the enormous pressure staff were under.  Carole Nicholls, Director of Governance & Assurance replied that numbers had remained the same over the last few months; however any COVID-19 related cases had gone through COVID Command and had been addressed immediately.


Julie Soutter, Non-Executive Director asked, following media reports that obesity was thought to be one of the biggest risk factors, was there any evidence of additional pressures on community services with patients suffering obesity.  It was noted there had been no reports.




that the report be noted.



Chair of Quality & Governance Committee Overview pdf icon PDF 368 KB

Nick Bishop, Non-Executive Director


The Board received and considered a paper which summarised key issues considered by the Quality & Governance Committee at meetings held on 19 March and 23 April 2020 with the following highlighted:-


Covid-19  -  The Committee were assured that all patients were being treated in accordance with national guidelines for best practice and wished to congratulate the organisation in the way it had responded to the pandemic so quickly.


Mortality Rates  -  The Trust’s rolling 12 month SHMI had increased month on month for the past 8 months.    It remained below average (favourable) nationally. The Committee were satisfied that the Trust was not an outlier and recognised  there were many underlying demographic factors to the rising trend, however the recently appointed Consultant Lead for Mortality would examine the trend further.


Julie Soutter, Non-Executive Director asked why the WHO checklist was not used in 100% of areas.  Nick Bishop, replied that the low usage rate reported in March 2020 (70%), which triggered the investigation, was due to the administrative side in obtaining final signature sign off for the procedure.  Julie Marshman, Chief Nurse added that the checklist was being used in all areas and where it was not used there was a justifiable explanation and not in any area of significance.  Julie Soutter responded that she was not assured enough and believed that signatures should be obtained post procedures.  It was agreed to refer this back through the Quality & Governance Committee to see an improvement in this area.

Action :   Chief Nurse


There followed a discussion around the rate of hospital acquired COVID-19 and moving to the next phase particularly around the importance of tracking to ensure infection prevention and control processes were robust. It was recognised that this would be a national issue and guidance would be issued at some point.




(a)           that the report is received; and,


(b)           the WHO checklist is referred back to Quality & Governance Committee to see further improvement in sign off.



Quality Report pdf icon PDF 282 KB

Julie Marshman, Chief Nurse

Charlotte Forsyth, Medical Director

Additional documents:


The Board received and considered a monthly report which provided commentary and progress on activity associated with key safety and quality indicators. The key points to note for March 2020 were as follows: -


Incidents  -   The latest data received from NHSE/I suggested potential under reporting between April to September 2019 by the Trust.  It was noted that a significant change in incident reporting processes had taken place in September 2019 and reporting had seen a significant increase since September 2019.  However it had been identified that clinical incident reporting was an area of concern, likely as a result of increased demand on clinical staff during the COVID-19 pandemic.  The Quality Team had developed contingency plans to ensure that identification of quality concerns and timely responses to these are achieved in the face of services under pressure due to COVID-19.


Harm Free Care  -  A Safer Care Group had been established to focus on areas of harm free care to further improve quality of care and to create a greater oversight on any issues.


Mortality Reviews   -  Assurance was given to the Board that every COVID-19 death was undergoing a mortality review.


Nick Bishop,  Non-Executive Director raised concerns around the completion of timely Electronic Discharge Summaries, and, although acknowledged that alternative routes were being explored, sought assurance that actions to resolve this were a priority.  There followed a discussion on the actions currently underway to clear the backlog which involved a plan and resource allocated, however it was recognised that a robust process going forward was still to be finalised.  Although this would be taken forward through the Quality & Governance Committee it would remain a Board action until resolved.

Action :  Medical Director




(a)   that the report and quality matters and exceptions contained within the report be noted;


(b)   swift completion of the backlog of Electronic Discharge Summaries; and,


(c)   a solution for the completion of timely Electronic Discharge Summaries going forward.



