Public Board of Directors papers 29.09.22

Board of Directors meeting Thursday 29 th September 2022 at 12.45 pm in Trust Admin Room 6 Agenda Clinical presentation: Board to attend Patient Experience Day of Peritoneal Service following meetings of the Board.

Public items

Page

29/22 Standard business a Apologies

Chair Chair Chair

b Declarations of interest

* *

c Minutes of previous meeting – 30 th June 2022 d Action plan rolling programme, action log & matters arising 30/22 Board assurance a Quality Assurance Committee report – June 2022 b Workforce Assurance Committee report – July 2022

2

CEO 8

* * * *

11 14 17 20

Committee chair

c Audit Committee report – July 2022 d Board assurance framework

CEO

31/22 Key Reports a Trust report

* *

CEO 25 COO 32

b Integrated performance, quality & finance report

p

c EPR update

CIO

68

32/22 Any other business

Chair

Date and time of the next meeting Thursday 27 th October 2022 at 12:45pm

CEO COO CIO

Chief Executive Officer Chief Operating Officer Chief Information Officer

* paper attached v verbal p presentation

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Public meeting of the Board of Directors Thursday 30 th June at 12.45 pm Trust meeting room 6 and through virtual access

Present: Chair: Chris Outram (CO), Chairman

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

Minutes: Louise Westcott (LW), Company Secretary In attendance: Jo D’Arcy, Assistant Company Secretary

Clinical presentation: MR Linac, Professor Ananya Choudhury, Honorary Academic Consultant & Cynthia Eccles, Consultant Research Radiographer CO welcomed AC to the meeting. AC outlined what MR Linac radiotherapy is about and how treatment has developed. The use of anatomical markers was how radiotherapy was initially targeted, clinicians then moved on to the use of low energy x-ray and from there to cone beam CT, a low dose CT scan. MR imaging is a step up from CT and they give more information. The images are much clearer. If we could have this clarity when giving radiotherapy this would be a huge advantage. We now have the MR Linac which offers better soft tissue contrast, imaging before, during and after treatment and imaging of the effects and biology of treatment. The Christie is part of the Elekta MR-Linac consortium that is now global and has grown considerably. Examples of what can be done with the MR Linac were shown, radiotherapy can be even further personalised e.g. to reflect daily changes to a bladder. AC noted how resource intensive it is on the MR Linac and it wouldn’t be possible to treat the volume of our patients this way, but it will be particularly helpful for some patients. AC outlined the advances relating to oxygen in tumours. A virtual tour of the department was shown to give Board an idea of what the department and the kit looks like. CE noted the complexity of the kit and the large multidisciplinary team needed, many of whom are dedicated to this service. CE outlined the challenges. The technology is very complex, and the radiation can bend the beam and vice versa. The physicists work to overcome this. Time is also a challenge as it takes longer. Real time decisions and recalculations are being made. This is also a hybrid technology & requires

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hybrid training. Funding is also a challenge, there is no national tariff, posts are non-permanent and there are issues of implementation versus research. CE outlined the educational framework developed by the team. A ‘bootcamp’ for clinicians and fellows was described for different staff led by radiographers and physics staff. A local quality system has been developed to ensure safe delivery of treatments Accomplishments were outlined. There are 10 open clinical trails, 2 international, 3 national and 5 local. Some of the detail of the trials was described. There are also a number of PhD students and fellows. Several world and UK firsts have been achieved and these were also described. The workflow was outlined and the move to reassign tasks so that radiographers can lead and not the consultant. The level of publications was shown over the last few years to show the output. Some patient feedback shows that the patients don’t like being on the table for so long as it takes more time. The experience can be uncomfortable. However, many patients show similar feedback on this machine as on a standard machine. There is a desire to improve patient comfort and look at ways to reduce the time of the machine. CE acknowledged the great team. CO thanked AC and CE for their presentation and the pioneering work around the MR Linac. Questions were invited. KW asked at what point the evidence base gets enough for this to move from research to standard treatment. CE noted that there’s a long way to go and talked about abdominal cancers that may be able to be done on this machine. There are also a small number of publications that show reduced toxicity for other cancers and we want to follow up on this. This is probably about 5 years away. AC noted that other technologies have been implemented without level 1a evidence, e.g., protons, robotic surgery etc. NB noted that the evidence takes a long time to catch up with the advances with radiotherapy and this has always been the way. AC noted that over 50% of patients will have radiotherapy at some point in their treatment and a very small proportion of research money goes to this form of therapy. CO noted the importance of world leading research and this is a great example of this. AC invited the Board to come and have a look at the kit. Item Action 24/22 Standard business a Apologies Apologies were received from Kathryn Riddle (KR), Non-executive director b Declarations of Interest No declarations of interest noted. c Minutes of the previous meeting – 26 th May 2022 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.

