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Quality Account 2020-21

Contents Content Introduction from the chief executive State ment of directors’ responsibilities About this report Gove rnance arrangements Care Quality Commission rating Priorities for quality im provement in 2021-22 State ment relating to the quality of care provided Progress against priorities set for 2020-21 Our patie nts  Responding to an emergency  Infection prevention and control  Quality improvements  Patient experience and engagement  Our Patient Panel  Improving care for vulnerable patients  Learning from safety incidents  Improving medicine safety Our pe ople  Recognising our amazing people  The national NHS staff survey  Inclusion Our pe rformance  Participation in clinical audits  Achievements in information technology  Research and development Our place s  Improving our estate  Environment and sustainability State ments from stakeholders Glos s ary of te rms

Page 2 4 4 5 5 8 9 26 33 33 39 43 46 47 49 45 53 56 56 57 58 61 69 70 71 73 80 83

Introduction from the chief executive Welcome to our quality account 2020-21. In any look back at the last year it is necessary, and unsurprising, that at the front of our minds, and our recollections, is the huge impact that the COVID-19 pandemic has had on us all. Since February 2020, our PAHT people have experienced the most challenging period of their careers. Their hard w ork, commitment and professionalism has remained central to caring for our patients and continuing to provide high quality care throughout the toughest of times. I am so very proud of the w ay our people have risen to, and met, the many challenges that COVID-19 has presented them w ith and the w ay that they have also cared about and cared for their colleagues too. During the last year, w e have put in place many changes in the w ays we deliver care as part of our clinical response to the demands and impact of COVID-19. Often put into action at pace, these changes have, in many w ays, escalated the introduction of a range of plans for improving and modernising the w ay we work and the environment w e work in. We have made hundreds of decisions about issues w e w ould never have thought about a year ago; w e have run at more than 600% critical care capacity; w e have turned w ards to COVID-19 w ards, back to non-COVID-19 and back to COVID-19 again; w e have rolled out 1,000s of laptops for virtual outpatient appointments and home w orking. As w e face our future w e are focusing on the changes that w e will build on as w e get back to better. We are able and equipped to w ork in a more agile w ay and to continue our new and transformed w ays of working, including virtual appointments for our patients. Many of our patients have told us how helpful they find virtual appointments in terms of fitting them around their w ork and family commitments w ithout the need to travel. As technology extends, w e will be able to offer more video-call appointments and bring the benefits of a virtual face-to-face appointment to a w ider range of patients. Our new Princess Alexandra Hospital programme continues at pace as w e work tow ards the next stage and the completion of the outline business case, w hich will be submitted at the end of the year. Included in the case w ill be the new models of care that have been developed and designed by our clinicians and clinical leaders. This huge piece of w ork has taken an in-depth look at how w e deliver care and the schedule for putting this in place. The new models of care need to be active before any move to our new hospital to ensure high quality care and improvements are fully operational. The COVID-19 pandemic continues and w e remain mindful of the impact on our people and making sure they have the help and support they need in terms of their health and w ellbeing as, every day, they continue to provide high quality care to our patients and support their colleagues too. They are amazing.

I commend this quality account to you, and I am, as alw ays, grateful to the many people w ho have contributed to its content. I confirm that, to the best of my know ledge, the information in this account is accurate.

Lance M cCarthy Chief executive

State ment of directors’ responsibilities in respect of the Quality Accounts 2020-21 The trust directors are required under the Health Act (2009) National Health Service (Quality Accounts) Regulations (2010) and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual quality accounts, w hich incorporates the above legal requirements. In preparing the Quality Accounts, directors are required to take steps to satisfy themselves that: • • • •

The Quality Accounts present a balanced picture of the trust’s performance over the reporting period The performance information in the Quality Account is reliable and accurate There are proper internal controls over the collection and reporting of the measures of performance included in the Quality accounts, and these controls are subject to review to confirm that they are w orking effectively in practice The data underpinning the measures of performance reported in the Quality Accounts is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review . The Quality Accounts have been prepared in accordance w ith Department of Health guidance.

The directors confirm that, to the best of their know ledge and belief, they have complied w ith the above requirements in preparing Quality Accounts. By order of the board About this report What is a Quality Account? Every year all NHS hospitals in England must w rite a report for the public about the quality of their services; this is called the annual Quality Account. The purpose of the report is to make the hospital more accountable to you and drive improvement in the quality of our services. In 2020-21, the COVID-19 pandemic has affected how all NHS organisations provide the best possible care and service. At The Princess Alexandra Hospital NHS Trust, w e are committed to making sure that w e keep our patients and our people safe. We have been w orking hard to respond to the fast-changing national situation through our incident management team. Our focus has been to ensure w e can provide all necessary care and treatment in the safest possible w ay. This year w e w ill be providing a more concise Quality account, looking at our performance over the last year, identifying areas for improvement. Through this, w e are making our pledge to you about the improvements w e intend to make over the period 2021-22.

The report w ill tell you how w ell w e performed against the quality priorities and goals w e set for the period of April 2020 to March 2021 and the areas w e have improved through the year. It w ill also detail the priorities w e have agreed for April 2021 to March 2022. We w ill describe to you the areas w here w e have review ed our patient care in order to evaluate the quality of services provided. The report w ill contain mandated information from our Board, along w ith statements from our commissioners and partners. We w ill also provide a glossary of terms. Gove rnance arrangements Our Quality Account is prepared in line w ith the Quality Accounts toolkit guidance (201011). Additional information is included in line w ith advice received by NHS England as follow s: • • •

Details of w ays in w hich staff can speak up (including how feedback is given to those w ho speak up), and how the trust ensures that staff w ho speak up do not suffer detriment A statement regarding progress in implementing the priority clinical standards for seven-day hospital services A statement that evidences an improvement plan to reduce rota gaps for NHS doctors and dentists (Schedule 6, Paragraph 11b of the terms and conditions of service for NHS doctors and dentists in training (England) 2016)

A draft of the report w as shared internally w ith the senior management team members for peer review and w ith external stakeholders (Clinical Commissioning Groups, Healthw atch and the Health Overview and Scrutiny committees for both Hertfordshire and Essex) in early June 2021. The draft quality account is planned to be presented to our Quality and Safety Committee (a subcommittee of trust board) for review on 25 June 2021. The final draft document w ill have delegated authority for the trust Quality and Safety Committee to approve on 25 June 2021. Care Quality Commission rating The trust is registered w ith the Care Quality Commission (CQC) and w e are “registered w ithout conditions”. Our people used the CQC inspection outcomes as the foundation upon w hich to critically examine our services and focus on how we plan and deliver the fundamental aspects of safe care. We have taken decisive action to change everyday activities, w hich have led to significant improvements. The last full trust inspection conducted by the CQC w as completed in March 2019, w ith the report published in July 2019. This show ed improvements, w ith five of our core services rated as Good. We received an outs tanding rating for caring for children and young people. The overall quality rating for the trust remained the same at Re quires

Im provement. How ever, the trust received an overall rating of Good for both the w ell-led assessment and for the use of resources assessment. Table 1: The current CQC ratings received in July 2019

During the 2019 inspection, the CQC identified areas w here w e were performing w ell and had made improvements from the previous inspection in 2017, these w ere:  Saf ety incid ents reported w ell  Pain management regularly monit ored  Patients treated with compassion, kindness, privacy and dignity.  Servic es w ere inclusive and complain ts treated seriously  Posit iv e culture where staff felt respected, supported and valued  Clear vision for the trust and embedding of large amounts of change over the last three years  72% of all ratings are now ‘good’ or ‘outstanding’  Caring rated as ‘good’ for the third consecutive inspection Within this inspection report, the CQC identified areas w here the trust needed to improve performance and these w ere:  Mandatory training not completed (doctors)  In sufficient nursing staf f  Poor and incomplete record keeping  Limited audit activity (national and local)  4-hour standard f or urgent and emergency care not achieved  Slow response to issues of risk and poor perf ormance The report detailed 42 recommendations for the trust;  22 m ust do actions  20 s hould do actions

The recommendations w ere collated into individual projects based upon themes, and using our quality improvement methodology to enable a consistent and sustained approach to the achievement of these objectives. Each project has a designated executive, a senior responsible officer (SRO) and may have a small project team appointed. We are using the quality improvement plan as a dynamic document; w ith additional topics added over the year, as w e identified areas that required further improvement. The quality improvement plan is monitored monthly through the clinical quality improvement group that reports into the trust compliance group and onto the Quality and Safety Committee. 2020 The CQC undertook an unannounced w inter assurance visit to the urgent and emergency care department on 3 February 2020. Their report w as published in April 2020 and rated the service Re quires Im provement with tw o areas receiving a regulation notice:  The trust must ensure sufficient provision of out of hours endoscopy service to minimise risk of treatment delay to patients w ho require to access the service  The trust must ensure detailed up to date records are kept in relation to provision of care and treatment and it is reflective of each patient’s full clinical pathw ay and include actions taken in response to individual risks The trust implemented a quality improvement plan to address recommendations raised and strengthen the leadership team w ith the service areas. 2021 The CQC conducted an unannounced inspection of the emergency and urgent care department on 14 February 2021. Their report w as published on 27 April 2021, giving the department a rating of inadequate and the trust received a section 29A w arning notice. The concerns identified by the CQC from their inspection w ere:  Risk assessments w ere not being completed for all patients w ithin the emergency department  Not assured that patients presenting w ith acute mental health illness w ere receiving timely assessments  There w as a lack of adherence to infection, prevention and control procedures  The process for the provision of the out of hours endoscopy service for patients presenting w ith acute upper gastrointestinal bleeding w as not embedded Immediate actions w ere implemented follow ing receipt of the w arning notice, w ith further actions underw ay. We have undertaken a review of these findings across the trust, for all core services to ensure the learning is shared w idely and improves services across the w hole trust. We are confident that the actions undertaken and planned in the coming w eeks will ensure w e continue to improve the safety of patients in our emergency department.

The CQC w ill complete a further unannounced inspection of the emergency department after 1 June 2021 to monitor our progress against the action plan and w e look forw ard to the opportunity to show them the improvements w e have made. Priorities for quality im provements 2021- 2022 Our eight Quality Account priorities for the next year are identified in line w ith the quality elements of the trust five Ps strategy: w hich covers our patients, our people, our performance and our places. Our patie nts: 1. We aim to reduce the trust mortality rate (improve the Hospital Standardised Mortality Rate - HSMR), continuing w ith the w ork already started on learning from every death. This w ill improve quality of care for all patients 2. Improve our performance for timeliness of treating patients requiring emergency and urgent care. This w ill improve the quality of care and experience for our patients Our pe ople 3. We w ill improve the health and w ellbeing of our people, offering a w ide range of support so that every member of staff can recover from the effects of w orking during the pandemic, can stay w ell and feel they can meet the demands of their roles. Measures of success w ill be improved staff health and w ellbeing results in the Staff Survey from 5.5 to 5.7 and low er sickness absence rate by 1%, from 4.43% to 3.43% 4. We w ill complete an annual report to review the doctors and dentists rota gaps for staff in training roles. This w ill help w ith planning of rotas going forw ard Our pe rformance Quality improvement projects to transform services are aiming to modernise how we deliver care and improve timeliness of treatment and patient experience. These projects include: 5. Outpatie nt im provement programme: We w ill improve the use of technology and redesign of our services to enable consultations to be completed to meet the needs of our patients and our services. In some instances this w ill mean few er attendances to the hospital. Measures of success w ill include improved patient experience, reduced numbers of face-to-face consultations and freeing up clinician time to deliver acute inpatient services 6. The atre transformation: We are aiming to ensure available operating resources (including staff) are used effectively and efficiently. Measures of success w ill include reduced additional operating sessions and reduced w ork being outsourced to other providers. There w ill be evidence of reduced w aiting times for necessary operations, improving patient experience. 7. M e dicines optimisation: We are aiming to ensure that patients are involved in the decision-making about their medications and that they receive the correct medications

at the correct time. Measures of success w ill include improved patient safety, reduced w aste caused by unnecessary prescribing of medications and improved patient outcomes. Our place s 8. We w ill work in partnership to improve our hospitals and health infrastructure for our patients. Our pounds There are no objectives regarding our pounds identified w ithin the Quality Account. M onitoring progress on our 2020-2021 quality im provements These priorities w ill be monitored using our existing governance structures; this w ill include being monitored through our Quality and Safety Committee. State ments relating to quality of care provided PAHT is a 414 bedded hospital w ith a full range of general acute services, including; a 24/7 accident and emergency department (A &E), plus an intensive care unit (ICU), a maternity unit (MU) and a level II neonatal intensive care unit (NICU). During 2020-21, w e opened a new building on the main site that holds the adult assessment unit and same day emergency care unit; both w ill provide an environment and new services that w ill improve patient experience for those patients requiring urgent care. We serve a core population of around 350,000 and are the natural hospital of choice for people living in East Hertfordshire and West Essex. In addition to the communities of Harlow and Epping, w e serve the populations of Bishop Stortford and Saffron Walden in the north, Loughton and Waltham Abbey in the south, Great Dunmow in the east, and Hoddesdon and Broxbourne in the w est. The extended catchment areas incorporate a population of up to 500,000. We ow n the main hospital site in Harlow , and operate outpatient and diagnostic services out of the Herts and Essex, Bishops Stortford and St Margaret’s Hospitals. The operation of these facilities forms part of the longer term strategy of bringing patient services closer to w here people live and making services, w here appropriate, that are more accessible and easily available to patients. We operate over forty different services to meet the needs of our patients (see the service portfolio in table 2)

Table 2: Dire ctory of our services Acute medicine including ambulatory care and same day emergency care Anticoagulant and haematology clinics Audiology

Breast screening Breast surgery

Dietetics

Interventional radiology

Early Pregnancy Unit

Patient at home service

Maternal and Foetal Assessment Unit (MAFU) Ear nose and throat Maternity comprising: Antenatal clinic Antenatal w ard Birthing unit Breastfeeding support Labour w ard Petal counselling service Postnatal w ard Ultrasound scanning Emergency Maxillofacial surgery department

Perioperative care medicine

Endocrinology

Radiology

Medical oncology

Pharmacy

Physiotherapy and occupational therapy

Cardiology and cardiac End of life care catheterisation unit

Research and development

Chemotherapy

Respiratory medicine

Clinical haematology

Mortuary and bereavement services Endoscopy services Neonatal critical care including special care baby unit Frailty service Neurology

Clinical oncology

Gastroenterology

Colorectal services

General medicine

New born hearing screening Obstetrics

Colposcopy and hysteroscopy services Community midw ifery team Community neonatal team

General surgery

Ophthalmology

Speech and language therapy Surgery clinics and inpatient care Tissue viability

Genito-urinary Medicine Gynaecology including

Oral surgery

Tongue tie service

Paediatric: Ambulatory care,

Transfusion services

Rheumatology

diabetic medicine, Ambulatory care Emergency Termination of pregnancy services department Day surgery

High dependency unit

Palliative care

Dermatology

Infection prevention Pathology and control

Urology

Diabetic medicine

Intensive care unit for adults

Vascular services

Patient appliances

Trauma and orthopaedics

The review of services and all associated data is undertaken through the trust governance structure. This includes monthly meetings review ing information covering patient experience and engagement, patient safety, learning from deaths, vulnerable patients and the infection prevention and control committee and tw o monthly clinical effectiveness and compliance groups. All of these groups report monthly into the Quality and Safety Committee, a subcommittee of trust Board. Review of each services’ performance (in table 2) w ithin the trust is monitored through the Performance and Finance Committee, w ith external review undertaken by both Essex and Hertfordshire commissioners at the monthly Service Performance and Quality Review Group. Table 3: State ments of assurance from the Board

Pre scribed information

Form of s tatement

The number of different types of relevant health services provided or subcontracted by the provider during the reporting period, as determined in accordance w ith the categorisation of services:

During 20/21, The Princess Alexandra Hospital NHS Trust (PAHT) has provided a range of health services listed in the directory of services, table 2.

