Public Board of Directors papers 27.01.22

Board of Directors meeting Thursday 27 th January 2022 at 12.45 – 1.45pm By virtual means Agenda

Public items

Page

01/22 Standard business a Apologies

Chair Chair Chair

b Declarations of interest

* *

c Minutes of previous meeting – 25 th November 2021 d Action plan rolling programme, action log & matters arising

2

CEO 9

02/22 Key Reports

a Chief executive’s situation report

v

CEO

b NHS Regional Office’s conclusions following the Rapid Review of the Research and Innovation Division *

CEO 12

03/22 For approval a Risk Management strategy & policy 2021-24

*

ECN 60

04/22 For information a Infection Prevention & Control Board assurance framework b Integrated performance, quality & finance report

* * *

100 144 181

c Board Assurance Framework 2021/22

05/22 Any other business

Chair

Date and time of the next meeting Thursday 31 st March 2022 at 12:45pm

CEO ECN

Chief Executive Officer Executive Chief Nurse

* paper attached v verbal p presentation

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Public meeting of the Board of Directors Thursday 25 th November 2021 at 12.45 pm By virtual means

Present: Chair: Chris Outram (CO), Chairman

Kathryn Riddle (KR), Non-executive director Dr Jane Maher (JM), Non-executive Director Robert Ainsworth (RA), Non-executive Director Tarun Kapur (TK), Non-executive Director Prof Kieran Walshe (KW), Non-executive Director Grenville Page (GP), Non-executive Director Alveena Malik (AM), Non-executive Director Roger Spencer (RS), Chief Executive Bernie Delahoyde (BD), Chief Operating Officer Eve Lightfoot (EL), Director of Workforce Prof Chris Harrison (CJH), Medical Director and Deputy CEO

Prof Janelle Yorke (JY), Executive Chief Nurse Dr Neil Bayman (NB), Executive Medical Director Sally Parkinson (SP), Interim Director of Finance Prof Richard Fuller (RF), Director of Education In attendance: Cathy Heaven (CHv), Associate Director of Education

Jo D’Arcy, Assistant Company Secretary Janet Morley, Public Governor, Manchester Scott Davis, Public Governor, Salford Mike Norcross, Public Governor, Cheshire Patrick Flynn, Senior Clinical Scientist MUFT

Minutes: Louise Westcott (LW), Company Secretary Clinical presentation: The Christie @ Macclesfield Cancer Centre

Bernie Delahoyde (BD), Chief Operating Officer Stuart Keen (SK), Director of Capital & Estates Catherine Fensom (CF), Operational Management Lead, The Christie @ Macclesfield

James McGovern (JMG), radiographer The Christie @ Macclesfield Hannah Davenport (HD), Lead Chemotherapy Nurse / Unit manager Aileen Gasco (AG), Chemotherapy Sister Janet Parkinson (JP), Information and Support Manager Dr Faye Sharple (FS), Consultant Haematologist

SK gave a tour of the external parts of the Christie @ Macclesfield cancer centre development. The project was costed at £26.5m and it remains within budget and was handed over in the specified timeframes. He outlined some of the challenges caused by the pandemic in terms of delays, especially in the early stages. He noted that there are solar panels that produce considerable amounts of power on the roof of the building. Vinci have been an excellent contractor and have contributed to the local area in a positive way whilst on the project. BD introduced Catherine Fensom (CF) and noted that the unit has been designed around the patient requirements. CF noted that the design is a direct result of patient feedback, particularly in the waiting area where it has been kept light and spacious but with some semi open screens to break up the open area and provide some privacy. JMG showed the cancer information centre and the radiotherapy facilities with the prep rooms, cannulation room, CT sim and changing areas etc. The office areas and clinic rooms were also