RS noted that the Annual Report & Financial statements have been approved and now submitted but the value for money assessment is outstanding.

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25/22 Key Reports

a Chief executive’s report RS drew attention to the following from his report;

Situation report – covid is still a feature of this and we were in a deescalating situation, but this is changing and there is an increasing prevalence in communities now reflected in the number of covid patients in general & acute beds, approximately 10% at this time. There are also other factors including emergency pressures and elective backlog. There is no significant impact at The Christie, although there is some increase in staff absence. A collective submission has now been made for the system plan for 2022/23. There are some significant challenges, but this has been agreed. RS confirmed that the Annual Report & Accounts has been submitted and we await the auditor’s assessment of value for money to complete our submission to be laid before parliament. Clinical academic successes were outlined including JY’s appointment to a NIHR role. RS noted that some of these clinicians are considered as emerging so are very positive. TK noted the 5Live interviews yesterday. RS noted that they were broadcasting from the Trust and it was very positive. NB noted that early diagnosis is a focus, and we are well connected with local and national media around promotion of these messages and raising awareness. GP asked about how we work with primary care around this. RS noted that Manchester Cancer work in this arena with Christie clinicians who engage through the primary care networks across GM. The numbers of referrals are back to just over what they were pre-pandemic which shows that we are getting the patients through. b Clinical leadership report NB noted that this is an update for the Board and shows the changes that have been made in clinical leadership across the organisation. This shows the fit with the clinical divisions and the leadership structures within the divisions and the development of aspirant leaders for clinical staff. Next steps are also outlined with leadership at a pathway level. CO asked what issues have been addressed through this. NB noted that we have more clinical leaders at Board with Research & Education represented. Digital clinical leadership is being prioritised as well as clinical outcomes. We are also looking to further represent allied health professionals (AHP’s). GP asked about the long-term vision and where are we furthest away from our ambition. NB responded that we need to look at our reach across the wider system as clinical leaders and influencing cancer care more. The internal clinical leadership is in a good place. JM noted the development programme and asked how this is measured. NB responded that we are looking at being more controlled around how we do this and who gets opportunities, the outreach and development of further leadership outside is being focused on. KW asked how well the current structure reflects all AHPs including pharmacists, physics, radiotherapists etc. JY responded that there is clear leadership in these

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areas but not laid out in this paper. The AHPs here are therapy AHPs. BD noted that the other AHPs do align with directorate structures, but this will be further developed. RS noted that further discussion will be had on this tomorrow at the service planning day.

c Integrated performance, quality & finance report BD outlined the key points from the report for month 2.

Safe – there were no serious incidents (SI’s) and no never events, no major incident and 8 moderate incidents all of which are going through process. There are 5 risks over 15, 2 at 20 and 2 at 15. No MRSA and 7 C Diff with no lapses of care. There were 7 cases of e-coli post 48 hours and 1 covid nosocomial infections. Responsive – 16 new complaints in month and 48 PALs contacts. Average length of stay was 6.72 days and there were 2 cancelled operations on the day relating to covid. Access – 18 weeks was 98.6%, slightly down on the previous month. 62 days achieved 69.9% and this is being closely monitored, many referrals are coming in late and problem areas have been targeted, 24 days was 79.9% and there were 19 ‘104 day’ waiters, these were tracked and treated with 24 days. Referrals have returned to normal. Activity at month 2 is roughly in line with plan. Surgical operations are above and elective care are slightly behind plan. New patients & follow up’s are slightly below plan. Treatments are on or above plan for SACT and slightly under for radiotherapy. HR – PDR and essential training are improving, overall absence is back to a low level (including covid) in May. Vacancies – there’s been an increase in our establishment. Turnover rate is at around 17%, this is high. Finance  Deficit £446k compared to £439k deficit plan,  EBITDA surplus £3.7m,  I&E deficit £3.3m  Cash balance £152m  Debtor days of 14  Capital expenditure at 39% below NHSI plan  CIP - £2.4m has been identified against a plan of £11.8m Further detail was given around CIP delivery and it was noted that we are making progress on recurrent CIP. Report noted. RA asked about the activity level. BD noted that we are 4% above what we need to do and this would allow us to access additional funding. RA asked about the 62 day target. BD noted that this is being looked at but we aim to get back to 85% as this is about treating patients quickly. RA asked if there is any comeback on the system for not hitting the target. RS noted the system are required to hit a trajectory target by March 2023, we are within 10% of pre-pandemic. They are also looking at the total number of patients.