(a) Specified under the contracts, agreements or arrangements under w hich those services are provided or

Services are provided by the trust to Clinical Commissioning Groups (CCGs) and are usually commissioned under standard form NHS contracts. How ever, in order to support the COVID-19 response during 20/21 operating plans and normal contractual arrangements w ere suspended. Instead, a national ‘adapted financial regime’ w as in place. This reverted activity based contracts to be block contracts i.e. fixed levels of income. Block

(b) In the case of an NHS body providing services other than under a contract, agreement or arrangements, adopted by the provider.

contracts w ere supplemented by ‘top up’ and COVID-19 payments. These payments w ere agreed w ith the Integrated Care System (ICS). The above arrangements w ill remain in place until the first half year of 21/22. Subcontracted activity: During the year, the trust subcontracted a small number of services to private or other NHS providers. Services are generally subcontracted w here there is a short-term capacity constraint and the response to COVID-19 has required additional resources. Examples of subcontracted services w ere urology (day case and OPD), endoscopy surveillance, and gastroenterology and specialist clinical tests. The trust is the lead provider for musculoskeletal (MSK) services. The trust has subcontracted arrangements in place from our local mental health provider (EPUT) and Stellar Ltd, a local GP service. Subcontract arrangements are in place. Pre scribed information 1.1 The number of relevant health services identified under entry one in relation to w hich the provider has review ed all data available to it on the quality of care provided during the reporting period. 1.2 The percentage that the income generated by the relevant health services review ed by the provider, as identified under entry 1.1 represents of the total income for the provider for the reporting period under all contracts, agreements and arrangements held by the provider for the provision of, or subcontracting of, relevant health services.

Form of s tatement We have review ed all the data available on the quality of care provided by the services listed in table 2. In 2020-21, £267.8m (85%) of the total income of £315.1m w as received for patient care activities for services listed in table 2. In reality some income classified as other operating income as part of the adapted financial regime e.g. ‘top up’ (£27.5) funding related to the provision of patient care. Including

this reimbursement, 94% of income related to patient care. The most significant element of nonpatient income (£7.6m) related to provision of education and training. 2

The number of national clinical audits (a) and national confidential enquiries (b) w hich collected data during the reporting period and w hich covered the relevant health services that the provider provides or subcontracts. The number, as a percentage, of national clinical audits and national confidential enquiries, identified under entry tw o, that the provider participated in during the reporting period.

PAHT has during 2020-21 participated in 37 national clinical audits and five national confidential enquiries covering relevant health services that are provided.

2.2

A list of the national clinical audits and national confidential enquiries identified under entry tw o that the provider w as eligible to participate in.

2.3

A list of the national clinical audits and national confidential enquiries, identified under entry 2.1, that the provider participated in.

The national clinical audits and national confidential enquiries that the trust w as eligible to participate in during 2020-21 are detailed in tables 11 and 12. The national clinical audits and national confidential enquiries that w e have participated in during 202021 are detailed in tables 11 and 12.

2.4

A list of each national clinical audit and national confidential enquiry that the provider participated in, and w hich data collection w as completed during the reporting period, alongside the number of cases submitted to each audit, as a percentage of the number required by the terms of the audit or enquiry.

2.5

The number of national clinical audit reports published during the reporting period that w ere review ed by the provider during the reporting period.

2.6

A description of the action the provider intends to take to improve the quality of

2.1

During that period, w e have participated in 73% national clinical audits and 100% of those national confidential enquiries that w ere relevant and w hich PAHT w as eligible to participate in.

The national clinical audits and national confidential enquiries that w e have participated in, and for w hich data collection w as completed during 2020-21, are listed alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. The reports of no national clinical audits w ere review ed by the provider in 2020-21. See statement detailed against point 2.6 During 2020-21 the local review of national clinical audits reports w as

healthcare follow ing the review of reports identified under entry 2.5.

Pre scribed information 2.7

2.8

The number of local clinical audit (a) reports that w ere review ed by the provider during the reporting period. A description of the action the provider intends to take to improve the quality of healthcare follow ing the review of reports identified under entry 2.7. The number of patients receiving relevant health services provided or subcontracted by the provider during the reporting period that w ere recruited during that period to participate in research approved by a research ethics committee w ithin the National Research Ethics Service. Whether or not a proportion of the provider’s income during the reporting period w as conditional on achieving quality improvement and innovation goals under the Commissioning for Quality and Innovation (CQUIN) payment framew ork agreed betw een the provider and any person or body they have entered into a contract, agreement or arrangement w ith for the provision of relevant health services.

impacted by COVID-19 and w ork is now taking place to address this. Reports published during the 20/21 reporting period and their recommendations are being review ed to identify actions required to improve the quality of healthcare Form of s tatement The reports of 20 local clinical audits w ere review ed by the trust in 202021. Please see the section on infection prevention and control w here actions are detailed. The number of patients receiving relevant health services provided or subcontracted by PAHT in 2020-21 that w ere recruited into research studies during the period and approved by a research ethics committee w as 1,331. As part of the response to COVID19 and the adoption of an ‘adapted financial regime’, the basis of the trust’s income w as derived from block contract arrangements supplemented by ‘top up’ arrangements. During the first half of the financial year the ‘top up’ arrangements ensured providers met a breakeven position and w ere reimbursed for costs. This is unlike previous years w here some aspects of the trust’s income w ere predicated on delivery of quality related factors e.g. CQUIN and maternity incentive, these w ere removed.

4.1

4.2

If a proportion of the provider’s income Not applicable for 2020/21. during the reporting period w as not conditional on achieving quality improvement and innovation goals through the CQUIN payment framew ork, the reason for this. Not applicable for 2020/21. If a proportion of the provider’s income during the reporting period w as conditional on achieving quality improvement and innovation goals through the CQUIN payment framew ork, w here further details of the agreed goals for the reporting period and the follow ing 12-month period can be obtained. Pre scribed information Form of s tatement

Whether or not the provider is required to register w ith the CQC under Section 10 of the Health and Social Care Act 2008.

PAHT is required to register w ith the Care Quality Commission. The current registration status is “registered w ithout condition”.

5.1

If the provider is required to register w ith the CQC: w hether at end of the reporting period the provider is: (i) registered w ith the CQC w ith no conditions attached to registration (ii) registered w ith the CQC w ith conditions attached to registration If the provider’s registration w ith the CQC is subject to conditions, w hat those conditions are and w hether the CQC has taken enforcement action against the provider during the reporting period.

The current registration status is “registered w ithout condition”. The Care Quality Commission issued a Section 29a w arning notice against the trust during 2020-21. A robust action plan has been completed and all actions are being tracked to ensure they are completed w ithin timeframes.

Removed from the legislation by amendments made in 2011

Whether or not the provider has taken part in any special review s or investigations by the CQC under Section 48 of the Health and Social Care Act 2008 during the reporting period.

PAHT has not participated in any special review s or investigations by the CQC during the reporting period.

7.1

If the provider has participated in a special review or investigation by CQC: (a) the subject matter of any review or investigation (b) the conclusions or requirements reported by the CQC follow ing any review or investigation (c) the action the provider intends to take to address the conclusions or requirements reported by the CQC and (d) any progress the provider has made in taking the action identified under paragraph (e ) prior to the end of the reporting period. Pre scribed information

Form of s tatement

Whether or not during the reporting period the provider submitted records to the secondary uses service for inclusion in the hospital episode statistics, w hich are included in the latest version of those statistics published prior to publication of the relevant document by the provider.

PAHT submitted records during 2020-21 to the secondary user service for inclusion in the hospital episode statistics, w hich are included in the latest published data.

8.1

If the provider submitted records to the secondary uses service for inclusion in the hospital episode statistics w hich are included in the latest published data:

PAHT w as not subject to the Payment by Results clinical coding audit during 2020-21 by the audit commission. How ever, an internal clinical coding information governance (IG) audit w as undertaken by an external NHS Digital qualified clinical coding auditor. The percentage of records in the published data w hich included the patient’s valid NHS number w as: 99.7% for admitted patient care 99.7% for outpatient care and 98.6% for accident and emergency care. This included the patient’s valid General Medical Practice Code w as: 99.8% for admitted patient care; 99.9% for outpatient care; and 99.4% for accident and emergency care.

(a) the percentage of records relating to admitted patient care w hich include the patient’s: (i) valid NHS number (ii) General Medical Practice Code (b) the percentage of records relating to outpatient care w hich included the patient’s: (i) valid NHS number (ii) General Medical Practice Code (c) the percentage of records relating to accident and emergency care w hich included the patient’s:

Pre scribed information

Form of s tatement

The provider’s Information Governance Assessment Report overall score for the reporting period as per the Data Security Protection Toolkit (DSPT) grading criteria. Whether or not the provider w as subject to the payment by results clinical coding audit at any time during the reporting period by the audit commission.

PAHT Information Governance Assessment Report via the DSPT has an overall score for 2020-2021 as Standard Met. PAHT w as not subject to the payment by results clinical coding audit during 2020-21 by the audit commission. How ever, an internal clinical coding information governance audit w as undertaken by an NHS Digital qualified clinical coding auditor. Not applicable for 2020/21.

10.1 If the provider w as subject to the payment by results clinical coding audit by the audit commission at any time during the reporting period, the error rates, as percentages, for clinical diagnosis coding and clinical treatment coding reported by the Audit Commission in any audit published in relation to the provider for the reporting period prior to publication of the relevant document by the provider. 11 The action taken by the provider to improve PAHT w ill be taking the follow ing data quality. actions to improve data quality: a) a full suite of data quality reports produced daily/w eekly and circulated to operational teams for resolution of key issues b) data quality issues are monitored and addressed through the trust data quality group c) data quality updates are provided to the Performance and Finance Committee, information governance steering group and elective care operational group d) respond in full to externally reported data quality issues from NHS Digital and our commissioners The NHS Digital Data Quality Maturity Index score is 92.7% for

12.

13. 14. 15. 16. 17. 18.

(a) The value and banding of the summary hospital-level mortality indicator (‘SHMI’) for the trust for the reporting period; and (b) The percentage of patient deaths w ith palliative care coded at either diagnosis or specialty level for the trust for the reporting period. Mental health trusts Ambulance trusts Ambulance trusts Ambulance trusts Mental health trusts The trust’s patient reported outcome measures scores for: (i) groin hernia surgery (ii) varicose vein surgery (iii) hip replacement surgery and (iv) knee replacement surgery during the reporting period.

January 2021; the national average is 82% e) Conducts full user training and refresher training to support the capture and recording of good quality data, operational processes are review ed and aligned to system functionality. Furthermore, system user training guides are regularly review ed and updated f) Complies w ith the data quality standards w ithin the data security and protection toolkit g) Specialist clinical coding w orkshops to develop coders’ know ledge a) SHIMI banding 105.37 ‘as expected’ range for period Jan 20 Dec 20 (the latest data available) b) Palliative care coding w as 3.10% at either diagnosis or speciality level This is an improvement on previous years, this continues to be slightly behind the national and peer group rates. N/A

EQ5D Inde x Hip replacement: 98.40% Knee replacement: 91.30% EQ-VAS Hip replacement: 83.10% Knee replacement: 74.50% National EQ5D Inde x Hip replacement: 95.50% Knee replacement: 92.00% EQ-VAS Hip replacement: 78.80% Knee replacement: 71.70%

19.

20.

The percentage of patients aged: (i) 0 to 14 and (ii) (ii) 15 or over Readmitted to a hospital that forms part of the trust w ithin 28 days of being discharged from a hospital that forms part of the trust during the reporting period.

It has been acknow ledged that an error w as made in the drafting of the regulations and that the split of patients for this indicator should be (i) % of 0 to 15 years readmitted w as 6.7% (ii) 16 years and over readmission rate w as 10.3% The regulations refer to 28-day readmissions rather than 30.

Prescribed information

Form of statement

The trust’s responsiveness to the personal needs of its patients during the reporting period.

PALS responded to 10.4% more cases in 2020-21. The patient advice and liaison service is our first contact and point of care resolution service and in total responded to 3467 cases (against 2827 in the previous year, a 22% increase).

21.

The percentage of staff employed by, or under contract to, the trust during the reporting period w ho w ould recommend the trust as a provider of care to their family or friends. 21.1 Friends and Family Test – patient. The data made available by the National Health Service Trust or NHS Foundation Trust by NHS Digital for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from accident and emergency (types 1 and 2)

23.

Please note: there is a not a statutory requirement to include this indicator in the Quality Accounts reporting, but provider organisations should consider doing so. The percentage of patients w ho w ere admitted to hospital and w ho w ere risk assessed for venous thromboembolism during the reporting period.

The Staff Friends and Family test did not run during 2020-21.

The staff friends and family test w as not conducted during 2020/21.

Data for period April 2020-December 2020 show s PAHT: 98.28% National: 95.47% Data for Q4 is not available as the trust moved to a new server and the programme w as being rew ritten.

24.

Pre scribed information

Form of s tatement

The rate per 100,000 bed days of cases of C.difficile infection reported w ithin the trust amongst patients aged 2 or over during the reporting period.

There w ere 43 hospital onset cases of Clostridium Difficile reported to the national surveillance database for April 2020-March 2021. Rate per 100,000 bed days as 30.76 (based on our ow n Trust data. This information has not been published for 20-21 by PHE)

25.

The number and, w here available, rate of patient safety incidents reported w ithin the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death.

April 2020 to March 2021: The total number of incidents w as 10226 w ith 6902 for patients. Severe harm incidents: 23 (0.33%) Death incidents: 93 (1.34%) of w hich 83 w ere hospital onset COVID-19 infection cases. The National Reporting and Learning System (NRLS) show s during the reporting period, the trust’s severe and death incidents is below 1%, w hich is in line w ith the national average. Due to the pandemic and the nationally recognised issue of hospital onset COVID-19 infection, there has been an increase in reported death incidents from below 1% to below 1.7%.

Statement on seven day hospital services - During 2020/21, the regular selfas a trust w e are w orking tow ards assessment reports that the trust implementation of seven day services. completed and submitted to NHSI w ere not required. Update from NHSI states: The 7-day service programme and service improvement support ceased w hen NHS E/I came together. There is no longer a national programme or meetings.

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27.1 The number of its patients w ho have died during the reporting period, including a quarterly breakdow n of the annual figure.

From 1 April 2020 to 31 March 2021, 1,341 of The Princess Alexandra Hospital NHS Trust patients died. This comprised the follow ing number of deaths each quarter: Quarter 1: 375 Quarter 2: 216 Quarter 3: 338 Quarter 4: 412

27.2 The number of deaths included in item 27.1 By March 2021, 497 case record w hich the provider has subjected to a case review s and 18 serious incident (SI) record review or an investigation to determine investigations w ere raised in relation w hat problems (if any) there w ere in the care to 1,341 deaths (item 27.1). provided to the patient, including a quarterly The number of deaths in each quarter breakdow n of the annual figure. for w hich a case record review or a serious investigation w as carried out w as: Quarter 1: 236 case record review s 18 SI investigations Quarter 2: 109 case record review s 3 SI investigations Quarter 3: 104 case record review s 31 SI investigations Quarter 4: 48 case record review s 31 SI investigations During Q1, 16 serious incidents w ere nosocomial COVID-19 related deaths that w ere investigated as part of an aggregated serious incident report. All of these deaths had an SJR completed; none w ere deemed to be an avoidable death (due to the patient comorbidities and frailty), how ever there w as other learning taken. During Q3 and Q4, 31 Serious Incidents in each reporting period w ere nosocomial COVID-19 related deaths and w ere investigated under one aggregated report.