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shown. Both linear accelerators at the centre are the same, images were shared with the meeting of the bunkers. CF showed the Systemic Anti-Cancer Therapy (SACT) treatment area. There are 16 treatment chairs in bays of 4, each bay has artwork on the walls and there is the ability to create privacy around each chair. BD and CF introduced some of the staff that will be running the centre. Introductions were made with HD, AG, JP and FS. Each member of the team introduced themselves and outlined their role in the centre. HD commented that it is an amazing space, very light and loads of privacy for chemotherapy patients. CF noted that this will be a comprehensive cancer centre and will offer a range of cancer care including haematology. CO noted the size and quality of the centre. KR noted that it really looks like The Christie and is fantastic. She asked if the corridors are wide enough for wheelchairs. CF responded that they have been made wide enough for hospital beds. JM noted that it a lovely building and asked if there is some space for staff to have downtime. BD responded that there is, this will be shown as the tour continues. TK asked if there is a full induction planned. CF noted that this is being finished off at the moment, the staff have started to visit to familiarise themselves with the centre and there is a full induction planned. CH linked the new facility with the health inequalities issues across GM & Cheshire, the unit provides excellent care to the Christie standard for the patients in this area in the same way that we do this in Oldham and Salford. GP asked about local businesses and community interest. FS noted that there are GP teaching sessions planned linking treatment in local communities. EL noted that different teams are being integrated from different organisations and this is supported by the HR team, efforts are being made to ensure the staff are connected. CF noted that staff can link into training at the main site in the seminar room to get access to everything virtually, this has got better in the pandemic. There is also a feel that the Macclesfield staff are a part of The Christie, they already have the Quality Mark and feel that connection with the Trust. The team also link in with the clinical skills team at The Christie. JP added that they are looking at how the centre links with the main site, the staff do feel like they are part of The Christie, it’s a development and continuation of the existing links. AM asked if there have been challenges in engaging the local community. CF responded that there have been some issues raised about parking and that there is a dedicated car park for radiotherapy and additional spaces at the centre. The local community have got behind this development very enthusiastically and there has been excellent support. RS noted the strong historic link with Christie teams working on the Macclesfield site. This builds on a well-developed partnership that’s very successful. It also builds on our experience in Oldham and Salford. He also noted the importance of having Haematology services on this site. RS added that there are car parking issues everywhere but one of the advantages to having this centre is around the miles saved on patient travel in having the care closer to home. There has been incredible support from charity supporters in Macclesfield, including business partners and local people as well as support from local politicians and health commissioners who have supported the project. KW asked how this feels for the East Cheshire Trust. CF responded that those employed by the Trust tend to live in the area and have had family & friends treated at The Christie and feel very strongly that this is a fantastic development for local people. It’s been very positive and really well received by the staff at East Cheshire.

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KW asked whether there will be an opportunity for those who have donated to be part of the opening of the centre. RS responded that there is a plan to do this within the current restrictions. BD noted that there will be an opportunity to provide detail on the benefits for patients through patient experience surveys etc. BD noted that this is in the business case requirements. RF noted that the School of Oncology would be interested in the centre leading education sessions and that this will be explored. Further facilities were shown including the research room, the physics room for planning, office space and the seminar room. This room will be used for health & wellbeing events, physiotherapy as well as staff training. CO noted that it is great to see education and research codesigned into the centre. CO thanked BD & SK and all the members of staff who participated for the tour and opportunity to see the fantastic new centre. Item Action 38/21 Standard business a Apologies Apologies were received from Fiona Blackhall (FB), Director of Research b Declarations of Interest No declarations of interest noted. c Minutes of the previous meeting – 28 th October 2021 The minutes were accepted as a correct record.

d Action plan rolling programme, action log & matters arising All items from the rolling programme are noted on the agenda. 39/21 Key Reports a Chief executive’s report

RS outlined the current situation report on site. We are in level 2 escalation, operating as business as usual but with a prevalence of covid as well as delivering cancer treatments. We continue to deliver treatments for patients who used to be treated elsewhere in Greater Manchester. RS noted the patient safety specialist role that is now in place in the trust and pointed to the details in the report. We are implementing a dedicated patient safety role in line with national requirements, more information will come to future meetings. RS noted the update on our developments in his report. No further comments or questions were raised. CO thanked RS.

b Integrated performance, quality & finance report BD outlined the key points from the report for month 5. Safe

• Two serious incidents and eight moderate incidents were reported in October. All the incidents are still progressing through to full root cause

analysis. No never events were reported in month. • There are seven Trust level risks scored at 15+. Responsive / Access

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• The 62 day cancer waiting time standard has not been met in October. Our position subject to validation is 83.8%. Within that performance we did achieve the internal 24 day standard with 87.7%. The large majority of breaches are shared breaches due to missing the internal target of 24 days. All 62 and 24 day breaches are reviewed to ensure delays are understood and harm is assessed. The number of patients waiting over 104 days as at the end of the month decreased. The large majority of these patients are referred to the Trust over day 100. All 31 day targets and 18 week referral to treatment standards have been achieved in October. Performance against the cancer waiting time thresholds is constantly monitored. Details were discussed at the Quality Assurance Committee in November. • There were 8 cancelled operations on the day due to a full critical care unit • Referrals in October are back at levels consistent with 2019/20. • Activity levels in most aspects are above GM recovery plans and in some areas back to 2019/20 levels. New attendances are behind 2019/20 due to a data classification problem. This issue has been resolved for September & October and a full year refresh will be reflected in the December report. Outpatient follow ups are above 2019/20 levels whilst surgical operations and radiotherapy fractions remain behind 2019/20 levels. • There were some coding issues relating to how virtual appointments were showing in the figures. This is being addressed. • The personal development review (PDR) position is under target but starting to recover • Sickness was up in month but managed without an impact on service. Effective • There have been no cases of MRSA bacteraemia and no cases of C-Difficile that were attributable to the trust in month with no lapses in care identified. • There were no cases of hospital acquired nosocomial Covid-19 infection in month. Well – Led • The trust position as at month 7 is a surplus of £1.558m against an agreed nil balance control total for the year which reflects the new GM financial arrangements in place for M1-12. • The month 7 I&E surplus is £12.509m, prior to adjusting for donated depreciation, charitably funded capital donations, donated grant income and impairments. • The cash balance is £162,776k • The Trust is showing a Capital underspend at Month 7 of £1,862k, which equates to 3.2% underperformance against the NHSEI plan and £3,733k (- 6.3%) underperformance underspend is driven mainly by underspends on the Paterson project, Macclesfield, the tiered car park and the Carbon Energy Fund and is expected to be recovered to a breakeven position in the coming months. BD invited questions. RA asked about CIP and the savings made through establishment underspend. This is non-recurrent. SP responded that we are looking at recurrent CIP and working with divisions to address CIP from 1 st April as we can manage in this year.