Chair of Performance, People & Place Committee Overview pdf icon PDF 231 KB

Peter Hill, Non-Executive Director


The Board received and considered a report that summarised key issues considered by the Performance, People and Place Committee at meetings held on 25 March and 29 April 2020.  The following was highlighted:-


Performance Acute Services  - There had been an update on ED performance which showed considerable improvement with the Trust being the third best performing in the country on the 4 hours standard.  This was due to COVID-19. 


There was also a deep dive into cancer services, and the effective use of Ridgeway Hospital to protect the treatment of cancer patient and the stroke service.


Performance Community Services  -  There was a comprehensive update on community services, together with primary care.  The team was congratulated on their impressive performance to date.


Workforce  -  HR were supporting staff with positive feedback on all the impressive initiatives introduced throughout these unprecedented times.


52 Week Breaches  -  The Committee received a report on the management and lessons learnt through external reports on the RTT waiting list.  The Committee would monitor closely the recommendations to ensure they were acted upon.  It was noted that this would be used as a case study at a future Board Development Workshop to develop different ways of working.




that the report is received.



Operational Performance Report pdf icon PDF 263 KB

Jim O’Connell, Chief Operating Officer

Lorraine Austen, Associate Director for Swindon Community Health Services

Additional documents:


The Board considered the operational performance report which provided an update on performance during February/March 2020 against key national and local performance standards in addition to progress against key work streams and remedial recovery plans with headlines as follows: -


Stranded Patients  -  There had been a significant improvement in the number of patients with 21+ day length of stay due to COVID-19 and the implementation of different ways of working.


Julie Soutter, Non-Executive Director highlighted that this was a prime example of how different ways of working could resolve issues and hoped that innovative ways of working would be trialled during this transition period before full services were resumed.  Peter Hill, Non-Executive Director added that this was also an opportunity to rebase targets, for instance super stranded patients baseline should now be 20 and not revert back to 60-90 as previously.


Hold File  -  As a result of COVID-19 and ceasing all routine activity in March 2020 it was unlikely that the Trust would see a further reduction in the waiting list size and potentially at risk of not achieving March trajectory.  Work had been undertaken to discuss with Divisions the challenges and to produce actions plans to tackle the issue.


Cancer Performance  -  62 Day Wait for First Treatment had not been achieved in February 2020, however it was noted that the target had been met in March 2020.


Community Services and Primary Care

A brief description of the changes within community services and GP surgeries that had been made as a result of the COVID-19 pandemic was noted.  Due to the number of vulnerable patients and those shielding new ways of working had been implemented with pace, with staff up-skilling and flexible working.  In the GP surgeries, virtual GP and nursing consultations were introduced with only essential patient attendance in a safe and protected environment. The 2nd phase had now started which involved system working across the Trust to use any intelligence through the Primary Care Network for outpatient, elective and diagnostics planning.


It was noted that the draft CQC Inspection Report for the GP surgeries had been received however this was currently going through the factual accuracy process before a final report would be issued.




that the report be received and the on-going plans to maintain and improve performance be accepted, acknowledged and supported.



Workforce Report: Key Performance Indicators (Month 12) pdf icon PDF 790 KB

Jude Gray, Director of Human Resources


The Board received and considered a paper that summarised the key workforce issues and risks identified from the workforce report in March 2020 (month 12).  The following was highlighted:-


Staff Risk Assessments  -  The Trust had implemented a staff risk assessment to take into account the national reporting of the disproportionate rate of COVID-19 infection in BAME backgrounds. Although early days this had been received well by staff.

Health and Wellbeing  -  A comprehensive health and wellbeing programme had been developed to support staff during these unprecedented times.  Every week a calendar of health and wellbeing support was available to staff.


Nightingale  -  The Trust was involved in discussions on future use of the Bristol Nightingale hospital.


Liam Coleman, Chair asked if there were plans to ease the workforce that had been deployed to other areas within the Trust back into their core specialisms.  Jude Gray, Director of HR replied that this was part of the phase 2 re- planning post COVID.