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27.3 An estimate of the number of deaths during the reporting period included in item 27.2 for w hich a case record review or investigation has been carried out w hich the provider judges as a result of the review or investigation w ere more likely than not to have been due to problems in the care provided to the patient (including a quarterly breakdow n), w ith an explanation of the methods used to assess this.

7 cases [0.52%] of the patient deaths during the reporting period are judged more likely than not to have been due to problems in the care provided to the patients. In relation to each quarter, this consisted of: Quarter 1: 1 - [0.07%] 1 investigation remains in progress Quarter 2: 1 - [0.07%] 2 investigations are still in progress Quarter 3: 1 - 1 [0.07%] Quarter 4: 4 - [0.29%] Cases referred for a structured judgment review (case record review ) have data captured on an electronic system called Clarity. All of these cases are rated w ith an avoidability rating of: Score 1: Definitely avoidable Score 2: Strong evidence of avoidability Score 3: probably avoidable (more then 50:50) Score 4: Possibly avoidable, (less than 50:50) Score 5: Slight evidence of avoidability Score 6: No evidence of avoidability The seven cases have had an avoidability score of tw o on SJR. All cases that receive a score of one or tw o are referred for: - a review by the trust’s learning from deaths panel - are logged on Datix as an incident and investigated - w ill be review ed by the trust’s Incident Management Group - The investigation w ill identify any learning, an action w ill be

completed and monitored by the relevant healthcare group - Are reported to the clinical commissioning group (CCG) Form of s tatement

Pre scribed information 27.4 A summary of w hat the provider has learnt from case record review s and investigations conducted in relation to the deaths identified in item 27.3.

The majority of learning identified has been in relation to nosocomial COVID19 from both the first and the second w ave of the pandemic, this includes: - The trust has implemented the 10 key actions for infection control published by NHS England (NHSE) - A robust testing pathw ay is core to ensuring that patients are on the correct pathw ay and that staff w ho are COVID-19 positive are identified - The flow of information in relation to patients being transferred from one COVID-19 pathw ay to another betw een clinical team members and the site management team needs to be strengthened - High standards of infection prevention and control including the w earing of personal protective equipment (PPE) must follow the standards detailed in the trust guidance - The number of bed moves has reduced since the first w ave 27.5 A description of the actions w hich the - Lateral flow testing is now in place provider has taken in the reporting period, in the emergency department and proposes to take follow ing the reporting (ED) w hich is helping stream period, in consequence of w hat the provider emergency admissions into red has learnt during the reporting period (see and amber pathw ays earlier in item 27.4). their admission - Lateral flow testing biw eekly is in place for all frontline staff - A simplified testing pathw ay has been introduced from 25/1/21 - Perspex screen installation is in progress to bed spaces w here beds cannot be tw o metres apart

Most visiting w as virtual as special case exemptions w ere in place - PPE competency and audits of compliance are being undertaken to ensure staff know ledge and compliance - There is a continued focus on reducing the number of bed and w ard moves Form of s tatement

Pre scribed information 27.6 An assessment of the impact of the actions described in item 27.5, w hich were taken by the provider during the reporting period.

Reduced length of stay in ED for patients w aiting to be admitted to w ards due to lateral flow testing in ED - started 31/11/2020. Reduction in asymptomatic staff shedding due to lateral flow testing for staff bi-w eekly Perspex screen installation to maximise the tw o metre social distancing guidance, thus reducing cross-contamination Virtual visiting minimised cross-contamination w ithin the hospital setting PPE compliance audits demonstrated improvement in use of PPE. PPE champions w ere implemented. Bed move reduction w as apparent in w ave tw o, minimising cross-contamination

27.7 The number of case record review s or Four case review s and investigations investigations finished in this reporting period w ere concluded for incidents taking w hich related to deaths during the previous place in 2019/20. reporting period but w ere not included in item 27.2 in the relevant document for that previous reporting period (2019/20). 27.8 An estimate of the number of deaths included Tw o deaths harm cases w ere in item 27.7 w hich the provider judges as a confirmed follow ing investigation and result of the review or investigation w ere w ere more likely than not due to the more likely than not to have been due to problems in the care provided. problems in the care provided to the patient, w ith an explanation of the methods used to assess this.

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27.9 A revised estimate of the number of deaths during this reporting period stated in item 27.3, and for that previous reporting period, taking account of the deaths referred to in item 27.8.

The total number of deaths is seven detailed in 27.3 and 2 in 27.8, making a total of nine.

There are a number of w ays in w hich our people can speak up or raise concerns, either as an individual, or as a w itness. Avenues for raising concerns include:  The trust Freedom to Speak Up Guardians  Staff side  The people team  The guardian of safer w orking  Our staff netw orks and inclusion champions

In response to the Gosport Independent Panel Report, provide details of w ays in w hich staff can speak up (including how feedback is given to those w ho speak up) and how w e ensure staff w ho speak up do not suffer detriment. This disclosure should explain the different w ays in w hich staff can speak up if they have concerns over quality of care, patient safety or bullying and harassment.

In all instances, the individual is advised on both informal and formal options of how to proceed w ith their concern, and a w ay forw ard agreed w ith them in order to reach a resolution. Annual surveys including the Staff Survey and Staff Friends and Family Test enable us to identify key themes and that action plans are developed w ithin the healthcare groups to respond to these key themes. These action plans are monitored and review ed throughout the year.

Follow ing the terms and conditions of service The trust did not complete an annual for NHS Doctors and dentists in training report in 2020/21, due to COVID-19 (England) 2016 requires a consolidated priorities. We have a plan to complete annual report on rota gaps and the plans to a report for 2021/22. reduce rota gaps.

Priorities we set for completion in 2020/21 1. Our patie nts To reduce mortality, improve HSMR and improve our patients’ experience. Our patie nts: Aim : To reduce trust mortality rate (improve Hospital Standardised Mortality Rate - HSMR), and continue w ith the w ork already started on learning from every death. Outcom e: This objective remains ongoing PAHT has show n significantly high HSMR since November 2016. The relative risk score of 118.5 show s the data for the most recent 12 months available up to September 2020, figure 1 below . While the previous months show special cause improvement, this should be taken w ith caution, as the trust is still a significant outlier in our HSMR.

As a result of changes to data submission requirements, the trust information affecting HSMR and SHMI from September 2020 to date is not accurate. We anticipate the HSMR and SHMI data to be corrected from August 2021 onw ards. Sum mary Hos pital-level M ortality Indicator (SHM I) The most recent SHMI value is 1.038 (data available covers period up to July 2020 in figure 2 below ). We have not alerted since April 2019.

There are five diagnostic groups that are significantly higher than expected (HSMR only):  COPD and bronchiectasis  Senility and organic mental disorders  Septicaemia (except in labour)  Acute and unspecified renal failure  Fracture of neck of femur (broken hip) Phase 1 in our implementation of the SMART database w as delayed due to technical issues, including extra development requirements by the information team to ensure data can feed straight into the system. This issue has now been resolved and the team expect the system to go live by the end of June 2021. Our current contract w ith our existing supplier is due to expire in July 2021. Once the system implementation has been completed, the team w ill move onto the development and enhancement of the learning from every death and mortality dashboard, incorporating all of the know ledge and w ork that has taken place so far, including the external review . Our patie nts Aim : Improve our performance for timeliness of treating patients requiring emergency and urgent Care Outcom e: This objective remains ongoing

The urgent care attendances during the year have been atypical of an average year, w ith the w aves of COVID-19 resulting in reduced attendances for people w ith other conditions; how ever attendances in March 2021 have show n an increase to pre-COVID-19 w inter levels. The emergency department rapidly created a respiratory emergency department to take COVID-19 attendances and ensure segregated non-COVID-19 urgent care services. During the majority of 2020 the trust maintained performance against the four hour standard, (figure 3 below ) ahead of the national average, how ever in the w inter and early 2021 the increased COVID-19 admissions

created huge pressure on bed capacity and the urgent care departments w ere unable to place patients on w ards quickly to maintain the 4 hour standard. This also then affected the ambulance handover performance and patients w aited longer for handover to the emergency departments, figure 4 below . The Rapid Assessment Treatment (RAT) pathw ays continued to be in place over the year but staff absence due to COVID-19 affected the number of RAT teams available for this pathw ay. We have continued to w ork w ith our system partners to further develop streamlined services that can be delivered in the most effective location and to prevent attendances and admissions to hospital. The local delivery board has continued to forge close w orking relationships across organisations and enabled improved service provision such as increased intermediate care capacity and patient at home support for patients w ith existing care packages. The opening of the adult assessment unit and same day emergency care in addition to improvements in the frailty unit has enhanced patient experience.

The trust has continued to focus on reducing long length of stays for patients through collaborative w ork w ith the community across the ICS. The length of stay of COVID-19 patients directly impacted the overall non-elective length of stay, particularly as each pandemic w ave show ed different average lengths of stay. Our pe ople Aim : To improve nurse staffing levels by reducing vacancies Outcom e: Achie ved In 2020-21, w e continued to reduce our nurse vacancy rate, reaching 7.2% by March 2021 (from 26.8% in April 2019). Recruitment of band 5 nurses w as extremely successful w ith 32 nurses recruited follow ing student placements at the trust and by grow ing our ow n registered nurses w ho have undertaken an apprenticeship programme from being healthcare support w orkers to registered nurses. In addition, w e w elcomed 81 international nurses despite restrictions on global travel due to the pandemic, all of w hich contributed to a band 5 vacancy rate of 5.8% in March 2021. Our nursing w orkforce establishments w ere uplifted in October 2020 follow ing an establishment review , w hich increased the overall number of established nursing posts by 23.64WTE, and band 5 posts by 34.27WTE. It is w orth noting that w ithout the increase in establishment the overall nurse vacancy rate w ould have been 4.8%. Turnover rates have continued to reduce and w ere 8.65% in March 2021 from 10.53% in April 2020. Our pe rformance Aim : Quality improvement projects to transform services including our outpatient im provement programme to reduce face-to-face consultations through better use of technology and redesigned

services. Measures of success w ill include improved patient experience, reduced numbers of faceto-face consultations and freeing up clinician time to deliver acute inpatient services. Outcom e: This objective remains ongoing Telemedicine was rolled out rapid ly, using the Attend Anyw here platform, as part of the national response to COVID-19 in April 2020, w it h 70% of specialt ie s on-boarded to use the system. Template le tters and processes establishe d to support the delivery of telemedicine. We are now engaging w ith operational teams to identify opportunities to increase non-face-to-face capacity, in line with new hospital ambitions. Patient initiated follow up (PIFU) allow s patients to determine w hether their condition requires clinical intervention and allow s access to the specialist w hen it is needed. In turn, this reduces the number of follow -up appointments needed. The first pilot w as for fracture and w ent live on 22 February 2021 and as at 25 March 2021, 38 patients have been discharged onto this pathw ay. Prior to PIFU, these patients w ould have been booked for a follow -up appointment. Plans are in place for a pilot in our neurology clinics to go live on 12 April 2021. We w ill be w orking w ith specialties to determine the roll out plan for PIFU across the trust. Doctor Dr w as introduced and enabled paperless communic at ion f or patients. A text message generates a link for correspondence to be viewed. This is in place f or all appointments in outpatients w ith outcome letters due to go live in April 2021. There has been a 71% uptake of patients choosin g to view their letters electronically, w hich has both cost savings, due to reduction in postage, and environmental saving, less paper used. We moved away from a one-w ay messaging flow provider to a new provider enablin g tw o w ay messaging w ith our patients. We have gone liv e w ith paediatric and paediatric diabetes as a tw o w ay messaging flow f or appoint me nts. Other main outpatient services w ill be live by October 2021 and pilots are due to commence for gynaecology electiv e activity in April before roll out to all electiv e activity. Our pe rformance Aim : Quality im provement projects to transform services including theatre transformation to ensure available operating resources (including staff) are used effectively and efficiently. Measures of success w ill include reduced additional operating sessions and reduced w ork being outsourced to other providers. There w ill be evidence of reduced w aiting time for necessary operations , so improving patient experience. Outcom e: This objective remains ongoing. The development of a QlikView dashboard to show performance in theatres to help identify opportunity for improvement w as completed and w ent live on 15 September 2020. This development w ill support focus for the surgical teams to improve theatre utilisation to achieve 85% utilisation by March 2022. The focus is now on improving utilisation w ithin three clinical specialties, ophthalmology, ENT and maxillofacial. If w e reach 85% w ithin these specialties, it w ill increase the trust’s utilisation by 10%.

Our pe rformance Aim : Quality im provement projects to transform services, including medicines optimisation to ensure that patients are involved in the decision making about their medications and that they receive the correct medications at the correct time. Measures of success w ill include improved patient safety; reduced w aste caused by unnecessary prescribing of medications and improved patient outcomes. Outcom e: Im provement partnership programme is ongoing but m any projected achieved in ye ar The ‘Improvement Partnership’ is our programme for enrolling, engaging, involving and developing our staff in quality improvement. The quality first team runs leading change and leading projects learning and development sessions w ith the objective of enabling them to deliver successful quality improvement projects. When the staff member completes a quality improvement project (capturing project outcomes in poster), they become PAHT improvement partners: The improvement partnership is an enabler addressing the leadership, culture and organisational development required to embed quality improvement at PAHT. We continue to develop our people w ith quality improvement skills, know ledge and capability w ith a focus on leading change and leading projects. 385 staff members have completed leading change, w ith 198 completing leading projects. We now have 52 improvement partners at PAHT. Im proving patient outcomes Our w ork to improve outcomes (mortality rates and unw arranted variation of care) for our patients has continued throughout the COVID-19 pandemic. Original plans w ere amended as many of the clinical and operational leads had to prioritise supporting our response to the pandemic; how ever, there are some notable achievements from the previous year. Every specialty has a clear clinical strategy in place and a big part of delivering these w ill address unw arranted variation in care and ultimately improve patient outcomes. A significant milestone achievement for the trust w as being able to provide non-invasive positive pressure ventilation in our respiratory w ard in addition to critical care. We know beginning noninvasive positive pressure ventilation quickly can improve patient outcomes, reduce length of stay in hospital and reduce the need for admission to critical care. Thank you to the respiratory, Locke Ward, critical care, emergency department and clinical site teams for their support w ith developing the pathw ay. 2. Our place s Improve our clinical areas and critical functions Our place s Aim : Working in partnership to improve our hospitals and health infrastructure

Outcom e: Achie ved During 2020/21, w e have continued to develop our Outline Business Case for the new hospital, w ith the aim of submitting it to regulators in October 2021. The process requires that w e look carefully at all the options, including w hat could be done on the current site. The trust’s preferred w ay forward remains a new build on a greenfield site, as this offers the best value for money and full alignment to our strategy. Betw een January-March 2020, the trust built its new hospital programme team consisting of a clinical leadership team, full project management office (PMO), health planners, and design team. Over 2020/2021 the new hospital programme team have w orked tirelessly to deliver the follow ing elements of the Outline Business Case:  A full demand and capacity modelling exercise determining the predicted population grow th and capacity required over the next 20+ years  A fully developed integrated and innovative model of care fit for the next 20+ years  An ambitious digital strategy illustrating how the trust w ill become the most technically advanced hospital in the country  A net zero carbon strategy for the new hospital  A set of clinically designed 1:200 layouts for each department in the hospital that w ill support the delivery of care for the foreseeable future During the last year, w e also have undertaken a w ide range of engagement w ith internal and external stakeholders. Several public and staff focus groups w ere held in Summer 2020 to feed ideas into our design brief, follow ed by the launch of our new hospital microsite. Our communications and engagement strategy w as approved in November 2020 w ith (to date) over 70 meetings, reaching nearly 500 stakeholders helping shape that strategy and subsequent development and roll-out of our action plan. We have:  Run briefing sessions w ith all councillors at district and county level  Regularly briefed our local MPs  Held patient engagement meetings in partnership w ith East and North Hertfordshire Clinical Commissioning Group and West Essex Clinical Commissioning Group  Met youth w orkers and the Youth Essex Assembly to develop a programme of engagement activities specifically for young people  Held a w orkshop w ith young people w ith learning disabilities at Harlow College  Led discussions w ith Ghana Union Harlow , Harlow Voluntary Sector Forum and more We ran tw o virtual tow n hall events in early 2021, attended by over 220 people, w ith 95% rating our second event as excellent. The events w ere promoted extensively and w e secured a lunchtime slot on BBC Look East on 4 February. Over 230 people completed our online survey on the new hospital w elcome space; w e have also run several polls to gauge public opinion; had nearly 2,000 hits on our new hospital questions page, and have introduced a regular email new sletter w ith an open rate of up to 68%. We have also been active on social media and to date have received over 125,500 view s of new hospital content across all channels.