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SP noted that to deliver the required level of mutual aid we asked what staff we would need, this is what is in the budget. For budget setting for next year we will review all of this and may take some of these out. GP asked about high patient satisfaction but asked what we do with any poor responses. BD noted that we pick these up through incidents, complaints etc and work closely with the Quality & Standards team to respond. GP asked about the underspends and if we will have a surplus what do we do. SP noted that money is coming in with little notice so it is difficult to plan, we can reallocate at year end across the system. GP asked about the higher sickness rates in estates & facilities and whether this gets additional attention. EL noted that we know what the hotspots are and we are working with these areas with higher levels and this is managed closely with the HR team. JY noted that all patient experience and safety data is well scrutinised at Quality Assurance Committee. CO congratulated the team on the improving position on waiting times that is a massive effort. No further comments or questions raised. Report noted. c Medical directors report – School of Oncology update CH introduced RF as the new Director of Education and CHv as Associate Director of Education. RF introduced himself, he is from an academic education background. RF thanked Richard Cowan for his work so far and noted the success of the team over the pandemic. CHv noted the student placements activities. There is a push to increase the number we train due to shortages going forward. We have done this through a virtual radiotherapy placement for protons which has been well evaluated and award winning. We have been funded by Health Education England to allow a 1 or 2 week virtual placement for therapy radiography students in protons and radiotherapy. This will be broadened to over 1500 students. We have introduced a new practice educator in SACT delivery. We have specialist leads on this work alongside the University of Manchester and the School of Oncology on a SACT module to teach others how to effectively deliver chemotherapy, this will be opened up nationally and then internationally. Our education offerings relating to the PET-CT and Gateway-C training have been very successful virtually, the numbers of people using these are very impressive. The events team have converted over 80% of our education to purely virtual, the remaining 20% is highbred. They have doubled the numbers that are accessing the courses & events offered. Internationally we are supporting work in Kenya, China and Nigeria and this work is now funding a Fellow post to come and learn here. RF reflected that there’s a huge amount of energy to develop education. This is mainly about education for Christie colleagues to deliver excellent care, it is about the GM ICS and how education is supported across the system. We are also looking at education for all staff including non-clinical. Patient and public involvement (PPI) and patient education is also included. The School is recognising academic achievement but looking at outputs and

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impact is key to the future. Questions invited.

AM noted that this is very exciting and there is a lot of potential. AM noted the virtual direction is excellent. She asked about the demographics and who can be reached to come into oncology, particularly a pipeline through schools. RF responded that it is a balance, we must keep technology simple to ensure there is easier access for all. It is about simplicity and easier access, reaching out to schools in a positive way, we will be looking at getting links with schools and would appreciate input. We are looking to use existing tools to support learning e.g. Microsoft Office. CHv noted the kickstart programme, we have 12 recruits and have another 16 coming, we have a target of 60. AM noted how good this is. JM asked about the challenges between online, face to face and telephone and asked if there is enough focus on making this work. She also asked about the measures of the impact of Gateway-C and GP engagement. CHv noted that there is a questionnaire to assess impact that shows positive feedback. There is GM focused work to connect with the referrers in GM and with pathway leads so they know who they are referring to. KW noted the main purpose is to train staff, the other area is revenue driven. He also asked about apprenticeship funding and making full use of the contribution. CHv noted there is focus on both training Cristie staff and generating revenue. In terms of the apprenticeship levy we are doing OK, there’s a clinical trial coordinator apprenticeship and we are using this as well as others, we are using as much as we can currently. RF noted that education must be accessible and relevant and we want to see how it can lead to change. We could do better with certain staff groups so we must start well and get it good here in order to then offer it out. CO noted the report.