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GP asked what we are doing to address the delays in the system. BD noted that we work at pathway level and GM exec led meetings discuss this. We look at harm analysis for delayed patients both here and at other Trusts. GP asked if the delays come from particular Trusts. RS noted that there are pinch points, mainly in the 2 biggest providers in the system. There is increasing scrutiny of this at a national level and they have their own trajectories. The cancer alliance are looking to help these organisations. The main issue is delays in the diagnostic pathways. The majority of these delayed in the diagnostic stage are not cancer. There are also delays with surgical pathways. TK asked about the numbers of complaints and if these are low levels dependent on the activity levels. RS noted that it’s very low. AM asked about the categorisation of concerns and was informed that these are detailed at a local level & managed. AM asked what is worrying BD. BD answered that the 62-day target is a focus and delays for patients adds stress and needs to be avoided. RS reminded Board that only about 10% of our patients are on a 62-day pathway. Report noted. d Digital Services update CO welcomed ARP. ARP noted some highlights from the report. In the next 6 months (June- December) a draft strategy has been released that will go out for consultation and ratification. The Digital Board meet every 3 months and review the objectives. There is also a digital delivery board that looks at what has actually been done. There are some key appointments out for advert currently in the senior management team. There is a new nursing CCIO who starts next week. ARP has been working closely with the cancer alliance on their next steps. CO noted that it would be helpful for the NEDs to have an engagement session around the digital strategy. It would be helpful to discuss this at the time out on 14 th July. CH noted that there was an interim period for Digital leadership and 2 issues were discussed with Board. The first was leadership which is being sorted and the other is the development of the strategy. This further discussion will take place with Board. RS noted that the way the Board oversees Digital has been discussed and there needs to be space in the assurance committees for consideration of the risks in this. GP asked what the vision is for Digital and how this aligns to the overall strategy and what it means for patients & staff and what they will experience in the future. BD responded that this is all part of the consultation, there will be a 1, 2 and 5 year vision. KW asked if this is a clean sheet approach and asked about some elements that are in the delivery phase whereas others are not yet decided. ARP noted that some of this is driven by the HIMMS level 5 national requirement and recent funding received. CH noted that there is a programme for development of the electronic patient record or EPR (CWP). ARP noted that we have a modular EPR and there is a strategy for each module. There are different components that we build over time.

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CO noted that we look forward to more discussion in July.

26/22 Approvals

a Schedule of reservation of powers SP noted that this has been through the Audit Committee and now includes the inclusion of the additional assurance committee. Tracked changes are included. GP asked for a couple of points of clarification. Approved. 27/22 Board Assurance a Board assurance framework 2022/23 RS presented the updated BAF and noted the position against the risks to the Corporate Objectives. This has been reviewed through the assurance committees. One risk has been removed since the last meeting. RS noted that we are looking to connect this to assurance levels assigned through the committees against each risk. GP asked for a focus or programme for these risks where the current risk is well above the target risk or risk appetite. Noted. b Audit Committee Report – June 2022 GP presented the report reflecting the items discussed in the last meeting. The report gives the assurance rating and any actions or commentary relating to those items. Questions invited. None received. 28/22 Any other business No items raised. Date and time of the next meeting Thursday 29 th September 2022 at 12:45pm

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Agenda item 29/22d

Meeting of the Board of Directors - September 2022 Action plan rolling programme after June 2022 meeting

Month Sep-22

From Agenda No

Issue

Responsible Director

Action

To Agenda no

Annual reporting cycle Integrated performance & quality report and finance report

COO

Monthly report

30/22b

Annual reporting cycle Strategy refresh, corporate objectives & board assurance framework

DCEO

Interim review & update

Christie role in addressing healthcare inequalities Integrated performance & quality report and finance report

DCEO COO

Report

Monthly report Six month review Quarterly review Annual report Monthly report Six month review

October 2022

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

DoR

Workforce update

DoW

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

COO

Monthly report Annual Review

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

January 2023

CN&EDoQ

Integrated performance & quality report and finance report

COO

Monthly report

By email

February 2023 - no meeting

Annual reporting cycle Corporate planning (corporate objectives / BAF 2022/23) Annual reporting cycle Letter of representation & independence Annual reporting cycle Integrated performance & quality report and finance report Annual reporting cycle Declaration of independence (non-executive directors only) Annual reporting cycle Register of directors interests