We continue to hold regular virtual briefings for our PAHT people and have a monthly page in the staff magazine, InTouch. We have also installed promotional graphics in the w elcome space and canteen, run promotional content on on-site digital screens, and have held over 150 hours of design w orkshops w ith more than 350 clinicians and staff to drive our new hospital design requirements. The Outline Business Case w ill be submitted to national regulators in October 2021 and w e aim to begin construction on the new hospital site by 2023, w ith full opening by early 2027.

Our patie nts Re s ponding in an e mergency Throughout 2020-21, the resilience team focused predominantly on supporting colleagues across the organisation w ith the response to the COVID-19 pandemic. The response to COVID-19 has not been w ithout its challenges; how ever, our people have gone above and beyond to demonstrate their ability to respond to challenges in a safe, coordinated and effective manner to ensure that our patients receive the best possible care. From the end of January 2020, a full ‘command and control’ structure w as implemented to ensure a robust response to w hat has been at times a rapidly changing situation. This structure comprised a Strategic Command Cell, w ith tactical cells managing operational response, clinical response, infection prevention and control, supporting our people, communications response and the management of our estate and infrastructure. Along w ith our internal w ork, w e recognise the importance of multi-agency w orking, and continue to actively engage in the w ork of the local health resilience partnership, the Essex Resilience Forum and local organisations w ithin our care system to provide a coordinated approach to emergency preparedness, resilience and response. As required nationally, w e undertook an assessment against the NHS England emergency preparedness, resilience and response core standards for w hich we were able to provide full assurance to NHS England. The coming year w ill see us w orking alongside our partners and a range of other organisations, as w e face the continued challenges posed by the COVID-19 pandemic, and our w ork to recover, identify learning, and restore our services, in a w ay that reflects a dramatically different w ay of w orking. Infe ction prevention and control At PAHT, our infection prevention and control (IPC) programme w as in place w ell before our first COVID-19 admission on 15/03/20. The IPC programme w as supported and escalated using the trust ‘command and control’ structure, as the pandemic evolved. Numbers of COVID-19 positive inpatients are listed below in table four from the dates stated until 31/03/21.

Table 4: COVID-19 data up to 31-03-21 Total inpatient spells (w ith a positive sw ab): Inpatients (positive) - on 31 03 21: Inpatients (previously positive) - on 31 03 21: Discharged home (w ith a positive sw ab in spell): Discharged other (w ith positive sw ab in spell): Inpatient deaths (w ith positive sw ab in spell): Transferred (w ith positive sw ab in spell):

Inpatient spells since: 01 02 20: First w ave 01 09 20: Second w ave 2069

1542

1249

1018

529

330

210

135

Figure 5:

The above graph show s the number of new positive inpatients by day, and also the total cumulative number of positive patients admitted. The prevalence and transmissibility of the virus has meant staff and other patients in the hospital became infected w ith the virus in many NHS settings. Table 5: Numbers of nosocomial COVID-19 01/04/20 – 31/03/21 Patients testing positive for the first time 3-7 days after admission (indeterminate cases) Patients positive for the first time 8-14 days after admission (probable nosocomial infection) Patients positive for the first time >15 days after admission (definite nosocomial infection)

at PAHT, using national definitions Q1 Q2 Q3

 Cases are ‘indeterminate’ as it is possible these are community acquired and not hospital associated cases.  It is likely patients had the more transmissible Kent variant in Q3 and 4, as nosocomial infection rose steeply despite outbreak control measures. A variety of strategies w ere put in place to manage patients admitted w ith SARS CoV2 and control COVID-19 infections at PAHT. The trust board supported this.   

The executive team had access to national and regional support and feedback, provided visible leadership and chaired all trust meetings There w as acceleration of coordination, planning, monitoring, training including infection prevention and control training, staff resource and finance 27 COVID-19 associated outbreaks w ere noted in the trust from 01/04/20 to 31/03/21; 22 associated w ith clinical areas and five w ith non-clinical areas. Regular reporting to East of England regional leads took place.

What w e le arnt and changes implemented to manage COVID-19 Changes made in March 2020 to the w ay the organisation and the IPC team functioned continued throughout 20-21. The IPC cell, clinical cell, people cell, and strategic cell shared decision making w ith the incident management team for onw ard action throughout the trust. A variety of strategies w ere put in place to manage patients admitted w ith SARS CoV2 and control COVD-19 infections at PAHT.  There w as acceleration of coordination, planning, monitoring, training including IPC training, staff resource and finance  Risk communication, operational support and logistics, and supply chains w ere optimised  CCG and Public Health (Essex Health Protection Unit) engagement w ith the IPCT and executive team occurred on a regular basis  Data management (COVID-19 data, mortality, operational data), IT support and remote w orking w as facilitated throughout the year  Constant review of national guidance took place w ith adherence in all aspects of IPC including uniform policy, linen and w aste disposal  Improvements in treatment regimens, national trial data availability, oxygen supplies, and communication, meant that overall patient management and staff support during the second w ave improved  In order to reduce staff sickness and staff outbreaks, close contact betw een staff w as minimised at w orkstations, w ard rounds and handover sessions, moving to ‘virtual’ multi-disciplinary meetings, and staggering staff breaks  Mortality review s of all probable and definite nosocomial COVID-19 cases took place. This helped us learn lessons and implement improvements in practice such as minimal w ard transfers

We appointed ten personal protective equipment (PPE) safety marshals to w ork alongside the IPC team to support and monitor the PPE programme and to w ork w ith our people to improve practice. Other IPC measures continued including:  respiratory segregation and respiratory etiquette  Polymerase chain reaction (PCR) testing of inpatients every 48 hours for COVID-19, to detect cases early  w ard cleaning up to four times daily, using a neutral detergent and a chlorine-based disinfectant  single use items w ere used w here possible, including allocations for side rooms  social distancing w hen possible, w ith our inpatients and visitors all w earing masks (FRSM IIR) w hen possible  all staff in appropriate PPE to meet their level of assessed risk (including gloves, scrubs, aprons/gow ns, goggles/visors). Masks are now w orn in non-clinical areas  Staff support w as provided up to seven days a w eek, by staff health and w ellbeing and the people team  Robust IPC risk assessment processes and control practices, including for non COVID19 infections and pathogens The follow ing measures w ere also implemented and escalated at the trust:  Epidemiological investigation and contact tracing w ithin the hospital and via public health links in the community  Adherence to all mandatory reporting systems, risk registers, board assurance framew ork  Individual risk assessments for all staff, redeployment and COVID-19 secure settings  Ventilation review s, system modifications, and introducing air cleaning and disinfection devices to reduce airborne transmission  Isolation of immunocompromised using a side room priority isolation list stratified by pathogen and infection risk  PPE supply and compliance monitoring, for low risk (green), medium risk (amber) and high risk (red) patient pathw ays  A significant expansion in microbiology laboratory capacity and diagnostics: in-house PCR testing capacity increased to 252 tests per day on w eek days, w ith 126 tests per day during w eekends  The introduction of point of care (POC) tests, mainly Samba II nucleic acid amplification units w ith ED testing capacity of 72 samples a day, increasing to 96 samples per day  Daily meeting of the infection prevention and control (IPC) cell including w eekends w hen required, w ith roll out and monitoring of all IPC methods  Protection of the health w orkforce, including monitoring of staff sickness, database of COVID-19 related staff illness, lateral flow testing and participation in the national PHE run SIREN study  Case management, and improvements in therapeutics managed by the PAHT clinical cell  Introduction of the COVID-19 care bundle at the trust, w hich included protocols on use of antibiotics only for concurrent bacterial infections

  

A w ell-publicised vaccine programme made available to all staff from December 2020 w ith booster doses in March-April 2021 In line w ith national guidance, monitoring for variants of concern by isolating any patients w ith a travel history, and providing positive isolates for genome sequencing. Only the UK Kent variant B.1.1.7 has been detected at PAHT to date Monitoring patients for COVID-19 re-infections, and more recently also being vigilant for COVID-19 infections post-vaccination

Ale rt organisms Clostridium difficile (C.difficile) There w ere a total of 43 hospital-onset and 11 community-onset healthcare associated (i.e. these patients w ere inpatients in the previous four w eeks). C.difficile cases at the trust during the financial year for 2020-2021 (the first tw o categories are in table 6 below ). This compares w ith 17 hospital-onset and five community-onset healthcare associated cases last year. The rise in cases is likely to be associated w ith the COVID-19 pandemic and the increase in use of broad spectrum antibiotic prescribing, in particular IV Ceftriaxone and oral Azithromycin used for treatment of most inpatients w ith COVID-19. Of the C.difficile cases in January to March 2021, at least half w ere know n to have had COVID-19. Community cases have also risen, and C.difficile in the w hole population of West Essex CCG is higher; 73% compared to around 60% in the other tw o CCGs in the Integrated Care System (ICS). Table 6: C.difficile – cases by month Clostridium difficile (C.difficile) Apr-20 May-20 Hospital onset healthcare associated: 0 2 Community onset healthcare associated: 1 0 Community onset indeterminate association: 1 1 Community onset community association: 0 2

Jun-20

Jul-20 Aug-20

Sep-20

Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21

Control of C.difficile w ill be a top priority for our clinical teams, the IPC Committee, and the Antimicrobial Stew ardship Group in the months to come. Having significantly reduced committee activity during the pandemic, the Antimicrobial Stew ardship (AMS) Group has now re-launched w ith the follow ing key elements in place:  Agreement to review trends in total antibiotic consumption using the IT system define, and consider introducing refine  Promote improved compliance w ith our peer review ed, evidence based empirical antimicrobial prescribing guidelines  Restriction/protection of certain antibiotics e.g. Meropenem, Ciprofloxacin, Ceftriaxone to control antimicrobial resistance  Agree the quality first team share antibiotic prescribing data at w ard and consultant level, encouraging peer review of prescribing

  

An active w ard focused antimicrobial team including a consultant microbiologist and antimicrobial pharmacist w ill also undertake C.difficile w ard rounds Significant CCG input including communication w ith East of England AMS leads is underw ay Plans are being progressed for an STP w ide AMS group from June 2021 for shared learning. For the first time, from March 2021 there is a single primary care antibiotic policy for the STP.

M RSA Bacte rae mia: There have been no trust-attributable MRSA bacteraemia cases this year, w hich means the organisation remains in an excellent position nationally. Community cases have increased (four in 2020-2021) and are being investigated by the CCG. M SSA Bacte raemia: There is no trajectory in place for MSSA bacteraemia. There w ere seven trust-apportioned cases during the year; this is a low number of cases. Case numbers are the same this year as for the previous year. Gram Ne gative Blood Stream Infections (GNBSIs ): There is a w hole healthcare economy ambition for reducing healthcare associated GNBSIs by 50% by 2023-2024. Cases during 2020-21 w ere comparable w ith the number seen in 2019-20. Shared learning from some other trusts w as that there w ere increased case numbers of post 48 hour Klebsiella bacteraemia possibly associated w ith not changing long sleeved protective gow ns betw een patients. Table 7: Total number of cases during the year 2020 - 2021 Gram ne gative blood s tream Pre 48 hour cases infe ctions E.coli bacteraemia 156 Klebsiella spp. bacteraemia 33 14 Pseudomonas Aeruginosa bacteraemia

Pos t 48 hour cases 12 8 3

Infection incidents and outbreaks

Norovirus: There w ere no outbreaks of norovirus. Influe nza and other respiratory viruses: From 28/09/20, influenza A and B, and RSV testing w as undertaken routinely. Just six of 20,000 patients tested w ere positive for Influenza A, nine w ere positive for Influenza B and ten w ere positive for RSV throughout the six-month period. These are extraordinarily low numbers, show ing the predominant role of SARS CoV 2, and the success of influenza vaccination. This compares to 29 flu A cases , seen in 2019-2020. Audits and surveillance PPE com pliance: The PAHT IPC cell w anted assurance that staff across healthcare groups (HCGs) had access to PPE, w ere complying w ith ‘donning’ and ‘doffing’ procedures, and practiced good hand hygiene and social distancing in MDT/staff rooms. Our new ly

appointed PPE champions undertook audits; overall trust w ide compliance score w as 85%. The main area of concern w as around the removal (‘doffing’) of PPE. Hand hygie ne audits: The PPE champions audited four elements of the hand hygiene policy. There w as a 94-100% compliance seen w ith bare below the elbow s and after contact w ith patients and their surroundings; how ever, improvement is required in hand hygiene before patient contact. The trust w ide score for this element of the audit in March 2021 w as 69% and the requirement to improve this has been an ongoing issue, w hich w e are w orking to resolve. As w ith PPE audits, actions plans are being implemented by the HCGs and feedback given to the IPC Cell/IPC Committee. Conclusion Over a year later, in April 2021, together w ith colleagues in the UK, w e are all still review ing lessons learned about the COVID-19 virus and our response, identifying gaps in our know ledge and anticipating potential challenges ahead. With global travel stopping and starting depending on the evolving epidemiological situation around the w orld, the COVID19 vaccination programme and emergence of SARS-CoV-2 variants of concern, the virus is currently still being monitored very closely. Case numbers at the end of March 2021 are very low , how ever, the IPC cell continues to meet and remain vigilant for the foreseeable future. The IPC Committee and IPCT w ill oversee management of C.difficile and continue to monitor other alert organisms.

Quality im provement The trust has been innovative in its approach to quality improvement in the last year and supported by our quality first team, w e have developed the follow ing improvements: Le arning from death  Implementation of guidance to deliver a structure to all local mortality and morbidity (M&M) meetings  Supported the team in the appointment of a lead medical examiner, w hose role is to lead a team of independent consultant colleagues w hose role is to enhance the governance and regulatory systems by scrutinising the deaths of patients not under review or inquest by the coroner  Procurement approved for the purchase of the SMART system to record our M&M review s Non-invas ive ventilation (NIV)  Implementation of non-invasive ventilation (NIV) on Locke Ward. This has been a significant milestone achievement for 2019/20 for the trust to provide non-invasive positive pressure ventilation in our respiratory w ard in addition to critical care  The trust w as confident that beginning non-invasive positive pressure ventilation quickly can improve patient outcomes, reduce length of stay in hospital and reduce the need for admission to critical care.