40/21 Board Assurance

a Board assurance framework 2021/22 RS noted the BAF. There are no suggested changes in month. No questions. b Staff engagement activities

BD noted the paper that outlines some of the operational engagement sessions that have been put on. The Board are asked to note this, a more comprehensive report will be brought back in a future meeting. RS noted that previously the Board could look at activities relating to executive walk rounds etc, this is an opportunity to demonstrate the alternative activities that are taking place across the organisation. A broader set of activities will be presented in a future meeting. GP noted that this is very impressive. He asked if there’s been any feeling that some of the engagement has been disproportionate in certain groups. RS responded that this hasn’t been tested but that we endeavour to reach all groups of staff including the Equality, Diversity & Inclusion groups. The network groups are very engaged and we seek their feedback more, the pandemic has made this stronger. JY noted that feedback from staff is that they find virtual sessions more inclusive.

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Its more flexible and attendance has improved. CO thanked the team for the report, noted. c Quality Assurance Committee report KW noted the report of the last committee meeting. There was extensive discussion around complaints and cancer waiting times. Noted. 41/21 Any other business No items raised. Date and time of the next meeting Thursday 27 th January 2022 at 12:45pm

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Agenda item 01/22d

Meeting of the Board of Directors - 27th January 2022 Action plan rolling programme after November 2021 meeting

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance report Annual reporting cycle Risk Management strategy 2021-24

COO

Monthly report

04/22b 03/22a

January 2022

CN&EDoQ Approve

Integrated performance & quality report and finance report

COO

Monthly report

By email

February 2022 - no meeting

Annual reporting cycle Corporate planning (corporate objectives / BAF 2022/23)

Executive directors Approve next year's BAF / note delay in planning

Annual reporting cycle Letter of representation & independence Annual reporting cycle Register of directors interests

Chair Chair COO Chair

Directors to sign Report for approval

Annual reporting cycle Integrated performance & quality report and finance report Annual reporting cycle Declaration of independence (non-executive directors only)

Monthly report

For completion by NEDs

March 2022

Digital Update

EMD/Dep CEO Update EDoF&BD Update

Annual sustainability report

Workforce update

DoW IEMD

Quarterly review

Responsible Officer report

Medical Appraisal & Revalidation Annual report

Annual reporting cycle

Chair

Approve

Six monthly compliance with NICE safe staffing guidelines

CN&EDoQ Review

Annual reporting cycle Integrated performance & quality report and finance report

COO CEO DoR CEO CEO

Monthly report

Register of matters approved by the board

April 2020 to March 2021

Annual reporting cycle Medical directors report - Research update (key issues, progress against objectives and future plans)

Review

April 2022

Annual reporting cycle Annual Corporate Objectives

Review 2020/21 progress

Modern Slavery Act update Board effectiveness review

Approve

Chairman

Undertake survey Quarterly review Quarterly update

Workforce update

DoW

Freedom to speak up Guardian report

FTSUG

9

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

Provider licence

Self certification declarations

EDoF&BD To approve the declarations CN&EDoQ Declaration / approval

May 2022

Annual reporting cycle Annual compliance with the CQC requirements Annual reporting cycle Medical directors report - Education update Annual reporting cycle Annual reports from audit & quality assurance committees

DoSoO

Review

Committee chairs Assurance

Emergency Preparedness, Resilience and Response (EPRR) annual report 2021-22

COO

For approval

Annual reporting cycle Integrated performance & quality report and finance report

COO DoW

Monthly report Quarterly review Progress report

Workforce update Digital update

CIO/CCIO/CCIO (nursing)

Jun-22

Trust Draft Sustainable Development Management Plan 2021 - 2024

DoC&E

Approve

Annual reporting cycle Annual report, financial statements and quality accounts (incl Annual governance statement / Statement on code of governance)

EDoF&BD Approve

Integrated performance & quality report and finance report

COO

Monthly report

By email

July 2022 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

August 2022 - no meeting

COO

Monthly report Six month review

Annual reporting cycle Integrated performance & quality report and finance report

Compliance with NICE Safe Staffing Guidelines

CN&EDoQ

Emergency Preparedness, Resilience and Response assurance process

Sepember 2022

Annual reporting cycle

COO CEO

Approval of compliance status Provide update to Board

MIAA audit recommendation Anti-bribery briefing

Annual reporting cycle Corporate objectives & board assurance framework

CEO COO DoR CIO DoW

Interim review Monthly report Six month review Progress report Quarterly review Annual report Monthly report Six month review

Integrated performance & quality report and finance report

Annual reporting cycle Executive medical directors report - Research review (key issues, progress against objectives and future plans)

October 2022

Digital update Workforce update

Freedom to speak up guardian

FTSUG

Annual reporting cycle Integrated performance & quality report and finance report Annual reporting cycle Executive medical directors report - Education review (key issues, progress against objectives and future plans)

COO

November 2022

DoSoO

December 2022 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

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Agenda item: 01/22d

Action log following the Board of Directors meetings held on Thursday 25 th November 2021

No. Agenda

Action

By who

Progress

Board review

No actions were raised during the meeting.