Executive directors

Approve next year's BAF

Chair Chair COO Chair DCEO

Directors to sign Report for approval

Monthly report

For completion by NEDs

March 2023

5 year strategy 2023-29

Approve

Digital Update Workforce update

EMD/Dep CEO Update

DoW EMD

Quarterly review

Responsible Officer report

Medical Appraisal & Revalidation Annual report

Annual reporting cycle

Chair

Approve

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 2022 to March 2023

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

Review

April 2023

Review 2022/23 progress

Annual reporting cycle Annual Corporate Objectives

Modern Slavery Act update Board effectiveness review

Approve

Chairman FTSUG

Undertake survey Quarterly update

Freedom to speak up Guardian report

8

Month

From Agenda No

Issue

Responsible Director

Action

To Agenda no

COO

Monthly report

Annual reporting cycle Integrated performance & quality report and finance report

Self certification declarations

To approve the declarations Declaration / approval

EDoF&BD

Provider licence

Annual reporting cycle Annual compliance with the CQC requirements Annual reporting cycle Medical directors report - Education update

ECN DoE ECN

May 2023

Review Update

Annual sustainability report

Committee chairs

Assurance

Annual reporting cycle Annual reports from audit & quality assurance committees

COO CCIO

Monthly report Progress report

Annual reporting cycle Integrated performance & quality report and finance report

Digital update

June 2023

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

EDoF&BD

Approve

July 2023 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

August 2023 - no meeting

Integrated performance & quality report and finance report

COO

Monthly report

By email

9

Agenda item: 29/22d

Action log following the Board of Directors meetings held on Thursday 30 th June 2022

No. Agenda

Action

By who

Progress

Board review

No actions arising from the meeting

10

Agenda Item 30/22a

Meeting of the Board of Directors Thursday 29 th September 2022

Subject / Title

Quality Assurance Committee Report – June 2022

Author(s)

Company Secretary’s Office

Presented by

Committee Chair

This paper provides the board with a summary of the assurance items considered by the Quality Assurance Committee at their June meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

Background papers

Quality Assurance Committee papers 23 rd June 2022

Risk score

BAF references noted within the report

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

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.

CIO

Chief Information Officer General Medical Council

GMC

11

Agenda item 30/22a

Meeting of the Board of Directors Thursday 29 th September 2022

Quality Assurance Committee Report – June 2022

1

Introduction The Quality Assurance Committee took place on 23 rd June 2022. The following summary gives the Board information on the items that were considered, and any actions required by the Board.

2

Quality Assurance Committee agenda items The items listed below were all presented to the Quality Assurance Committee for assurance in June:

Agenda item

Associated action (where applicable) and/or comments to note No actions identified during meeting. Noted that the number of corporate key risks has reduced to 4. Questions raised in relation to progress with Digital programme; confirmed that CIO attending Board in June. No actions identified during meeting. Progress to be monitored through Committee. No actions identified during meeting. Consideration to be given to broaden the communication to the public. No actions identified during meeting. No actions identified during meeting. Consideration to be given to the use of protected characteristics data. Hand hygiene audits to take a focus and audit data to be expanded for future reports to include number of audits performed. No actions identified during meeting. Audit on clinical research facility to be covered as part of Board Time Out in July. No actions identified during meeting. Ongoing challenges with changes to

BAF reference

Assurance rating given

Briefing from the Risk and Quality Governance Committee

N/A

N/A

Quality strategy & implementation plan 2022-2025

N/A

N/A

Quality report 2021-22

N/A

N/A

Serious incident panels Q4 2021-22 Learning from deaths - Inpatient mortality reviews at the Christie 2021- 22 Infection prevention and control (IPC) annual report 2021-22

1.2 N/A

High

N/A

1.1

High

Annual clinical audit plan

N/A

N/A

Consent practice / audit

N/A

N/A

12

GMC guidance noted and discussed in detail. No actions identified during meeting.

Delivery of Chemotherapy Strategy – Christie @ Macclesfield Update Patient Safety and Experience quarterly report January - March 2022

1.4

High

1.2 / 1.3

High

No actions identified during meeting.

Learning for Improvement Bulletin

N/A

N/A

No actions identified during meeting.

The Committee Chair will note any actions required by Board and make escalations to Board as necessary.