End of life e ducation  A video developed and uploaded to YouTube for our people to view  We are in the final stages of developing mandatory e-training in conjunction w ith the provider  Development of acceptance criteria for hospices Patie nt initiate d follow up (PIFU)  This pathw ay allow s patients to determine w hether their condition requires clinical intervention by allow ing access to the specialist w hen it is needed  In turn, this reduces the number of follow up appointments needed for patients.  The first pilot w as completed for patients w ith fractures and this w ent live on 22 February 2021. By 25 March 2021, 38 patients have been discharged onto this pathw ay  Prior to PIFU these patients w ould have been booked a follow up appointment.  This commenced for neurology patients in April 2021 and the trust is now working w ith specialties to determine the roll out plan across PAHT Dr Doctor  Dr Doctor has gone live w ith a paperless communication for patients. A text message generates a link for correspondence to be view ed  This is in place for all appointments in outpatients w ith outcome letters due to go live from April 2021. There has been a 71% uptake of patients choosing to view their letters electronically w hich has both a cost savings due to reduction in postage, and environmental saving w ith less paper used  Full savings realisation being assessed Tw o way te xt messaging  Moved aw ay from a one-w ay messaging flow to enable tw o w ay messaging w ith our patients  This w ent live for our paediatric and paediatric diabetes patients w ith a tw o way messaging flow for appointments  Our other main outpatient services w ill be live on this system by October 2021 Virtual fracture clinic  During April, the trust undertook a test of the process and established that the referral forms w ould need to be completed in our emergency department (using the electronic Cosmic system) to provide information to both patients and staff about patients participating in this service. The aim is to release clinical capacity for patients w ho need to be seen face to face and saves patients visiting the hospital unnecessarily  The final process w ith a scheduled go-live date is now planned for September 2021  A review of how this concept could support other specialties is planned to be undertaken The atre dashboard  The development of a QlikView dashboard to show performance in theatres w ent live on 15 September 2020.  This development w ill support a focus for the surgical teams to improve utilisation of

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theatres to achieve the target of 85% utilisation by March 2022 The focus on increasing utilisation w ithin three clinical specialties of ENT, maxillofacial and ophthalmology began in April 2021 If w e can reach 85% w ithin these specialties, it w ill increase the theatre utilisation by 10%

Dom estics and housekeeping transformation  Move to provide cleaning services for 11 hours per day, 7 days a w eek on each inpatient w ard and in the emergency department for 24 hours per day  This has included implementation of a proactive and reactive roving cleaning cover for the hours of 7am to 8pm  This team are responsible for the maintenance and deep cleans of w ards and departments including delivery of a proactive deep cleaning programme  Outcomes: the consultation w as completed and new hours of w orking benefits are yet to be realised Hous ekeeping  Moving the current w ard assistants to a housekeeper role  Implementing a w orkforce plan to cover 11 hours per w ard 7 days a w eek  Housekeeper consultation w as completed and recruitment remains ongoing, as not all posts are filled Equipm ent  Purchase of new modern equipment, including hydrogen peroxide systems to enable increased productivity, measured by improvements in the metres of cleaning capacity completed  This project is not yet fully completed due to the need for a new storage area being required. Our capital team are w orking on this currently  Implementation of a comprehensive training programme for the new equipment  The outcome w ill be that equipment is purchased and in place, w ith training having taken place. The benefits are yet to be realised Ele ctronic ordering  In year w e have started requesting porters using an electronic requesting system  All cleanliness audits are completed using this electronic tool  The w ork has been completed, so in 2021/2 w e can commence use of electronic food ordering for our patients. This is expected to improve efficiency for catering as w ell as a reduction in food w aste and an improvement in patient experience overall Surgical die ts  Evidence based guidelines for patients and clinicians have been drafted after research and amending via a project group  Both patient and clinician guidelines have had approval from surgical teams and the Patient Panel to proceed  The guidelines w ill ensure our patients have consistent and best practice advice and guidance in relation to their diets post-surgery (based on evidence and expert oversight)

STOP-IT  STOP-IT is a process w hereby our medical and pharmacy team members w ill undertake a detailed review of all medications that patents are on during their admission. The aim is to see if w e can stop any medications for our patients and in turn, this is expected to reduce falls and reduce medication costs  STOP-IT w ent live on Lister Ward initially and this pilot show ed a 22.6% reduction of regular medication on discharge. This has been successfully rollout and embedded on Lister Ward  The next w ards for this to be completed in are Charnley, Ray and Tye Green and our new Frailty Unit Stom a e -referral  The project team, consisting of colleagues in IT, colposcopy and the surgical healthcare group to develop an electronic referral solution to streamline the stoma referral process  This w ill improve our turnaround times and improve length of stay for patients that in turn w ill reduce risk of hospital-acquired infection  The project aims to achieve stoma competence by patients w ithin three to four days (opposed to current 5-7). In turn, this w ill improve our patients’ experiences Sys tem transformation  The quality first team have w orked in partnership w ith the strategy team to support the facilitation of clinical strategy w orkshops using the quality improvement methodology to embed change into each of the specialty level strategies  This w ill ensure our plans have clear aims, measurable delivery targets and achievable actions (tests of change)  The team have w orked w ith system partners in the development and delivery of the integrated care partnership transformation plan by supporting expert oversight groups (EOGs) in the delivery of quality improvement COVID-19 vaccination and late ral flow testing  The quality first team led, in partnership w ith the staff health and w ellbeing (SHaW) team, the establishment and delivery of COVID-19 vaccinations  The team vaccinated approximately 7000 people  Furthermore, the team oversaw the rollout of lateral flow testing for our PAHT people. To date 7317 test kits have been distributed to staff over tw o phases  A reporting tool w as developed to allow our staff to enter their tw ice weekly test results  We are continuing to deliver phase three of our lateral flow testing, 810 test kits have been distributed to both our emergency department and our maternity unit for patient/partner testing Patie nts experience 3778 PALS cas es in 2020-21, an incre ase in activity by 10.4% The patient advice and liaison service (PALS) operated on site throughout the pandemic and they saw increased activity, receiving 357 more enquiries than in 2019-20 (total 3778).

The service does not generally need significant promotion and many of our callers have made contact before demonstrating the resilience and significant value added by the service. Without the liaison services and thematic analysis of 3778 cases received, it w ould be much more challenging to identify the main concerns the public have. The top three categories relate to communication issues (n=891), delays (n=638) and appointments (n=481). A further analysis of the sub-categories is show n below , with the most frequent sub-themes being: poor communication or lack of communication betw een professionals and patients w ith 542 cases relating to this issue, 274 cases of delays in appointment times being the second top issue w ithin delays and inadequate communication about appointments relating to 182 cases and being the most frequently occurring sub-theme w ithin appointments. Table 8: Themes related to communication A08 – Com munication 891 A03 De lays A08Q Poor 542 A03A Delay in communication/lack of appointment time communication betw een professionals/patients A08W No reply to telephone 192 A03B Delay in contact operation time taking place A08I Written communication - 37 A03F Delay in inaccurate (i.e. out of date) test results (i.e. X-ray results) A08Z Clarity/confusing 34 A03H Delay in referral - internal A08J Written communication 24 A03E Delay in - delay in sending treatment (i.e. IV correspondence, letters, etc. Fluids)

638 A17 - Appointments 481 274 A17I Inadequate 182 communication about an appointment 126 A17J Appointments poorly organised/scheduled 126 A17H Cancellation of an appointment

116

A17D Long w ait for appointment A17F Delay in being seen

107

Se ction 18 re port 204 com plaints in 2020-21, incre ase in activity of 18% Every year, w e must make a statement under the NHS Health and Social Care Act 2009 about how many complaints w e received, their subject, the issue they raise, w hether or not they w ere w ell founded and any actions taken. Com plaints received In the previous year (2019-20), w e received 172 complaints. This year the number of complaints increased for the first time in eight years. We received 204 complaints in 202021. Subje cts of complaints The most frequently occurring themes w ere medical care expectations (61), communication (33) and nursing care (19). A more detailed breakdow n of sub-themes is listed below .

Table 9: Themes from complaints Com munication Lack of information 31 shared w ith relatives Poor 29 communication/lack of betw een professionals/patients No telephone contact 13 w ith relatives Conflict of information 9 betw een professionals Lack of information 9 shared w ith the patient

M e dical care Missed diagnosis

Nurs ing care Inadequate monitoring Poor standard of care provided

Inadequate treatment provided

Poor treatment provided No treatment provided Failure to refer to another speciality

Poor pain control

Poor nutrition

Lack of assistance 13 w ith personal and oral hygiene

Actions taken Actions are taken over the year and should demonstrate a clear connection from the concern raised to the change the organisation has made. From an operational perspective, w e are taking a number of actions in response, some of these are summarised below : 

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Existing support projects continue, w ith 1,542 video calls completed through our seven-day virtual visiting service, over 1533 family and relatives’ messages have been distributed and 128 ITU patients’ relatives have been provided w ith ITU information over the last year The team has developed new inpatient visiting guidance, w hich has restarted, supports a more open approach to visiting for high-risk groups, as w ell as at the w ard manager’s discretion for those for w hom this w ould enhance communication and the care experience We have completely redesigned our patient belonging policy and process so that w e are proactively managing patient belongings w ith 150 patients’ property reunited w ith their ow ners in just one month Development of tw o new partnerships for supporting people w ith learning disabilities (PWLD) w ith Harlow College and learning disability (LD) organisations to contribute to the new hospital development, the hospital passport and better communication w ith people w ith learning disabilities New funding for cancer information and to support a better carer experience The continuing development w ith The Anne Robson Trust of the Butterfly Hub to support the families of patients w ho are the end of their lives Community partnerships w ith Rainbow Services to combat digital exclusion

From a strategic perspective:

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Our next steps are to use a detailed analysis of the sub-themes of communications issues in complaints. These reveal the top sub-themes to be lack of information to relatives, poor communication or a lack of communication betw een professionals and patients and a lack of telephone contact w ith relatives. We w ill use these to develop framew orks, communication models and implementation or support for development programmes w hich address these issues, in co-production w ith patients. An example of this is the SAGE and THYME model for communication developed by Manchester University Hospitals NHS Trust We w ill be addressing this during a series of events, w orking w ith our people and patients. The first event w as held on 24 March and key issues w hich arose related to broken agreements, a lack of listening, no clear explanation of plans of care, a lack of compassion and empathy, w ith staff behaving defensively w hen challenged To further develop the response to these issues, w e will be carrying out an online survey of key stakeholders in patient experience, delivering further listening events w ith patients online and a w orkshop to summarise the findings w ith survey respondents w ho agreed to stay in touch. This w ill help to shape the first draft of an integrated patient safety, experience and quality strategy

Cas e study one A patient raised a complaint regarding her admission on Tye Green Ward and the medical staff that treated her. Follow ing the complaint, the acute pain team started a quality improvement project w ith the follow ing goals, some of w hich are show n below . Le arning - 42 of the actions planned had been completed including:  All policy and guidelines ratified  Implementation of the JAC pain bundle  Implemented generalised pain teaching for all staff  Introduced new observation charts for pumps to the w ards. Ward managers to return completed compliance document  Pain champion study day/s planned and completed  Started a ketamine trial Cas e study two A patient raised concerns about the length of time her MRI results took. The patient w aited seven months to be told she had a tumour in her brain and she w as later told that it w as benign, but she experienced several months of anxiety. Le arning - Clearer communication is needed, as the patient had an unnecessary time of anxiety. Even though the referral w as made and the patient w as on the correct clinical pathw ay, this w as not clearly explained until the complaint meeting. A clearer process is needed from radiology’s initial scan report details that a follow -up is required. This w as discussed at the radiology learning meeting and a new standard operating procedure (SOP) w as developed in February 2021.

The standard operating procedure outlines the process to be follow ed for ensuring any recall imaging requests are properly actioned and completed in a timely manner. Cas e study three A patient's daughter raised issues regarding her late mother's missing rings. The rings w ere not located and the case w as referred to our legal team. Le arning – We appointed a lead for the repatriation of patient property, a steering group w as formed w ho met w eekly during the pandemic and now meets bi-monthly as the numbers are significantly reduced and the policy is w orking effectively since the move to green bags for all property. The policy sets out the framew ork, arrangements and responsibilities for managing patients’ belongings at The Princess Alexandra Hospital NHS Trust. It explains our procedures for dealing w ith patients’ belongings, and defines the levels of responsibility and liability for both patients and PAHT. Patie nt Pane l This year has been challenging, for not only the Patient Panel. They w ere advised to shield by the government during w ave one of the pandemic. For the first couple of w eeks, all managed to catch up on tasks. How ever, it became obvious that the pandemic w ould not be over quickly and w ith it being important that they maintained a presence to support patients, the group stayed together, and undertook smaller tasks. Initially this w as to update the terms of reference, looking at new initiatives and so by June, the panel had mastered new skills of WebEx, Zoom and Microsoft Teams. During lockdow n, they progressed their w ork plan and completed the follow ing:  Worked w ith Emma Harnett, MacMillan primary care nurse facilitator (WECCG) and Shahid Sardar, associate director of patient engagement, w ith support from the Integrated Care System cancer team to develop: o A film ‘One step at a time’ on the cancer journey from a non-clinical position, plus an information card. Both items have been translated into five languages: Italian, Polish, Punjabi, Romanian and Urdu. The cards are being used across the ICS region therefore also Lister and Watford hospitals o They made tw o additional cancer films; in one a young person spoke about hearing their mother had cancer and the other, a patient diagnosed w ith cancer during COVID-19 discusses their journey o The Panel w ill be holding a cancer conference in September 2021  Preparation for a diabetes conference in 2020 (deferred to July 2021) o The panel have w orked to develop a diabetes conference and have invited Professor Roman Hovorka, PhD and chief investigator on several trials evaluating the artificial pancreas in populations such as young children and new ly diagnosed type 1 diabetes, as the keynote speaker o Our panel are linking into Lane Desborough, founder and chief executive officer of Nudge BG in California, w ho is using his engineering skills to

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develop new ways for young people diagnosed w ith diabetes. Sir Lindsay Hoyle, speaker of the House of Commons has also w ritten an article for the conference pack on his experience of being diagnosed w ith diabetes and also a number of our consultants and senior staff w ill be participating in this public event The panel w rote numerous letters of support to the healthcare groups and our staff thanking them for their dedication; w e sadly w rote letters of condolence to the families of staff members w ho lost their lives Once again, the panel have published their popular annual report By September, the panel w ere fully engaged in all pre-COVID-19 w ork, attending meetings using Microsoft Teams, taking part in interview s, and re-establishing the complaints reference group This prepared panel members for the second lock dow n, w hich did not have much impact on their w orking as all completed w ork from home The Patient Panel had both their vaccinations and completed the COVID-19 training and by April 2021 w ere able to start to visit the hospital, carrying out peer review s and visits to various departments It w as important for our Patient Panel that they kept going through these unusual times to ensure our patients’ voices w ere heard, as services moved into telephone and video consultations and limited face-to-face meetings The panel are part of the teams that are planning for the new hospital Our Patient Panel have w orked w ith Harlow College to ensure w e hear the voices of young people w ith a learning disability regarding the services they receive. They have w orked to obtain the family and friends test produced in easy read format for this group of patients Our panel are w orking w ith the children and families’ team to establish a young people’s board at the hospital After delays due to COVID-19 restrictions, The Lord Lieutenant of Essex w ill be presenting the Queen’s Aw ard for Voluntary Services to the Patient Panel on the 21 July 2021 The panel are w orking w ith the people team to develop a policy on engaging patients in all areas of the interview process

Im proving care for vulnerable patients - delirium and dementia We have made good progress on our goal to deliver the very best possible care for our patients w ith dementia, in line w ith national policy. We have in place an integrated dementia strategy, w hich has key performance indicators in the follow ing areas and is monitored through our dementia and delirium steering group.    