1

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Agenda item 02/22b

Board of Directors meeting Thursday 27 th January 2022

Subject / Title

NHS Regional Office’s conclusions following the Rapid Review of the Research and Innovation Division

Author(s)

Deputy CEO/Medical Director and Executive Team

Presented by

Chairman and CEO

Summary / purpose of paper

To bring the NHS Regional Office’s conclusions following the “Rapid Review of the Research and Innovation Division” to the attention of the board To confirm the action taken in relation to the R+I Division whilst awaiting the findings of the “Rapid Review” To confirm that all recommendations of the “Rapid Review” had been anticipated and addressed or are in progress ahead of receipt of the report Note the conclusions of The NHS Regional Office including that no regulatory intervention or other action is required 2. Note the comments and responses to the recommendations 3. Note the learning points arising from our experience of the past 2 years 4. To continue to revise and update policies in line with good practice 1. Letter from Amanda Doyle, NHS Regional Director 2. Report of Rapid Review Team into the R+I Division at The Christie The serious allegations carried a risk to our reputation and the confidence of patients in our services if incorrectly repeated in the media. However, The Rapid Review has found t here is no evidence of wrong doing by staff and board members of The Christie in relation to allegations of bribery and embezzlement , our clinical trials performance has been maintained in the top national category during the pandemic, our Freedom to Speak Up approach is in line with national requirements, our staff survey results and our Speaking Up Index are better than peer group benchmarks, there have been no contraventions of data protection requirements, information has been considered by the board of directors in a timely way. The board of directors is invited to: 1.

Recommendation(s)

Background Papers (Enclosed)

Risk Score

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It is acknowledged that some aspects of the internal communication and engagement of academic staff required improvement and this has been achieved Reputational Risk: Potential Impact 3 Likelihood 2 = Overall Risk of 6 Operational Risk: Potential Impact 1 Likelihood 2 = Overall Risk 2 Maintenance of our status as an OECI accredited Cancer Centre of Excellence Aspiration for our research and innovation to be competitive with the top international cancer centres BAME - Black and Minority Ethnic CCRF - NIHR Manchester Clinical Research Facility at The Christie - The Christie site of the Manchester Clinical Research Facility FTC - Fixed Term Contract FTSUG - Freedom to Speak Up Guardian HIVE - The Christie’s Intranet MCRC - Manchester Cancer Research Centre

Link to:  Direction  Objectives

Trust’s Strategic

Corporate

You are reminded not to use acronyms or abbreviations wherever possible. However, if they appear in the attached paper, please list them in the adjacent box.

R+ID - Research and Innovation Division WRES - Workforce Race Equality Standard

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Agenda item 02/22b

Board of Directors meeting Thursday 27 th January 2022 NHSEI Rapid Review

Introduction This report brings to the attention of the board of directors the conclusions of the NHS Regional Office from the report of the Rapid Review that it commissioned in September 2020 into concerns raised about the Research and Innovation Division (R+ID) at The Christie. These concerns relate to planning and leadership functions within the R+ID and at no stage have any concerns been raised about direct patient care. The letter from NHSE/I North West notes that the majority of the report’s recommendations have already been addressed and confirms that as the commissioner of the “Rapid Review” the regional office has concluded that • There is no need for any regulatory action. • There is no evidence of wrong doing by staff and board members of The Christie in relation to allegations of bribery and embezzlement. The review report, which has been approved for publication by the Regional Office, also indicates that: • The Christie’s systems and processes for supporting speaking through the Freedom to Speak Up policy up are consistent with national guidance, are appropriately reported and have been updated in the past 12 months. • The confidentiality of those raising concerns about the R+ID in early 2020 has been maintained by the Trust and the report shows no evidence of detriment to the individuals involved because of the speaking up process. • There have been significant changes to the leadership arrangements and structure of the R+ID at the Trust since early 2020 with appointment of a new R+I Director and appointment of a new Medical Director for the National Institute of Health research (NIHR) Manchester Clinical Research Facility at The Christie (CCRF). • Some specific matters relating to individual employment circumstances are being pursued through the Employment Tribunal, but the review team has found no evidence of systematic discrimination or poor practice at The Christie. • No regulatory action is needed because of the findings, but the Trust is advised to continue to update and review its policies in line with good practice. These findings are entirely consistent with the conclusions of our external auditors, Grant Thornton, who before passing approving our annual accounts in 2021 made enquiries with the then NHS Regional Director about the possible implications of the review and concluded that there was no evidence of any serious weaknesses in the Trust’s governance systems and no evidence of bribery or embezzlement as alleged by one of the people raising concerns. Other objective data about The Christie from the most recent NHS national staff survey also supports these conclusions: • Overall - we score at or better than the national average in 9 out of the 10 categories • Equality and Diversity - our score of 9.1 (out of 10) is the second highest within our benchmark group