3

Recommendation The Board are asked to note the reports received for assurance by the Quality Assurance Committee in June 2022.

13

Agenda Item 30/22b

Meeting of the Board of Directors Thursday 29 th September 2022

Subject / Title

Workforce Assurance Committee Report – July 2022

Author(s)

Company Secretary Office

Presented by

Committee Chair

This paper provides the board with a summary of the assurance items considered by the Workforce Assurance Committee at their July meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

th July

Workforce Assurance Committee papers 19

Background papers

2022

Risk score

BAF references noted within the report

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

EDG BAF

Ethnic Diversity Group

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.

Board Assurance Framework Workforce race equality standard Workforce disability equality standard

WRES WDES FTSU

freedom to speak up

14

Agenda item 30/22b

Meeting of the Board of Directors Thursday 29 th September 2022

Workforce Assurance Committee report – July 2022

1

Introduction The Workforce Assurance Committee took place on 19 th July 2022. The following summary gives the Board information on the items that were considered, and any actions required by the Board. Quality Assurance Committee agenda items The items listed below were all presented to the Workforce Assurance Committee for assurance in July. Agenda item BAF reference Assurance

2

Key points and associated action (where applicable) Detail from video noted and important that any requirement to escalate any issues to the Board on future progress noted. Culture and values in progress of being reviewed with final product due by the end of September, update to be brought back to November meeting. Key actions in place noted. Investigating managers attending EDI training. Agreed and noted on completion of audit action. Policy to be further reviewed following release of new guidance. Will be brought back to future meeting. Key points from report noted. New EDI Manager in place.

rating given

Staff story presentation – Ethnic Diversity Group (EDG) video

N/A

N/A

Director of Workforce Report

N/A

N/A

Monitoring of the Raising Concerns Policy FTSU governance and escalation procedure FTSU Audit update

N/A

N/A

N/A

N/A

N/A

N/A

WRES and WDES Progress Update Report Recruitment & Retention Final Report

7.6

High

N/A

N/A

Substantial

assurance

noted.

15

The Committee Chair will note any actions required by Board and make escalations to Board as necessary.

3

Recommendation The Board are asked to note the reports received for assurance by the Workforce Assurance Committee in July 2022.

16

Agenda Item 30/22c

Meeting of the Board of Directors Thursday 29 th September 2022

Subject / Title

Audit Committee report – July 2022

Author(s)

Company Secretary’s Office

Presented by

Committee chair

This paper provides the board with a summary of the assurance items considered by the Audit Committee at their July meeting and any subsequent actions required by the Board.

Summary / purpose of paper

Recommendation(s)

To note the report and any actions

Background papers

Audit Committee papers 21 st July 2022

Risk score

BAF references noted within report

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

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.

DoF CIO

Director of Finance

Chief Information Officer

17

Agenda item 30/22c

Meeting of the Board of Directors Thursday 29 th September 2022

Audit Committee report – July 2022

1 Introduction The Audit Committee took place on 21 st July 2022. The following summary gives the Board information on the items that were considered and any actions required by the Board. Audit Committee agenda items The items listed below were all presented to the Audit Committee for assurance. Agenda item BAF reference Assurance rating given Comments and associated action (where applicable) Audit recommendation tracking report N/A N/A 2

Good progress noted with 42 recommendations having been implemented, actions identified as follows: • Discussions to be held with Pharmacy on outstanding actions. • Comments to be added to tracker to on nearing deadlines to confirm status. • Assurance committee responsibility to be added to tracker. Key parts of the report were summarised with the following actions noted: • Update to be provided at next meeting on the tasks to be undertaken by the Counter Fraud Champion. • DoF to liaise with procurement and confirm whether any reporting on non-Purchase Orders can be completed. • Increased level of detail to support the reasoning for formal waivers to feature in the next report. Detailed discussion took place in relation to BAF risk 6.2 and 6.4. Action to circulate categorisation of risk scoring methodology for the next meeting. Update provided on investigation into technical solutions available for enhancing the registers. Detailed presentation by CIO given to the Committee. Future updates will focus on the work undertaken within the last six months against planned work.

Executive Director of Finance report

6.2

High

Board Assurance framework (BAF) 2022-23 Gifts & hospitality quarterly review 2022-23 Q1 Digital six- monthly update report

6.2, 6.4

High with clear agreed actions

N/A

N/A

6.3, 6.5

High with clear agreed actions

18

Agenda item

BAF reference

Assurance rating given

Comments and associated action (where applicable) Discussion held on how assurances are gained for key control areas within Trust policies. Question to be posed to Board to give consideration to Executive key control self- assessments. Overview of current audits discussed noting substantial assurance received on Recruitment and Retention review although some high levels of non-compliance in some areas noted.