Paul Lewis, Non-Executive Director asked if it was worth a review of the short term succession planning in the context of staff having to deputise for any long absenteeism.  Jude Gray, Director of HR responded that a review had already been undertaken  at the beginning of the pandemic of the availability of the senior leadership team with a rota produced which aimed to get the balance between staff being on site/off site/rested so that as the situation changed cover was in place.


Julie Soutter, Non-Executive Director asked if a buddying system had been explored for those staff shielding to keep in touch and updated.  Jude Gray, Director of HR replied that there was no formal buddying system, however a survey monkey had gone out to staff for views and ideas to shape any further action to support staff during this time.




that the report be noted. 



Chair of Finance & Investment Committee Overview pdf icon PDF 378 KB

Andy Copestake, Non-Executive Director


The Board received and considered a report that summarised key issues considered by the Finance & Investment Committee at meetings on 23 March and 27 April 2020.  The following was highlighted:-


2019/20 Year End Position  -  The Committee were pleased to see the final 2019/20 result delivered in line with revised forecast and congratulated the Executive team for this big achievement considering the challenges through the year.


2020/21 Financial Year  -  The immediate challenge for the finance team at the beginning of the new financial year was to develop a robust process to analyse financial performance between the underlying position, funded and unfunded COVID-19 costs/impact to help maintain overall financial control.


Financial Recovery  -  CIPs were under pressure due to COVID.  Work was underway on the next phase of the financial recovery plan which was to analyse the Trust’s deficit between the structural, strategic and operational components and the part related to costs shifting.


Business Cases  -  The Committee agreed to recommend for approval the Aseptic Suite business case to the Board.


Cash  -  The Trust’s cash position was in a stronger place at the end of March 2020 and forecast over the next few month, together with a better performance in paying creditors.




that the report is received.


Finance Report pdf icon PDF 322 KB

Tracey Cotterill, Interim Director of Finance

Additional documents:



The Board received and considered a report on finance for month 12 (ending 31 March 2020).  The following was highlighted:-


·         An overview on how the Trust was currently operating under a very different financial regime in line with guidance from NHSI/E was noted.  

·         The 2019/20 year end position delivered against the revised forecast of £8.854k adverse to plan.

·         Pay costs for in March 2020 were significantly above plan due to costs associated with COVID-19, and an increase in annual leave accrual, overtime, agency and bank staff.

·         The end year cash balance was higher than plan due to a cash injection. Capital expenditure was also higher than forecast which included capital costs in relation to COVID-19.  There followed a discussion on capital funding which included clarification around the new rules on available capital money through the STPs.

·         A full asset revaluation of land and building had been undertaken.  It was noted that there was a national concern through audit of a material uncertainty clause within valuation reports which may be referenced in annual report and accounts.  However, there was no significant impact to the Trust with an overall £1.9m increase in overall asset value.

·         The Balance Sheet and Loans tables had been updated to reflect the DHSC decision to convert Interim revenue and capital loans to PDC from 1 April 2020. NHSI issued guidance that the loans to be converted should all be included in short term creditors at year end.

·         The Trust’s Finance & Use of Resources Rating had been forecast at 3 through the year, due to an improvement in liquidity. However, due to the change in national policy on Loans, the movement of debt from long term to current liabilities had moved the final rating to 4.


Lizzie Abderrahim, Non-Executive Director asked if the expectation was for the Trust not to reach its target on the Better Payment Practice Code.  Tracey Cotterill, Director of Finance replied that the national expectation was to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or valid invoice, whichever the latter.  As a result of clearing old aged creditors meant that the Trusts performance reduced.  There had been considerable work undertaken to improve and streamline processes for timely approval of invoices which had seen a steady improvement however there was still a long way to go to.


Andy Copestake, Non-Executive Director asked for clarification around the Use of Resource score and whether once the debt was converted to PDC the score would convert to 3.  Tracey Cotterill, Director of Finance responded that once the debt converted to PDC the balance sheet dramatically improved and therefore would have a beneficial impact on the liquidity metric and the score would expect to move to 3.