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• Bullying and Harrassment - our score of 8.7 (out of 10) is significantly better than the national average and is the best score of all Trusts in Greater Manchester • Freedom to Speak Up Index - our score 81% is better than the national benchmark of 79% • Workforce Race Equality Standard - BAME staff at The Christie report better experience than the national average across all four measures of the Workforce Race Equality Standard. For example, 80.2% of BAME staff at The Christie believe the organisation provides equal opportunities for career progression and promotion compared to the national average of 72.9% • Workforce Disability Equality Standard - Staff with a long term condition or illness at The Christie report better experience across 6 of the 8 measures of the WDES. For example, 79.6% of staff with a long term condition or illness at The Christie believe that adequate adaptations have been made for them to carry out their work compared to the national average of 77% Objective data for our Research and Innovation Division also supports the Regional Office’s conclusions: • The staff survey scores for our R+I Division are better than the national average for 9 out of 10 of the national staff survey categories, with similar results to the rest of our organisation. For example, the R+I Division scored 10 (out of 10) for having a Safe Environment (Violence). • Throughout the pandemic we have continued to provide high levels of access to clinical trials, being in the top national category (League 1) both for number of trials initiated and reported set up times being better than benchmark cancer centres and comparable with the leading large multi-speciality teaching hospitals nationally. As with all organisations there are many things that can be improved. Regretfully, there are a small number of staff who are dissatisfied or aggrieved and whose concerns we consider carefully. However the clear conclusions of the Regional Office and the objective data based on surveys of 1500 staff in our organisation and 175 staff in our R+I Division suggest that, whilst improvements can be made, we do not have systematic problems with discrimination, bullying or respon d ing to concerns. The Board of Directors has agreed to support the report’s recommendations whilst noting the majority were already encompassed by the Trust’s existing action plan at the time of the review. The Board of Directors has also identified, based on its self-reflection, key additional learning points as set out towards the end of this paper. Because of the passage of time since the review the actions have been completed or are about to be completed, as set out in Appendix 1. There are a number of comments in the report which the Board of Directors believes are not accurate and for which the evidence base has not been provided. It would have been of great help to the Board of Directors for there to have been an opportunity to discuss these and other details in the report with the review team. Background In February 2020, a series of anonymous concerns about the R+ID were raised with The Trust through the Freedom to Speak Up Guardian (FTSUG). These concerns were assessed by the responsible director and a series of investigations initiated. These included a review by a non-executive director, an external review of the NIHR Manchester Clinical Research Facility at The Christie, a review of our discussions with a major commercial organisation (later known as the Andrew Hughes Report), external investigations into specific allegations of bullying and investigation of other grievances and issues. Together with discussions and advice from a group of senior academics that had also expressed concerns at the R+ID these activities were drawn together, over the summer period, into an agreed action plan for R+I that was approved by the Management Board and reported to the Board of Directors.

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The concerns raised in February 2020 were reported to the Board of Directors at its meeting in June 2020 as part of the Freedom to Speak Up Guardian’s regular report. Intervening board meetings had been curtailed, as had many internal meetings, in line with national direction to ensure that The Trust focussed on the operational emergency of the first wave of the COVID pandemic and was able to maintain access to cancer treatments. On 6 th August 2020, an initial response was sent, via the FTSUG to preserve anonymity, to those who had raised concerns. This reply purposefully dealt only with the initial stages of the response and, as pointed out in the covering letter, other matters including allegations of inappropriate behaviour and the review of the CRF remained in progress as part of a comprehensive response. In August 2020, those who had raised a concern expressed their dissatisfaction with the initial response. Their feedback was shared with the executive team on the 11 th August 2020. On the exact same date an individual escalated the matter to the Trust chairman in a widely circulated email which repeated some of the initial allegations and raised a series of further, more serious allegations. In view of this immediate escalation without further discussion with the FTSUG the usual practice of offering a conversation with those raising concerns was pre-empted. In response to the further allegations The Trust chairman commissioned an external review by a senior Trust chairman with a medical background from another region and asked for the audit committee to commission investigations where appropriate. The reviews were not completed and the option to speak to an executive director was not offered at this time (as would be usual practice) because of the further escalation to and intervention by the Regional Office. The Regional Office intervention came about because in August 2020, an external third party who appears to have been contacted by at least some of the staff raising concerns expressed concerns directly to the NHS Regional Office without informing The Trust. This escalation led The Regional Office to commission a “Rapid Review” and require The Trust to stop its own external investigation and the investigations of the audit committee. The Trust was not shown the specific concerns raised with the Regional Office. The Trust was also not consulted on the scope of the “Rapid Review” but was given a set of Terms of Reference which indicated the broad areas of enquiry. These and the composition of the review team, which was also not prospectively discussed with the Trust, are set out in the “Rapid Review” team’s report. In October 2020, The Trust supplied a comprehensive dossier of background information to the ‘Rapid Review” team. Interviews took place with Trust staff selected by the “Rapid Review” team during January and February 2021. The team also interviewed staff who contacted them directly through an email inbox following an open invitation to all staff. In July 2021, some of the Trust staff who had been interviewed by the “Rapid Review” team received short extracts from a draft report asking for comments. The extracts provided information suggestive of the conclusions that the "Rapid Review" team had reached but did not provide the information used to reach these conclusions in a way which made it possible to understand how the conclusions had been arrived at. The chief executive provided the requested coordinated response on 19 th July 2021 after discussion with the board of directors. This 22-page response drew attention to a range of factual errors.