Compliance with policies

N/A

N/A

internal audit progress report

N/A

N/A

The Committee chair will note any actions required by Board and make escalations to Board as necessary.

3

Recommendation The Board are asked to note the reports received for assurance by the Audit Committee in July.

19

Agenda Item 30/22d

Meeting of the Board of Directors Thursday 29 th September 2022

Subject / Title

Board Assurance Framework 2022/23

Author(s)

Louise Westcott, Company Secretary

Presented by

Chief Executive Officer

This paper provides the board with the Board Assurance Framework 2022/23 that summarises the risks to achievement of the corporate objectives. The cover paper gives detail of the refreshed risks for the new financial year.

Summary / purpose of paper

Recommendation(s)

To note the Board Assurance Framework (BAF) 2022/23

Board assurance framework 2021/22. Corporate objectives 2022/23, operational plan and revenue and capital plan 2021/22.

Background papers

N/A

Risk score

• Trust’s strategic direction • Divisional implementation plans • Our Strategy • Key stakeholder relationships

Link to:  Trust strategy  Corporate objectives

BAF Board assurance framework CN&EDoQ Chief nurse & executive director of quality EDoF&BD Executive director of finance & business development EMD Executive medical director COO Chief operating officer DoW Director of workforce

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.

20

Agenda Item 30/22d

Meeting of the Board of Directors Thursday 29 th September 2022 Board Assurance Framework 2022/23

1 Introduction The Board Assurance Framework (BAF) 2022/23 was presented to the Board of Directors and Quality Assurance Committee in June and Audit and the Workforce Assurance Committees in July. Further review of the BAF has taken place by the Executive team and Company Secretary since the meetings. 2 Updates to risks All risks in the 2022/23 framework have been reviewed to reflect the most up to date situation in the Trust and wider system. Updates have been made to the assurance and key controls columns for many of the risks. Where one of the assurance committees has reviewed a risk, the level of assurance they have assigned has been added into the assurance level column. Risk 2.2 Failure to deliver the Paterson building within timescale and budget, description of assurance updated and other minor changes. Risk 3.1 ‘Risk to delivery of the School of Oncology strategy’ has been rescored. This was previously scored as 8 (4/2) and is now reduced to a 6 (3/2). This risk is reviewed through the Workforce Assurance Committee. Risk 6.2 Change in financial regime resulting in inability to deliver the Trust's strategic plan, minor changes made to key controls and assurance. The target date for completion for Risk 6.6 ‘Networked infrastructure failure due to out of support computer room hardware and capacity limitations’ has been extended to November 2022 to reflect the expected date for the completion of the new data centre. This risk is reviewed through the Audit Committee. Risk 8.1 Impact on our ability to obtain planning approval for future capital developments, minor changes have been made to key controls. 3 Suggested updates There are no other suggested updates to the risks identified in the Board Assurance Framework. Consideration will be given to the allocated risks at each Assurance Committee meeting, and these have been added to rolling programmes to ensure appropriate oversight. 4 Recommendation To note the Board Assurance Framework (BAF) 2022/23 that reflects the risks to achievement of the corporate objectives and the levels of assurance given to the various risks.

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BOARD ASSURANCE FRAMEWORK 2022-23

Corporate objective 1 - To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness for those patients living with and beyond cancer

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Number

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Patients with known or suspected HCAI are isolated. Medicines management policy contains prescribing guidelines to minimise risk of predisposition to C-Diff & other HCAI's. Need to maintain low levels of Gram negative bacteraemia. RCA undertaken for each known case. Review of harm undertaken. Induction training & bespoke training if issues identified. Close working with NHS England at NIPR meetings. Clinical advisory group in place. Daily monitoing of staff / patient impact of covid cases. Following national guidance. IPC BAF presented to Board Jan 22. Monthly patient satisfaction survey undertaken and reported through performance report. Negative comments fed back to specific area and plans developed by ward leaders to address issues. Action plans developed and monitored from national surveys. Complaints and PALs procedures in place. Action plans monitored through the Patient Experience Committee Trust aim to maintain 2016/17 levels. Collaborative projects in place. All falls come through executive nursing panel process. Call don't fall initiative. Falls group. Introduction of the TAB system. Executive review group looks at attribution of avoidable / unavoidable. System for assessment of ulcers / grading used. Training across the trust (focus on theatres/critical care). NHSI criteria for assessment & expectations around pressure ulcers - internal review undertaken.Maintain low rates of catheter associated UTI's and maintain 95%+ VTE assessments. Increase in low harm Approval for the trust to further expand the management of local oncology and chemeotherapy services across GM. Focus on improved digital access e.g. appointments / ePROMs and Shared Decision Making. Chemotherapy services in locations across GM & Cheshire - strategy on track but constrained by other trusts.