Find, assess and refer pathw ay Person-centred care (recording of ‘This is Me’) Comparison of harm related incidents for patients w ith dementia (development of a dashboard) Training

We participated in the national audit of dementia care in general hospitals, The Royal College of Psychiatrists (2019), and the recommendations now form part of our strategy document. M usic therapy In 2019 w e undertook a project to introduce singing for the brain into the hospital setting. The aims w ere to reduce the social isolation that patients often experience during a stay in hospital, to improve w ellbeing and mobility. Music therapy is know n to play a crucial role in the care of many people w ith or w ithout dementia, helping to minimise apathy, anxiety, restlessness and depression. Follow ing the successful pilot, w e provided a w eekly music therapy session, w hich was facilitated by the clinical nurse specialist for Dementia and volunteers. In the past 12 months, due to COVID-19 restrictions, the clinical nurse specialist has continued to deliver this at the bedside for one to one musical therapy sessions. The plan for the next few months is to re-establish w ith small groups in particular areas and w ork alongside therapy teams to develop a meaningful activities group. The output from the success of this project has been presented at a national nursing conference and w ill be submitted to an appropriate journal for publication. Feedback from family members and carers has been very positive; there has been a notable change in interaction, improved appetite and reduction in delirium related anxiety. De lirium work Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, w hich has an acute onset and fluctuating course (NICE 2010). Older people admitted to hospital w ith infections are vulnerable to developing delirium; this can be very frightening for them and their loved ones. To support our staff in the care of patients presenting or developing delirium in hospital, w e now have established new pathw ays and guidelines. We also have a leaflet designed to be given to patients and their families or carers. There is a plan to have an electronic assessment. Training To support our patients, w e have introduced mandatory training on delirium as w ell as creating simulation training, w hich has received excellent evaluation. The national audit of dementia care (2019) identified an improvement in the screening of our patients for delirium. The training complements the dementia training that already exists for staff and w e are proud of our virtual dementia tour, w hich enables staff to experience w hat it may be like to have dementia, and learn how to w ork with people living w ith dementia. Nam as te care Namaste care offers a respectful and supportive approach to care for those living w ith advanced dementia, integrating compassionate nursing and therapeutic activities. Working closely w ith St Clare’s Hospice, w e plan to introduce Namaste care in PAHT w ith the support of the dementia clinical nurse specialist (Namaste champion), w ho will develop the role of Namaste volunteers in partnership w ith PAHT volunteers. A dedicated room space w ill need to be identified.

Working with our patients and their carers We introduced a w eekly carers group and revised the carer’s card, w hich allow ed extended visiting time to meet the needs of vulnerable patients and their loved ones. Due to infection control restrictions, w e continued this group virtually throughout the pandemic. There are now plans to re-establish the group face to face in July 2021. There are more than 63 dementia and delirium champions in the organisation. Their role is to lead by example and share best practice in the w orkplace. Le arning from incidents, investigations and changes im plemented Patient safety is a key trust priority, w e continually strive to ensure incidents are managed effectively and most importantly that w e learn and share the improvements that arise from them. A patient safety incident is defined as ‘any unintended or unexpected incident w hich could or did lead to harm for one or more patients receiving NHS funded care’. During 2020-21, w e reported a total of 10,226 incidents. Of the incidents, 97% resulted in either no or low harm, the remaining resulting in moderate (1.8%), severe (0.25%) or death (0.95%), figure six below . The total number of incidents reported has remained consistent w hen compared w ith 2019-20 other than death graded harm, w hich has increased from 0.06%, attributed to hospital onset COVID-19 infection, a recognised national issue. 1200 1000 800 600 400 200 0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2020 2020 2020 2020 2020 2020 2020 2020 2020 2021 2021 2021 2021 2021 None

Minor

Moderate

Severe

Death

This year saw changes in the incident management process in response to the impact of th e pandemic. Twice w eekly incident management group meetings (IMG) took over from the historical daily oversight and serious incident group meetings. IMG activity for the year resulted in the management of 785 incid ents of w hich 141 required internal investigation . Incide nt themes • Documentation not fully comple ted or missing • Time ly assessment and allocation to the correct speciality team fir st time • Number of falls in patients requir ing close observatio n • Staf f unaw are their patients requested radiological investigat io ns have been ref used, therefore patients experie ncin g delays • Patient medication pods at each bedside noted not all to be locking

• • •

Two critical medic ations (insulin) not prescribed/given af ter unplanned admis sion. This w il be part of the patient safety priorities in the coming year Compliance w ith the recording and escalation of observatio ns Care of the deterioratin g adult w ith COVID-19 outsid e of the critical care area

Actions to address the themes from incidents and investigations are taken over the year and demonstrate a clear connection from the incident raised to the change the organisation has made. The follow ing examples illustrate the approach to learning. What w e have changed following incidents this ye ar • Paper based ris k assessment transferred onto Nervecentre, allow in g transparency of results and the escalation of non-completion • Speciality review and treatment of patients w ith abdominal pain pathway developed in consultation betw een the emergency department (ED), paediatrics and s urgery • Enhanced care process implemented • Radiology consultants provide a clinical rationale on the electronic request f or radiology in vestigatio n if it is declined • Trust w ide review of all bedside lockers undertaken and new pods provided • Improvements to medic ine reconcilia tio n by daily pharmacist presence in the acute admissio ns unit to undertake this role • The imple mentation of the consultant of the week in maternity to support obstetric emergencie s • The introduction of an acute response team during wave one of the COV ID-19 pandemic to s upport the care of critically unw ell patients w ithin the ward environments • The imple mentation of e-observations w ithin paediatric ED to support the escalation of the sick child • Changes to PAHT policies (f alls, GI bleed policy, maternity related policies) as a result of le arning and embedding changes into practice Im proving medicine safety Over the last 12 months, the pharmacy team have w orked collaboratively w ith colleagues across the w hole organisation and other local trust partners to strengthen and improve medication safety. M e dicine optimisation during COVID-19 The pharmacy department supported the trust in a number of w ays during COVID-19. This included the vaccination programme, maintaining and managing supplies of critical medicines, contributing to clinical trials involving medication, medicine management during w ard moves, w riting and validating clinical guidelines and support for home delivery of medication to patients w ith cancer. De ve loping the roles of our pharmacists We have specialist pharmacists w orking in critical care, anticoagulation, gastroenterology, rheumatology and dermatology; these individuals provide expert advice and guidance to support patient care. In addition, w e now have a specialist neurology pharmacist w ho provides expert pharmaceutical support to this group of

patients. We are also developing our integrated w orkforce w ithin the Integrated Care Partnership (ICP) by having tw o joint posts w ith West Essex Clinical Commissioning Group (CCG). One of these posts is a lead frailty pharmacist. M e dicines optimisation to acute assessment As part of new models of medicine optimisation care and to support the new ly opened medical assessment unit, pharmacy staff w ill be providing support to the unit 12 hours a day, seven days a w eek. This w ill support safe management of medication and patient flow . Antim icrobial s tewardship This vital role ensures that local antimicrobial guidelines are easily available (including the use of an app) to doctors and other prescribers. This means that our patients receive the shortest effective course of antibiotics by the most appropriate route. A programme of audit, feedback, surveillance and education and review of patient safety incidents related to antimicrobial use is in place so that w e can monitor our practices and ensure that our patients are receiving safe care. Ele ctronic Prescribing and Medicines Administration (EPM A) The EPMA team have implemented automatic stop dates for antibiotics, based on the indication selected w hen the prescription is made. The indications and durations are matched to the antimicrobial guidelines, therefore they actively support antimicrobial stew ardship. A number of clinical trials for COVID-19 w ere initiated over the past year, all of w hich were configured on EPMA. This has facilitated prescribing and management of the trials through reporting available in EPMA. A new chemotherapy prescribing system called ChemoCare has been implemented w hich w ill significantly increase the safety and w orkflows for chemotherapy for doctors, nurses and the pharmacy department. M e dication incidents The most recent report from NHS Improvement, for incidents occurring betw een 1 October 2019 and 31 March 2020, show ed that the proportion of reported incidents that w ere medication incidents w as 8.8% for PAHT. This is just below the average for acute (non-specialist) trusts in England, but is above the average for other hospitals in Essex and Hertfordshire (figure 7 below ).

M e dication safety programme Other areas w here good progress has been achieved includes:  Our medicines optimisation group meets monthly to review and discuss the results of audits relating to medicines; incident trends and patient safety alerts; proposed changes to improve medication safety and to approve policies, guidelines, procedures and patient group directions  Medication incident multi-disciplinary review meetings take place on a monthly basis. This includes identification of trends and actions that should be taken trust w ide or w ithin each healthcare group. These actions are approved by the medicines optimisation group and presented to the trust patient safety group to provide assurance of shared learning  The medication safety officer is a regular attendee at the tw ice-weekly incident management group meetings, helping to ensure that all issues relating to medication safety from reported incidents are identified and addressed  The w eekly new sletter for our people continues to include a ‘medication safety tip of the w eek’  Medicine storage audits are in place to ensure that medicine cupboards are fit for purpose and locked and that medicine storage rooms and fridges are maintained at the appropriate temperature A senior pharmacist now attends patient safety and quality meetings in each healthcare group, to provide advice on medicines optimisation, including the safe storage and use of medicines and compliance w ith governance requirements  There is regular communication betw een the medication safety officer and the EPMA team to see how JAC can be used to improve the safety of prescribing and medicines administration  The safety of patients prescribed anticoagulants is monitored through our multidisciplinary anticoagulation monitoring service

 

Staff are made aw are of national medicine shortages and receive advice about alternative medicines that can be prescribed Air handling units are now in place across the w hole organisation to keep the temperature in drug rooms less than 25 C

Our pe ople In 2020-21, our people faced many challenges in response to the COVID-19 pandemic. Staff w ere required to w ork in significantly different w ays through skill development and redeployment in the management of unprecedented levels of acute patients, as w ell as COVID-19 related staff absences. We have continued to recruit throughout the year to both substantive posts and temporary recruitment to support the increase and pressure in the services. Table 10: The key w orkforce indicators are reflected in the table below : Pe ople KPI 2019-20 targe t Vacancy rate Sickness absence Voluntary turnover Statutory and mandatory training Appraisal Flu Time to hire

8.6% 4.3% 10.7% 92% 89% 80.1% 31 days

Ye ar to date pe rformance 8% 3.6% 9.7% 87% 71% 81% Average 41 days

The key themes below highlight the outputs form our people framew ork and clarifies the five key pillars of the people strategy:  Culture, health and w ellbeing  Workforce resourcing and planning  Learning, leadership and team development  New service and w orkforce models  Optimising technology It is acknow ledged that the last year has been a challenge for our w orkforce. In addition to PAHT’s people strategy, the NHS 2020/21 People Plan also sets out practical actions for employers and systems in light of the challenges faced by organisations in their response to COVID-19, as outlined below :  Looking afte r our people – w ith quality health and w ellbeing support for everyone  Belonging in the NHS – with a particular focus on tackling the discrimination that some staff face  New ways of working and delivering care – making effective use of the full range of our people’s skills and experience  Growing for the future – how we recruit and keep our people, and welcome back colleagues who want to return

We focused on how w e continue to look after each other and foster a culture of inclusion and belonging, as w ell as taking action to grow and develop our w orkforce, and w ork together differently to deliver patient care. He alth and w ellbeing One of the key priorities during 2020/21 w as to implement and embed a sustainable health and w ellbeing offer to our people in response to the impact of COVID-19 and the challenges that have been faced. We had 160 staff w ho w ere required to shield under government rules. Laptops w ere distributed to enable our people to w ork from home w here possible. This included some redeployment into roles and those staff could continue to provide support remotely from home. A seven days per w eek first line absence reporting service w as set up during the peak of the pandemic to take calls from staff reporting their absence either through their ow n sickness or through a requirement to self-isolate. This captured live absence data throughout the day and enabled clinical staff to review staffing levels on an ongoing basis. Individual risk assessments w ere carried out on staff w orking on all hospital sites, w hich assessed any underlying conditions that may affect their level of risk of becoming seriously unw ell if they tested positive for COVID-19. Advice and coaching w as provided to staff and managers on undertaking the risk assessment and managing outputs. Where required, action plans w ere then agreed betw een the staff member, their manager and the staff health and w ellbeing team (SHaW). Project Wingman w as a national initiative resourced voluntarily by pilots and cabin crew w ho w ere grounded at the time of the pandemic. The purpose of the initiative w as to provide a first class style socially distanced breakout area w here drinks and refreshments w ere served to our people. An additional key element of this initiative w as that all of the cabin crew were mental health first aiders. This w as well received by our people. The w inter flu campaign saw 81% of staff vaccinated, a slight increase on 19/20 rate. Webinars took place to provide staff w ith updated information and advice about the virus. A number of these w ere facilitated specifically for our Black, Asian and minority ethnic (BAME) staff to address emerging themes and concerns. We have developed a range of health and w ellbeing support initiatives for our people, w hether at the front line or in supporting services. A number of these services have been developed on a national and Integrated Care System (ICS) level and additional support has been implemented locally in partnership w ith SHaW (staff health and w ellbeing – our occupational health service), our employee assistance programme, the Red Cross and Essex Partnership University NHS Foundation Trust (EPUT). Work w as undertaken to support both people w ho were shielding and their managers in returning to w ork, and psychological and physical support w as made available. We

delivered an ongoing series of w ebinars for both staff and managers throughout the COVID-19 period. Lateral flow testing w as implemented across PAHT in October 2020, initially to front line staff and in December, this w as rolled out to all of our people. January 2021 saw the first doses of the COVID-19 vaccination delivered to staff, students and volunteers w orking at PAHT. Our staff health and w ellbeing team, w ith the support of the Quality First team, led this programme. The second vaccination dose programme began in March and w as completed in April. 85% of staff received their first vaccination through PAHT; those staff w ho were unable to receive their vaccinations w ere supported to book their vaccination through the community provider in Harlow . We introduced a peer support initiative called ‘Time to talk’. Either substantive staff from w ithin PAHT w ho are trained as mental health first aiders support this initiative or are trauma and risk management practitioners. The concept is to provide immediate intervention, w ith face-to-face drop in support to staff across PAHT at designated times and places, such as at the end of each shift. This support has been w ell received by staff and w ill continue as part of the recovery plan going forw ard. We introduced a 12 w eek ‘Back to better’ people focused campaign, w ith the aim of supporting our people to develop and drive refreshed approaches to delivering services follow ing the significant challenges that have been faced over the last 12 months, and w e w ill continue to face going forw ard. There are four themes underpinning this campaign:    

Health and w ellbeing Compassionate and inclusive leadership Civility Operational leadership

Work force, resourcing and planning We implemented agile w orking across the organisation, including w orking from home. The w ide use of laptops and digital telephone systems enabled us to implement social distancing rules and decrease footfall across our w orking sites. The impact of agile w orking/ w orking from home has enabled greater productivity efficiencies though re-evaluation of current processes and systems and has enabled specific objectives and targets to be set and measured more efficiently.  We continued to w elcome international nursing staff into PAHT, facilitating the required isolation period w ith designated hospital accommodation. The nursing staff group now has a vacancy rate of 7.2%. Recruitment pipelines continues to bring this dow n, aiming for 2% in the coming year  Across the trust overall vacancy rate is less than 10%  There have been a number of national initiatives to support staff groups in being deployed across the NHS in response to the pandemic. These included medical students, aspirant nurses and staff deployed from other organisations, both private and public sector

     

We have continued to support NHS management graduates placed w ithin the organisation Follow ing a pause during the pandemic, pre-registration students restarted placement w ith PAHT in March 2020 Whilst apprenticeships w ere paused in a number of areas during w ave one and w ave tw o of the COVID-19 pandemic, w e have continued to support this scheme w here possible and currently have 65 apprentices w orking across PAHT Our management and leadership development programmes w ere paused for most of 20/21, the w ard managers’ leadership programme began in March 2020 Non-statutory training w as paused during the pandemic to maximise availability of staff. All training w as reinstated in March 2021, a majority of w hich is either online or vis MS Teams Appraisals w ere also paused during the pandemic, these w ere reinstated in March 2021

Re cognising our people In a temporary move aw ay from aw ard categories, our annual Amazing People Aw ard w as given to everyone in recognition of their hard w ork, compassion and commitment to responding to the demands of the COVID-19 pandemic and delivering high quality care to our patients. Everyone w as given a certificate and an Amazing People Aw ard pin badge to mark the occasion. As a special recognition of the hard w ork and commitment of all our people, a gift of an extra day of leave in 2021 to celebrate each person’s birthday, or other special day, w as announced. Colleagues have been enjoying taking the extra day and the recognition has been appreciated. Our Long Service Aw ards were announced at a special virtual event, open to all, that gave people the opportunity to be recognised and celebrated by the executive team and colleagues. Certificates and badges w ere delivered to line managers w ho personally delivered them to the people in their team. The aw ards event also paid tribute to our colleagues w ho passed aw ay in the year, including three w ho were COVID-19 positive. This w as a poignant and moving w ay to remember and pay our shared respects to some very special people.