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In December 2021, The Trust received a final version of the “Rapid Review” team’s report with confirmation that no serious matters had been identified and that no regulatory interventions or actions were required. In January 2022, The Regional Director wrote to the Trust with The Regional Office’s assessment of the report and provided the appended conclusions, also set out in the introduction to this report. Summary of Findings Terms of Reference 1 - How the Trust responded to the review conducted by Wendy Fisher which highlighted issues in management and culture within the R+I division in 2018 Summary of findings: The review confirms that in 2018 the R+I Division commissioned an operational review to assist in improving clinical trial set up times with the action plan being monitored through the divisional board and recommendations on wider issues being addressed in the draft research strategy. Terms of Reference 2 - How the Trust handled the review into concerns about the R+I division in 2020, including whether the people that raised concerns suffered detriment as a result of speaking up Summary of findings: The review confirms that The Trust’s arrangements for FTSU generally reflect good practice but also highlights areas in which the review team suggests that the response to the concerns raised in 2020 (corresponding to the peak of the first wave of the COVID pandemic) could have been improved. Terms of Reference 3 - How the Trust handled allegations concerning the sharing of patient data with Roche through the Foundation Medicine (FM) programme and Flatiron in and around 2018-date. Including whether people that raised concerns suffered detriment as a result. Summary of findings: The “Rapid Review” report confirms that work taking place to evaluate a potential major commercial partnership was still at the exploratory pilot stage when it was paused due to concerns raised to the Executive Team by clinicians - no business case had been approved, and no contract had been signed. The report makes no reference to the question about detriment. In response to the concerns The Trust commissioned a review and audit by Professor Andrew Hughes to learn any lessons from this experience and has reflected on and built these into policies for future programmes. Terms of Reference 4 - Whether there was a failure at the Trust to engage with clinicians in relation to commercial partnerships to ensure that: The scope and benefits were clear; The decision-making including procurement was transparent; The risks had been identified and mitigated before any agreements were signed Summary of findings: The “Rapid Review” report confirms the earlier findings by Andrew Hughes that there was extensive involvement and engagement of clinicians in the work to evaluate the potential major commercial partnership with Roche and that, furthermore, it was escalation of concerns by clinicians to the Executive Team that led the project to be paused. Terms of Reference 5 - The appropriateness of recruitment decisions within the R+I Division during this period Summary of findings: The “Rapid Review” team report confirms that although there were necessary pragmatic responses to the COVID pandemic emergency there were no evidence of inappropriate HR practices within the R+I Division. The pragmatic responses included redeployment of R+I staff to support the bio security arrangements for the site and acting up arrangements to ensure continuity of leadership. Terms of Reference 6 - In the Context of These Issues Consider What learning the Trust Should Consider and Make Recommendations in that Respect