Peter Hill, Non-Executive Director referred to the Trust’s sensible decision to stop car parking charges, which was then mandated by the government, and asked whether the Trust anticipated any change in this policy.  Kevin McNamara, Chief Officer  ...  view the full minutes text for item 47/20


Chair of Audit, Risk & Assurance Committee Overview pdf icon PDF 147 KB

Julie Soutter, Non-Executive Director


The Board received and considered a report that summarised key issues considered by the Audit, Risk & Assurance Committee at the meeting held on 12 March 2020.  There were no further comments as a verbal update had been given at the previous Board meeting.




that the report is received.



Ratification of Decisions made via Board Circular/Board Workshop

Carole Nicholl, Director of Governance & Assurance


The Board was asked to ratify the following which had been approved via Board Circular : -


Radiotherapy Reporting    - The GWH contract for radiology reporting would expire in the near future.  Recognising the limited providers who were technically capable of delivering this service, opportunity analysis indicated that, to secure competitive pricing and improve service delivery, this contract would be approached as a joint STP procurement.


In accordance with the Trust Standing Financial Instructions and Public Contract Regulations 2015 a mini competition was undertaken through NHS Supply Chain to competitively tender the requirement for CT, MRI and X-Ray reporting across the 3 BSW STP Trusts.  Four suppliers met the minimum capability threshold and were subsequently evaluated.  Overall TMC were the highest scoring supplier. 


The proposed award would generate a cash releasing saving for GWH by working as an STP collaborative. Annually this represented £76,365 of savings for GWH. 


Terms of Reference for Great Western Clinical Ethics Advisory Group  -  It was agreed at the Board meeting on 9 April 2020 to revise the  terms of reference of the GWH Clinical Ethics Advisory Group to reflect the discussion at that meeting and approve the final version outside the meeting.




(a)   to ratify the award for the supply of radiology reporting as part of an STP contract to TMC as the highest scoring supplier following a competitive tender process; and


(b)  to ratify  the Terms of Reference for the GWH Clinical Ethics Advisory Group 2020-21.



Self Certifications pdf icon PDF 126 KB

Carole Nicholl, Director of Governance & Assurance

Additional documents:


The Board received and considered a number of self-certifications for Board approval prior to submission to NHSI/E.  The self-certifications were:-


1.     Effective systems to ensure compliance with the conditions of the NHS provider licence, NHS legislation and the duty to have regard to the NHS Constitution (condition G6);


2.     Complied with governance arrangements (condition FT4); and



3.     For NHS foundation trusts only, the required resources available if providing commissioner requested services (CRS) (condition CoS7).




that the annual self-certifications be approved.



Self Certification - Governor training pdf icon PDF 245 KB

Carole Nicholl, Director of Governance & Assurance


The Board received and considered a paper that provided an overview of the training to governors and invited the Board to approve a self-certification of compliance with training requirements.


It was noted that in addition to the training and development opportunities in this report, governors had access to the Board reports and had been provided with a very detailed welcome pack about governor specific roles and duties.


The Council of Governors meeting on 9 March 2020 had confirmed that it was satisfied with training requirements for 2019/20.




that it be agreed that the Board is satisfied that during the financial year most recently ended the Licensee has provided the necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledge they need to undertake their role.



Urgent Public Business (if any)

To consider any business which the Chairman has agreed should be considered as an item of urgent business and to note the reasons for the urgency.




Date and Time of next meeting

Date: 4 June 2020

Time: 9:30am

Venue: Trust Management Boardrooms, Trust HQ, 2nd Floor, Great Western Hospital


It was noted that the next meeting of the Board would be held on 4 June 2020 at 9:30am in Trust Management Boardrooms, Trust HQ, 2nd Floor, Great Western Hospital



Exclusion of the Public and Press

The Board is asked to resolve:-

that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest”




that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.