The National NHS Staff Survey The annual NHS National Staff Survey (NSS) is recognised as an important tool for ensuring that the view s of people w orking in the NHS are used to help inform local improvements. The feedback is useful in helping highlight strengths, and improvements that w ill make PAHT a better place to both w ork and be treated. A full census w as held at PAHT betw een October and November 2020, w ith all our people having the opportunity to take part. In total, 1368 (38%) completed their survey, w hich w as 7% low er than 2019, and 7% low er than the average acute trust response rate (there are 128 acute trusts w ithin the benchmark group).

Table 11: Summary of the trust results by the key national themes, benchmarked against the 85 acute trusts.

The report findings from the 2020 National Staff Survey w ere presented to the Workforce Committee in March 2021, and to trust board in April 2021. A series of response plans including improvement actions have been developed by each of the healthcare groups, w hich align to three priority actions identified by the trust (continuing from those identified for 2019-20): Priority one: Improving the physical and mental health and w ellbeing of our people Priority two: Improving our learning and safety culture, encouraging people to openly raise concerns and ensure they are acted upon (improving psychological safety) Priority three: Improving line manager effectiveness These are particularly important as w e continue to deliver our quality improvement plan, w hich focuses on enabling outstanding care for all of our patients, all of the time. Staff have been given the opportunity to attend a series of Here to hear listening events, w here they can share their view s on the Staff Survey results and improvement plans. Their feedback w ill help to further refine these plans, ensuring positive changes w ithin their areas, w hich w ill support better staff experience.

Inclus ion The equality, diversity and inclusion steering group meets monthly to review activities and initiatives to promote and support aw areness and education of equality, diversity and inclusion (EDI) at PAHT. Due to the COVID-19 pandemic, the monthly meetings have been successfully held virtually. It has also required the steering group to review the w ays it can highlight EDI activities, predominately through virtual events and a programme of planned activities continued throughout the year including LGBT+ Pride, celebrating Black History Month, International Women’s Day and International Men’s Day. Black, Asian and Minority Ethnic (BAME) staff w ere an identified group that is disproportionately more likely to be impacted by COVID-19. In collaboration w ith other trusts w ithin the Integrated Care System (ICS), w e developed a number of initiatives to support our BAME staff including: 

Establishment of a BAME staff support line



Agreed consistent risk assessment and outcomes for all COVID-19 identified vulnerable groups



Research methods w ere explored to understand BAME staffing needs and view s on the COVID-19 response



Creation of system-w ide EDI netw ork and BAME chairs netw ork for ongoing transformation

Our pe rformance Our operational performance against national and local standards is monitored and review ed at: 

Regular performance review meetings betw een members of the executive team and each healthcare group



The urgent care board



The elective access board



The cancer board



Senior management team meetings



The performance and finance committee



Trust board meetings

An integrated performance report is presented to the performance and finance c ommittee and trust board meetings. Externally, the trust is held to account for its operational performance by NHS England/Improvement.

Targets and national s tandards COVID-19 and the increased volume of emergency patients requiring care have significantly affected delivery of all national standards. The requirement to maintain separate COVID-19 minimised services, change w ard specialties to emergency care and the transfer of theatre staff to critical care significantly reduced the volume of elective activity that could be delivered. Elective operating w as paused on The Princess Alexandra Hospital main site in March 2020 and did not recommence until July 2020. The local independent sector provider hospital supported us by allow ing activity to be carried out at their location, w hich allow ed us to continue cancer and urgent elective surgery, along w ith associated diagnostics. The consequent impact on the 18-w eek RTT standard has been dramatic, although w e have continued to deliver performance higher than the national average, below in figure 8 below .

Delivery of the national cancer standards w as also impacted by COVID-19; how ever, w e prioritised the maintenance of cancer services by transferring activity to the independent sector. After each COVID-19 w ave, cancer recovery plans w ere implemented across all specialties and these led to sustained improvements in clearing the backlog of long w aiting patients in the autumn, w hich is reflected in the low 62 day performance seen as w e treated more patients over 62 days than in previous years. Our cancer performance w as below the national average, as it w as more impacted by COVID-19 than other providers that had more flexible facilities to maintain elective activity during COVID-19 w aves. We continue to be committed to the delivery of all national cancer standards and plans are now in place to reduce the backlog from the early year w ave. The new 28 day faster diagnosis standard is coming into effect during 2021 and w e have implemented a number of pathw ay changes in response to COVID-19 that sets up the achievement of the 28-day standard in 21/22, figure 9.

Diagnos tic performance Diagnostic performance w as impacted by COVID-19 demand, as routine appointments w ere paused tw ice during 2020/21. Cancer and urgent diagnostics continued and despite considerable staff absence levels, the diagnostics department delivered additional support to the emergency departments for COVID-19 patients. In betw een each w ave of COVID-19, the diagnostic services recommenced routine w ork and increased capacity as far as possible w ith the use of CT vans on site, offsite additional w orking and patients travelling to independent providers for their diagnostics, figure 10 below . The graph below show s clearly the drops in performance during COVID-19 and the rapid improvements in betw een.

Participation in clinical audits We are required to participate in national audits to ensure that w e are taking every opportunity to learn and improve. During the period 1 April 2020 to 31 March 2021, there w ere 51 national clinical audits and nine national confidential enquiries that covered NHS services that w e provide. During that period, the total number of national clinical audits that the trust w as eligible to participate in and submitted data to, w as 37. The trust did not participate in 12 audits that w ere paused due to COVID-19, and tw o audits due to local softw are issues. A summary of this information is in table 11. There w ere nine national confidential enquiries, w hich the trust w as eligible to participate in; four have been paused due to COVID-19 and the trust participated in five. The summary of this information is detailed in table 12. The national clinical audits and national confidential enquiries that w e have participated in, and for w hich data collection w as completed during 2020-21, are listed alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry, tables 12 and 13. During 2020-21, the local review of national clinical audits reports w as impacted on by COVID-19 and w ork is now taking place to address this.

Table 11: Nam e of audit programme – project name (providers) Antenatal and New -born National Audit Protocol 2019 to 2021 British Spine Registry (British Spine Registry) Case Mix Programme (CMP) (Intensive Care National Audit and Research Centre (ICNARC)) Cleft Registry and Audit Netw ork (CRANE) (Clinical Effectiveness Unit, The Royal College of Surgeons of England) Elective Surgery (National PROMs Programme) (NHS Digital) Emergency Medicine QIPs - Fractured Neck of Femur (Care In Emergency Departments) (Royal College of Emergency Medicine) Emergency Medicine QIPs - Infection Control (Care In Emergency Departments) (Royal College of Emergency Medicine) Emergency Medicine QIPs - Pain in Children (Royal College of Emergency Medicine) Falls and Fragility Fracture Audit Programme (FFFAP) - National Audit of Inpatient Falls (Royal College of Physicians (RCP) Falls and Fragility Fracture Audit Programme (FFFAP) - National Hip Fracture Database (NHFD) (Royal College of Physicians (RCP)) Falls and Fragility Fracture Audit Programme (FFFAP) - Vertebral Fracture Sprint Audit (Royal College of Physicians (RCP)) Inflammatory Bow el Disease (IBD) Audit - IBD Biological Therapies Audit (IBD Registry) Inflammatory Bow el Disease (IBD) Audit – IBD Service Standards (IBD UK) LeDeR - Learning Disabilities Mortality Review (NHS England and NHS Improvement) Mandatory Surveillance of HCAI (Public Health England) National Adult Diabetes Audit (NDA) - National Core Diabetes Audit (NHS Digital) National Adult Diabetes Audit (NDA) - National Diabetes in Pregnancy Audit (NHS Digital) National Adult Diabetes Audit (NDA) - National Diabetes Transition (linkage w ith NPDA) (NHS Digital)

Did PAHT participate ?

Stage / % of cas e s s ubmitted

Yes

100%

Yes

All procedures

Yes

100%

Not applicable Yes

92%

Yes

117 cases

Yes

94 cases

Yes

Data submission period extended

Yes

100%

Yes

352 cases = 100%

Not applicable Yes

189 cases

Not applicable Yes

100%

Yes

100%

No Yes

71%

Partial

Automatic data linkage from NDA and NPDA (not

Table 11: Nam e of audit programme – project name (providers)

Did PAHT participate ?

National Adult Diabetes Audit (NDA) - National Diabetes Foot Care Audit (NHS Digital) National Adult Diabetes Audit (NDA) - National Diabetes Inpatient Audit Harms (NaDIA-Harms) (NHS Digital) National Adult Diabetes Audit (NDA) - NDA Integrated Specialist Survey (NHS Digital) National Asthma and COPD Audit Programme (NACAP) - Adult asthma secondary care (Royal College of Physicians (RCP) ) National Asthma and COPD Audit Programme (NACAP) - Chronic Obstructive Pulmonary Disease (COPD) (Royal College of Physicians (RCP)) National Asthma and COPD Audit Programme (NACAP) - Paediatric - Children and Young People Asthma Secondary Care (Royal College of Physicians (RCP)) National Asthma and COPD Audit Programme (NACAP) - Pulmonary Rehabilitation (Royal College of Physicians (RCP)) National Audit of Breast Cancer in Older People (NABCOP) - (Clinical Effectiveness Unit, The Royal College of Surgeons of England) National Audit of Cardiac Rehabilitation (University of York)

Yes

currently submitting to NDA) Anticipate 100% submission of data by the deadline in July 2021 Paused due to COVID-19 – plans in place to restart

Yes Paused due to COVID-19 Paused due to COVID-19

Paused due to COVID-19 Not applicable Yes

100%

Not applicable Round 3 data collection cancelled to due impact of COVID-19 Data collection suspended due to COVID-19 Data collection suspended due to COVID-19

National Audit of Care at the End of Life (NACEL) - (NHS Benchmarking Netw ork) National Audit of Dementia (NAD) - Care in general hospitals (Royal College of Psychiatrists) National Audit of Dementia (NAD) - Spotlight audit in memory services (Royal College of Psychiatrists) National Audit of Pulmonary Hypertension (NAPH) - (NHS Digital)

Stage / % of cas e s s ubmitted

Not applicable

Table 11: Nam e of audit programme – project name (providers)

Did PAHT participate ?

National Audit of Seizures and Epilepsies in Children and Young People (Epilepsy 12) – Epilepsy 12 has separate w orkstreams/data collection for: Clinical Audit, Organisational Audit (Royal College of Paediatrics and Child Health (RCPCH)) National Bariatric Surgery Register - (British Obesity and Metabolic Surgery Society) National Cardiac Arrest Audit (NCAA) (Intensive Care National Audit & Research Centre (ICNARC)/Resuscitation Council UK (RCUK)) National Cardiac Audit Programme (NCAP) Myocardial Ischaemia National Audit Project (MINAP) (Barts Health NHS Trust) National Cardiac Audit Programme (NCAP) National Adult Cardiac Surgery Audit (Barts Health NHS Trust) National Cardiac Audit Programme (NCAP) National Audit of Cardiac Rhythm Management Devices and Ablation (Barts Health NHS Trust) National Cardiac Audit Programme (NCAP) National Audit of Percutaneous Coronary Interventions (PCI) (Coronary Angioplasty) (Barts Health NHS Trust) National Cardiac Audit Programme (NCAP) National Congenital Heart Disease Audit (NCHDA) (Barts Health NHS Trust) National Cardiac Audit Programme (NCAP) National Heart Failure Audit (Barts Health NHS Trust) National Clinical Audit of Anxiety and Depression (NCAAD) - Core Audit (Royal College of Psychiatrists) National Clinical Audit of Anxiety and Depression (NCAAD) - Psychological Therapies Spotlight (Royal College of Psychiatrists) National Clinical Audit of Psychosis - 2020/21 Spotlight Audit (Royal College of Psychiatrists)

Stage / % of cas e s s ubmitted

Paused due to COVID-19

Not applicable Yes

Not complete for w hole year due to impact of COVID-19

Yes

100%

Not applicable Yes

100%

Not applicable Not applicable

Yes

Not applicable Not applicable Not applicable

Data collection period still open – w orking to achieve 70% submission rate

Table 11: Nam e of audit programme – project name (providers)

Did PAHT participate ?

National Clinical Audit of Psychosis - EIP audit 2019/2020 (Royal College of Psychiatrists) National Clinical Audit of Psychosis - EIP audit 2020/2021 (Royal College of Psychiatrists) National Comparative Audit of Blood Transfusion - 2021 Audit of Blood Transfusion against NICE Guidelines (NHS Blood and Transplant) National Comparative Audit of Blood Transfusion - 2021 Audit of the Perioperative Management of Anaemia in Children Undergoing Elective Surgery (NHS Blood and Transplant) National Early Inflammatory Arthritis Audit (British Society for Rheumatology) National Emergency Laparotomy Audit (NELA) - (Royal College of Anaesthetists) National Gastrointestinal Cancer Audit Programme (GICAP) - National Bow el Cancer Audit (NBOCA) (Royal College of Surgeons (w ith project management subcontracted to NHS Digital)) National Gastrointestinal Cancer Audit Programme (GICAP) - National OesophagoGastric Cancer Audit (NOGCA) (Royal College of Surgeons (w ith project management subcontracted to NHS Digital)) National Joint Registry - 8 w orkstreams that all report w ithin annual report National Lung Cancer Audit Programme (Royal College of Physicians (RCP)) National Maternity and Perinatal Audit (NMPA) - (Royal College of Obstetricians and Gynaecologists) National Neonatal Audit Programme (NNAP) (Royal College of Paediatrics and Child Health (RCPCH)) National Ophthalmology Audit (NOD) - Adult Cataract Surgery (The Royal College of Ophthalmologists )

Stage / % of cas e s s ubmitted

Not applicable Not applicable Postponed due to COVID-19

Postponed due to COVID-19

Yes Yes

Yes

14 cases Data submission period still open Continuous data submission (submitted annually and retrospectively – 1 year behind) Continuous data submission (submitted annually and retrospectively – 1 year behind)

Yes

89%

Yes

100%

Yes

100%

Yes

100%

Table 11: Nam e of audit programme – project name (providers)

Did PAHT participate ?