Levels reported through performance report to Management Board and Board of Directors and quarterly to NHS Improvement.

Risk to patients and reputational risk to trust of exceeding healthcare associated infection (HCAI) standards

None identified. No formal threshold set by commissioners. 6

1.1

6

None identified

Averse Quality High 6 6

ECN 2 3

Year end

Failure to learn from patient feedback (patient satisfaction survey / external patient surveys / complaints / PALS)

6 Management Board and Board of Directors monthly Integrated performance and quality report. National survey results presented to Board of Directors.

1.2

4

ECN 2 3

None identified

None identified

Averse Quality High 6 6

Year end

6 Regular reports to Quality Assurance committee and board (through the integrated performance report).

4

1.3 Risk of exceeding the thresholds for harm free care indicators (falls, pressure ulcers)

ECN 2 3

None identified

None identified

Averse Quality High 6 6

Year end

Inequity of access for patients to Christie services due to delays in expanding care closer to home provision

Workforce and engagement from other trusts.

12 Reports to Management Board

8

None identified

Cautious Quality High 12 12

1.4

COO 3 4

Year end

Corporate objective 2 - To be an international leader in research and innovation which leads to direct patient benefits at all stages of the cancer journey

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Regular dialogue with national funding organisations on potential impact; open dialogue with strategic pharma partners; strong academic investment strategy to retain and attract world leading academics. Reporting to NHSE/I as and when required. Engaging in national webinars and updates. Sign up to regulators alerts - legislative changes assimilated into local processes as they arise. Any associated risks discussed and communicated. Levels of risk and mitigation reported through Research Division Board and Christie Research Strategy Committee

Oversight of potential legislative impact and consideration of any impact from COVID-19 pandemic

Risk to research profile and patient access to trials through reduced funding & changes to funding streams

8 Reports to Quality Assurance Committee

8

2.1

EMD 2 4

None identified

Cautious Quality Mediu m 8 8

Year end

10 Robust programme management (Steering Group, Finance Committee, Change Committee, Paterson Board) providing regular assurance reports to BoD

Impact of current economic environment on supply chain

10

10 10

2.2 Failure to deliver the Paterson building within timescale and budget.

EDoF / EMD 2 5 Build continues on plan and budget with established governace & reporting through board & committees.

None identified

Cautious Board

Feb-23

Corporate objective 3 - To be an international leader in professional and public education for cancer care

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Review the deliverables and prioritise in line with financial investment available. Maximise the potential of external income. Refresh the School of Oncology focus on integration of objectives with clinical and research divisions. Work with finance to review funding options, develop business cases for high priority initiatives and look at alternative funding sources. School of oncology board reports to Management Board.

Continuing inability to deliver all strategic objectives due to difficulty in accessing curent investment funds to deliver new initiatives.

Risk to delivery of the School of Oncology strategy due to restrictions of post COVID 19 financial regimes, creating strategic, financial, reputational and operational implications

6 Reporting to Workforce Assurance Committee and Board

3.1

EMD 3 2

None identified

Cautious Workforce

8 8

8

Year end

22

Corporate objective 4 - To integrate our clinical, research and educational activities as an internationally recognised and leading comprehensive cancer centre

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Key Control established

Assurance

Exec Lead

Key Gaps in Controls

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Reaccreditation by OECI . Baseline measures identified and presented to Board of Directors. Discussion at time out in March 2017. Looking at how we can be part of International Benchmarking. MCRC Strategy. Designated as the most technologically advanced cancer centre in the world outside North America. In segment 1 (System oversight framework).

Lack of evidence to show progress against the ambition to be leading comprehensive cancer centre

Availability of comprehensive data with which to compare ourselves

6 Updates to Board Time Outs / Board of Directors meetings

4.1

None identified

Cautious Board

6 6

6

DCEO 2 3

Year end

Corporate objective 5 - To provide leadership within the local network of cancer care

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Key Control established

Key Gaps in Controls

Assurance

Exec Lead

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

8 Integrated performance report to Management Board and Board of Directors. Reports to Quality Assurance Committee. 8 Progress monitored through integrated performance report to Management Board and Board of Directors. Reports to Quality Assurance Committee.