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Summary of findings: The recommendation is for the board to review the report and assure itself with regard the Freedom to Speak Up Process, such as colleagues feeling able and supported to speak up, the board having mechanisms to hear the experiences of colleagues, and the board being held to account as a fair employer. Other comments are made but without specific recommendations. Summary of Findings on Matters Outside the Terms of Reference 1. There were differences of opinion about the historical effectiveness of the R+I leadership team at The Christie 2. The Christie has a commitment to zero tolerance bullying and harassment as demonstrated by the “Respect Campaign” 3. There is no evidence of systemic or widespread racism at The Christie 4. There was no evidence of any criminal wrongdoing including of bribery and embezzlement and as alleged publicly and repeatedly in widely circulated emails and social media by a former employee 5. The full board was made aware of concerns raised in at its meeting of September 2020. Responses to Findings and Recommendations Terms of Reference 1 - How the Trust responded to the review conducted by Wendy Fisher which highlighted issues in management and culture within the R+I division in 2018 The review confirms that in 2018 the R+I Division commissioned an operational review to assist in improving clinical trial set up times with the action plan being monitored through the divisional board and recommendations on wider issues being addressed in the draft research strategy The “Wendy Fisher” report was the result of an operational review commissioned in 2018 by the R+I Division leadership to identify ways in which trial set up times, one of the key national metrics could be further improved. In response to the report’s recommendations the R+I Divisional Board and Research Strategy Group oversaw an action plan which was then discussed at the regular performance meetings with the executive team. As it was operational in nature the report was not considered by the full board of directors. The cultural issues referred to in the Wendy Fisher report relate to reported tensions between those responsible for delivering The Christie’s substantial clinical trials and research activities and those responsible to ensuring that clinical service performance standards are met. This is common in organisations such as ours which bring together clinical service, research, and education responsibilities as part of a comprehensive service. It is something that the executive team and board of directors are very aware of and is the frequent focus of support and performance activities within the hospital. The review report implies that the identified cultural issues relate to inappropriate behaviour whereas they in fact relate to more subtle differences of view on relative priorities within operational teams. We note that the review team itself does not appear to have enquired into this matter directly but relied on the findings of the 2018 report. Historically, The Christie has performed relatively well in relation to national (NIHR) metrics for trial set up, delivery and recruitment but as a leading cancer centre we want to better our performance. Throughout the pandemic period we have been consistently in the top performance category nationally, scoring above benchmark cancer centres and at the same level as large multi-speciality teaching centres. Between July 2020 and June 2021, The Christie were in 6 th position nationally (England) in terms of the number of studies submitted (119). In terms of set-up times, the Christie took 69 days to set-up a trial and recruit the first patient, faster than peer organisations and

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comparable with the national median (68). Our newly appointed R+I Director (commenced June 2021) is leading quality improvement work to enhance performance. In response to the recommendations of the review we can confirm that: • The reports referred to in the recommendations were appropriately considered when they were produced and were considered in full by the Board Directors on 25 th March 2021 • The BoD was satisfied that all currently relevant issues were being addressed through the R+I Action Plan in place at that time. • The BoD was involved in the appointment of a new R+I Director who is leading an engagement process as part of the development of a refreshed R+I strategy and quality improvement of the R+I service. Terms of Reference 2 - How the Trust handled the review into concerns about the R+I division in 2020, including whether the people that raised concerns suffered detriment as a result of speaking up The report confirms that The Trust’s arrangements for FTSU generally reflect good practice but also suggests areas in which the review team suggests that the response to the concerns raised in 2020 (corresponding to the first wave of the COVID pandemic) could have been improved. Unfortunately, the description of the sequence of events as described by the review team has some inaccuracies on the following issues: • The range of people consulted on and involved in the decision to ask a non-executive to review the concerns raised is inaccurate - this was smaller than described in the report in order to maintain confidentiality. • The incorrect suggestion that, had they not pre-empted it by further immediate escalation, those raising concerns would not have been offered opportunities to discuss with the executive directors by the FTSUG. • The incorrect suggestion that the mechanism for the review of HR issues, behaviours, leadership and culture was the investigation of a single grievance - A wide range of activities were involved as part of an overall comprehensive approach. • The incorrect suggestion that the letter of 3rd February 2021 was distributed to “all staff” and did not contain an offer for further discussion - the letter was sent only to Trust employees who had been involved in raising concerns and we regard this feedback and communication as good practice. Although specifically asked to draw a conclusion on whether the staff members raising concerns about the R+I Division had suffered detriment as a result, the review team merely reports that “some of them believe that they suffered detriment” and does not form a conclusion on this. Whilst the review team does not identify any breach of confidentiality two of those raising concerns have identified themselves through further emails and social media activity. These issues are currently the subject of proceedings in the Employment Tribunal. Although not included in the Terms of Reference the report makes comments about Freedom to Speak Up more generally using opinions received from a general invitation to all staff to comment and not confined to the R+I division. The Rapid Review report provides anonymous data from a self-selected sample that we are unable to validate. However, data from our 2020 national staff survey shows that 72% of our staff report feeling safe to speak up about anything that concerns them (compared to the national average for specialist Trusts of 69%). Our Freedom to Speak Up Index score of 81% (compared to a national average of 79%) also suggests that our staff can raise concerns when necessary. The “Rapid Review” team noted that the Trust’s FTSU policy was consistent with national guidance and that it had been further updated ahead of suggestions made by MIAA following an audit of the previous policy. The policy was discussed with staff side colleagues and approved at Staff Forum and Local Negotiating Committee (The forums for formal agreement with Trades Unions and Professional Representative Bodies).

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