Expansion of ambulatory care models. Impemetion of the programmes to reduce LOS. Twice daily huddles. Monitor via weekly performance reports and IPQFR. Number of patients sent elsewhere reported through Exec Team weekly. Biosecurity measures regularly reviewed across the organisation. Transformation projects within OP (virtual clinics). Activity monitored daily. Planning submissions sent. Weekly review of theatre and anaesthetic schdules in place. Work continuing to develop relationships with partnering Trusts to progress the use of mutual aid.

Lack of on site capacity for Christie patients resulting in additional pressure on neighbouring organisations

COO 2 4

None identified

Averse Quality

8 8

4

5.1

Workforce

Year end

0

5.2 Non delivery of the cancer element of the GM recovery plans

COO 2 4

None identified

None identified

Averse Quality

8 8

Year end

Corporate objective 6 - To maintain excellent operational, quality and financial performance

Risk appetite (Averse / Cautious / Eager)

Gaps in assurance

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score

Responsible committee

Assurance level achieved (High / Medium / Low) Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Executive led monthly divisional performance review meetings. Integrated performance & quality report to Management Board and Board of Directors monthly. Digital Maturity board meeting monthly (includes cyber security). Escalation internally & across GM of delays impacting waiting time targets. Monitoring cancer waiting time standards through GM Cancer & IPR. Participating at national level and ICS (Greater Manchester) level to influence the new financial framework and its implementation. Development of mitigating strategies including efficiency and transformational programmes. Identification and consideration of new models of working to deliver and finance the Trust's strategic plan. CWP (clinical web portal) on stable platform. Treview of digital programme and to align ditial strategy with Service strategies. Key projects moving forward e.g.Order comms. EPMA, ePROMs, clinical outcomes. Partnership Boards in place. Review of contract arrangemnts for CPP. TCP - Internal and external auditors in place. MIAA governance audit gave significant assurance. KPI's reported via partnerhip board structure. Risk committee regular reporting on cyber security alerts established. Digital Programme progression of key cyber security improvement projects continues. Digital Board reporting. NHS Digital linked monitoring tools being deployed. Internal scanning tools deployed. External summary reports provided. Regular testing and reporting of security vulnerabilities. Staff training mandatory. Cyber incident response support established via NHS Digital. Data Centre co-location business case approved April 2021. Additional time and mitigations identified with detailed project plan working through with all vendors, will continue to be monitored through project board. Hardware ordered with indicative timescales for delivery. Further contingencies identified (with cost) within the project budget.

12 Executive Team monitor activity weekly. Integrated performance report to Management Board, Quality Assurance Committee and Board of Directors.

6.1 Key performance targets not achieved

COO 4 3

4

None identified

None identified

Cautious Audit / Quality

12 12

Year end

12 To continue to report through Managment Board and Board of Directors via financial reports and updates. Executive Team monitor activity weekly.

Changes in national funding arrangements and delegation of commissioning functions.

20

None identified

Cautious Audit

High 20 20

6.2 Change in financial regime resulting in inability to deliver the Trust's strategic plan.

EDoF 3 4

Year end

Internal capability & expertise to support system going forward.

4

4 Reports to Management Board & Board of Directors.

6.3 Digital programme unable to support delivery of operational objectives

COO 1 4

None identified

Cautious Audit

High 4 4

Year end

Not delivering the objectives of our commercial partnerships resulting in negative financial / patient experience or reputational impact

6 Close contact with partners & management of joint incidents. Regular reports to Board and Audit Committee

None identified

Averse Audit / Board High 6 6

6

6.4

EDoF 2 3

None identified

Year end

20 Data Security and Protection Toolkit submissions with audits undertaken. Digital board reporting. Board level Senior Information Risk Owner in place.

The Trust does not currently have cyber security insurance.

COO 4 5

15

None identified

Averse

Audit

High 20 20

6.5 Reputational damage, service disruption and financial loss due to cyber-attack.

Year end

Networked infrastructure failure due to out of support computer room hardware and capacity limitations.

12 Reports to Digital Maturity Board, Management Board & Board of Directors.

0

COO 3 4

6.6

None identified

None identified

Cautious Audit

High 12 12

Nov-22

23