Stage / % of cas e s s ubmitted

Yes

135 cases

Yes

100%

National Vascular Registry - (Royal College of Surgeons of England)

Yes

Data submission period still open (extension given)

Neurosurgical National Audit Programme (Society of British Neurological Surgeons)

Not applicable

National Paediatric Diabetes Audit (NPDA) (Royal College of Paediatrics and Child Health (RCPCH)) National Prostate Cancer Audit (NPCA) (Royal College of Surgeons of England)

On Quality Account List 2020/21 but project closed in March 2020, to redirect staff to deal w ith COVID-19, by Public Health England

NHS provider interventions w ith suspected/confirmed carbapenemaseproducing Gram-negative colonisations / infections

Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) Registry - (University of Warw ick) Paediatric Intensive Care Audit Netw ork (PICANet) - (Universities of Leeds and Leicester)

Not applicable Not applicable Start delayed due to COVID but part of PAHT research restart programme

Perioperative Quality Improvement Programme (PQIP) - (Royal College of Anaesthetists ) Prescribing Observatory for Mental Health Prescribing for depression in adult mental health services (Royal College of Psychiatrists) Prescribing Observatory for Mental Health Prescribing for substance misuse: alcohol detoxification (Royal College of Psychiatrists) Prescribing Observatory for Mental Health Prescribing high-dose and combined antipsychotics on adult psychiatric w ards (Royal College of Psychiatrists) Sentinel Stroke National Audit Programme (SSNAP) - (King's College London) Serious Hazards of Transfusion (SHOT): UK National haemovigilance scheme - (Serious Hazards of Transfusion (SHOT)

Not applicable Not applicable Not applicable Not applicable Yes

100%

Table 11: Nam e of audit programme – project name (providers)

Did PAHT participate ?

Society for Acute Medicine Benchmarking Audit - (Society for Acute Medicine) Surgical Site Infection Surveillance - (Public Health England) The Prescribing Observatory for Mental Health - Antipsychotic prescribing in people w ith a learning disability under the care of mental health services (Royal College of Psychiatrists) The Prescribing Observatory for Mental Health - The quality of valproate prescribing in adult mental health services (Royal College of Psychiatrists) The Prescribing Observatory for Mental Health - The use of depot/long-acting injectable antipsychotic medication for relapse prevention (Royal College of Psychiatrists) The Prescribing Observatory for Mental Health - Use of clozapine (Royal College of Psychiatrists) The Trauma Audit and Research Netw ork (The Trauma Audit and Research Netw ork) UK Cystic Fibrosis Registry - (Cystic Fibrosis Trust) UK Registry of Endocrine and Thyroid Surgery (British Association of Endocrine and Thyroid Surgeons) UK Renal Registry National Acute Kidney Injury programme (UK Renal Registry) Urology Audits - Cytoreductive Radical Nephrectomy Audit (The British Association of Urological Surgeons (BAUS)) Urology Audits - Female Stress Urinary Incontinence Audit (The British Association of Urological Surgeons (BAUS)) Urology Audits - Renal Colic Audit (The British Association of Urological Surgeons (BAUS))

Not applicable Yes

100%

Not applicable

Not applicable Not applicable Yes Not applicable Yes

Not complete for w hole of year due to impact of COVID-19

Yes

100%

Not applicable Not applicable Not applicable

Table 12: Nam e of confidential e nquiry

Did PAHT participate ?

Child Health Clinical Outcome Review Programme - Transition from child to adult

Not yet started

Stage / % of cas e s s ubmitted

Stage / % of cas e s submitted

Table 12: Nam e of confidential e nquiry

Did PAHT participate ?

Stage / % of cas e s submitted

health services (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Maternal, New -born and Infant Clinical Outcome Review Programme - Maternal mortality surveillance and confidential enquiry (MBRRACE-UK led from the University of Oxford) Maternal, New -born and Infant Clinical Outcome Review Programme - Perinatal confidential enquiries (MBRRACE-UK led from the University of Oxford) Maternal, New -born and Infant Clinical Outcome Review Programme - Perinatal mortality surveillance (MBRRACE-UK led from the University of Oxford) Medical and Surgical Clinical Outcome Review Programme - Community acquired pneumonia (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Medical and Surgical Clinical Outcome Review Programme – Crohn’s Disease (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Medical and Surgical Clinical Outcome Review Programme - Dysphagia in Parkinson’s Disease (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Medical and Surgical Clinical Outcome Review Programme - Epilepsy Study (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Medical and Surgical Clinical Outcome Review Programme - Physical Health in Mental Health Hospitals (National Confidential Enquiry into Patient Outcome and Death (NCEPOD)) Mental Health Clinical Outcome Review Programme - Suicide and Homicide (National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) - University of Manchester)

Yes

Delayed due to COVID-19

Yes

Delayed due to COVID-19

Not applicable

Table 12: Nam e of confidential e nquiry Mental Health Clinical Outcome Review Programme - Suicide by middle-aged men (National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) - University of Manchester) National Perinatal Mortality Review Tool (MBRRACE-UK led from the University of Oxford)

Did PAHT participate ?

Stage / % of cas e s submitted

Not applicable

Yes

The reports of 20 local clinical audits w ere review ed by PAHT in 2020-21. How ever, during this time and because of COVID-19, front line clinical activity w as focused on the delivery of clinical care. To support local audit related to managing risk associated w ith the transmission of COVID-19, PPE safety marshals w ere seconded in the first w ave and w ere then replaced by PPE champions in the second w ave. Their role w as to carry out audits to measure compliance w ith safety measures introduced. Results w ere fed into the IPC (infection prevention and control) cell. The changes implemented are all detailed in the section for infection prevention and control. Achie vements in information technology The information and technology (ICT) team w orked w ell to meet the requirements for support. The requests became increasingly more urgent as staff adapted to new ways of w orking and a large number of w ard reconfigurations and moves occurred due to COVID19. The ICT team continued to deliver in line w ith the previously agreed strategy and embedded the follow ing:  As our people moved to agile w orking, utilising laptops and docking stations to allow social distancing and w orking from home, w e deployed 748 laptops at PAHT, improving speed and performance  A new telephony system has supported this, allow ing a direct dial number and extension to follow staff on their devices (including mobile phones)  A new single contract for mobile devices, providing a large CIP saving and increasing availability and remote tools, particularly for staff w orking aw ay from site, such as our midw ifery team  Developed and deployed forms to support lateral flow testing for PAHT  A lease programme has been put in place for iPads at a CIP saving of 15% to refresh our old estate that is incapable of supporting the new Apple operating system  Moved our non-staff facing team members to Kao Park, w ith all new equipment, to allow other teams to w ork in an agile w ay utilising hot desks, meeting rooms, etc.  During this period, ICT relocated from Florence Nightingale Medical Centre to Kao Park

 

Various application upgrades and deployments including ICE relaunch, upgrade to MediSight, upgrade to NerveCentre, etc. w ere undertaken Completed 100% of upgrades to Window s 10 and internet brow sers, this has improved speed for people to login and improved security for PAHT

ICT further developed our security protection w ith secure remote boundaries, increasing protection for data in transit and processes to improve reaction to security alerts. During the COVID-19 pandemic, our ICT team played and continue to play a significant role across every area of PAHT. The team provided support to individual staff members, to all clinical teams and they undertook significant change in an exemplary, agile manner. They managed a high number of urgent requests for support to clinical teams looking after our patients throughout the pandemic. This included our customer relationship officers and business partners bringing an increase in partnership w orking betw een the clinical teams and our ICT colleagues, this ensured the support w as there w hen it w as required. Re s earch and development

ACTIVE STUDIES (19/20 - 20/21) 80 70 60 50 40 30 20 10 0

19 Commercial 2019/20

Commercial 2020/21

Non Commercial Non Commercial 2019/20 2020/21

There w ere 13 commercial portfolio studies completed throughout 2020-21, figure 11 above and 12 below . Five w ere open w ith one having a significant delay/suspension due to the COVID-19 pandemic (Diamond Study). Eight of the studies w ere in follow up. We had 70 non-commercial studies in 2020-21. Out of the 50 open studies, 15 w ere significantly suspended or delayed due to the COVID-19 pandemic. There w as one non COVID-19 urgent public health (UPH) study and nine COVID-19 UPH studies. 17 w ere closed to recruitment and had moved into the ‘in follow -up’ category and three w ere closed follow ing the conclusion of follow -up.

2020/21 PAHT Accrual Figures

1500 1000 500 1

Commercial Studies Recruitment

Non-Commercial Studies 1289 Recruitment

Table 13: Re s earch recruitment per speciality Recruitm ent

Speciality

Dire ctorate

Com m ercial/Non com m ercial

Portfolio activity 777

Cancer

Cancer, cardiology and clinical Non-commercial support services

Gastroenterology

Medical

Non-commercial

Emergency department

Urgent and ambulatory

Non-commercial

Critical Care

Surgery

Non-commercial

369

People

Corporate

Non-commercial

Respiratory

Medical

Non-commercial

Maternity

Family and Non-commercial women’s services

Ophthalmology

Medical

Non-commercial

Musculoskeletal

Medical

Non-commercial

Diabetes

Medical

Non-commercial

Cancer

Cancer, cardiology and clinical Commercial support services

Our place s The trust has invested substantially in remodelling and maintaining the estate w ith the follow ing initiatives and priorities progressing at pace over 2020/21.

  

Improving the management of buildings and engineering systems Providing excellent facilities Ensuring safety and security

The approved capital programme w as significant, including £7.7m backlog maintenance and £17m investment in improving the estate. The programme w as made up of three elements, these include:  Emergency backlog and critical infrastructure maintenance schemes (£7.7m)  Capacity schemes (£11.3m)  Development schemes (£5.7m) 2020-21 saw us implementing agile w orking, reducing office accommodation onsite to enable maximising the availability for clinical space in line w ith the emerging demand from increased patient activity. Completed schemes include:  Fracture Clinic  Kao Park (administrative hub)  Adult Assessment Unit (AAU)  Multi-faith facility  Alex Study (Consultants Office)  Dolphin Ward upgrade  Drammen House upgrade  Kalmar House upgrade The locations of the projects are show n on the site plan below . Included are schemes initiated in 2020-21 but due for completion in early 2021-22.

In addition w e completed 54 schemes (90 individual projects) ranging from £10k to £500k to manage maintenance backlog and our critical infrastructural risks. These included:  Asbestos - encapsulation/removal w orks

               

Fire damper remedial w orks - trust w ide Replacement of kerosene tanks located in boiler house compound Water management remedial w orks from audit Labour w ard corridor and room upgrade Upgrade of the Bereavement Suite Bird proofing to roof mounted AHU/Chiller plant Site underground services survey update and required remedial w orks New external door sets to meet LSMS audit report Upgrade of main block (3No.) and Eye Unit lift Obsolete sw itchgear replacement - north and south side Medical gas plant remedial w orks identified in BOC audit CSSD - ventilation replacement New UPS/IPS to ED, theatres and ITU department on critical equipment. Basement fabric, electrical, mechanical repairs required for compliance and business continuity Refurbishment of main sew erage stack Site-w ide roadw ay and footpath repairs

The locations of the projects are show n on the site plan below .

Sus tainability Environm ent and sustainability As acknow ledged by the Clinical Senate Council (South West), climate change should be treated as a healthcare emergency and there is much that can be done both in the short and medium term to make the NHS more sustainable, at provider, organisational, procurement, estates and individual levels. We have continued to pursue our commitment to ensure our delivery of high quality healthcare services w ith minimal negative impact on the environment.

We reported significant progress on our Sustainable Development Management Plan (SDMP) for 2019/20 financial year; w here w e achieved 28% energy related carbon footprint reduction in compliance w ith the set regulatory target by the Environmental Agency on our Carbon Reduction Commitment (CRC) on 2013 baseline figures. This success w as replicated in our w aste management practices, w here w e laid emphasis on processes and methodology to support w aste hierarchy and circular economy and in w ater management, w ith reduction in w ater usage. Despite the impact of the COVID-19 pandemic in the 2020/21 financial year, w e continued to embark on environment and sustainability driven projects to realise set actions on our SDMP and to comply w ith requirements set by the Sustainable Development Unit (SDU), NHSI and the government. The projects focused on include:  

 

Completion of the LED lighting project to actualise the projected carbon and cost savings The Green Zone project: o Implementing the Green Travel Plan’ – installation of electric vehicle (EV) charging infrastructure o Cycle rack installation o Changing facilities for cyclists and runners o Waste recycling area ‘Green Plan’ requirement – review of SDMP activities and timelines to align them to the new Green Plan guideline introduced by the SDU, NHS England and NHSI Delivering net zero by 2045

Carbon footprint s tatement To refresh our SDMP in line w ith new SDU guidance the trust is w orking w ith a net zero consultancy firm, Energise, to establish our baseline emission data and to set measurable targets and pathw ay to achieve net zero by 2045. The analytics method is based on the tools proposed by the Intergovernmental Panel on Climate Change (IPCC) for compilation of Greenhouse Gas (GHG) emissions. The data stream includes limited emissions under scope one and tw o (purchased electricity, gas and fuel used in transport) and limited emissions under scope three (fuel used in personal/hire cars for business purposes, purchasing, generated w aste and w ater supply/sew erage). The interim report (using data available as at February 2021) show s total carbon emission of 17,321.77tCO2e and the follow ing percentage breakdow n by category (figure 13 below ):  Purchasing (scope three) – 64.21%  Natural gas (scope one) – 22.42%  Electricity (scope tw o) – 11.65%  Others (scope one and three) – 1.72%

Quarterly GHG Emissions by Category (tCO2e) 5000 4000 3000 2000

1000 0 FY20-21 Q1

FY20-21 Q2

FY20-21 Q3

FY20-21 Q4

Building Natural Gas

F-Gas

Building Electricity

Grey Fleet

Purchasing

Water Sewerage

Water Supply

Waste

The 2020/21 GHG emissions data indicates that a high percentage of our carbon footprint is from purchasing i.e. supply chain contributors, so a key action of the updated SDMP (Green Plan) w ill be to collaboratively w ork with our supply chain partners to fully integrate sustainable and ethical procurement practices into our procurement strategy/processes for all goods and services. Sus tainability activitie s update Light-Em itting Diode (LED) lighting project The estates and facilities team, along w ith the installation contractor, w orked through the challenges COVID-19 pandemic to deliver the first and second phases of the LED project to programme in December 2020. The total number of installations across the site and the benefits are as below :  Total number of LED luminaires / lamps installed – 4,144 units  Annual cost savings – £150,068.74  Annual energy savings – 1,005,016.35 kWh  Annual carbon savings – 384.18 Tons of CO2 Gre en Zone project The Green Zone construction phase w orks started in February 2021 (delayed due to COVID-19 pandemic). The scheme is split into tw o major elements – the installation of electric vehicle (EV) charging points and the cyclist and runners’ w elfare scheme. In addition to the reduction of travel related carbon footprint, these projects also support staff w elfare and travel modal shift as indicated in staff responses to the travel survey conducted in 2019. Ele ctric ve hicle (EV) charging point The EV charging point w orks are completed. This scheme w ill enhance modal shift to the use of electric vehicles rather than fossil fuelled vehicles. The installation provides the follow ing:

   

Capability to charge up to 22kW (fast charging) to ensure the system is future proofed ready for improvements in vehicle battery Load-balancing betw een multiple vehicles to optimise available supply capacity MID-approved (measuring instrument directive) compliant meters fitted to each charge point connection ensures accurate consumption monitoring Integrated Wi-Fi to enable remote monitoring and fault resolution

Changing facilitie s for cyclis t and runners The planned completion is May 2021. Deliverables from this element of the green zone scheme are:  Fully refurbished changing facilities w ith external cladding  Installation of cycle storage facilities  Improved landscape around the changing facilities, providing outdoor garden space for our people  Improved lighting and a footpath w ith benches Provis ion of waste recycling area and receptacles The provision of a recycling area and receptacles w ill enable us to embark on recycling more domestic w aste streams, as w ell as support the local community w ith recycling of clothing and glass bottles. This w ill complement the job of the dedicated staff resource (Yard Operative) allocated to w aste segregation (outcome of estates and facilities consultation exercise). Ne t ze ro s trategy project scope We are undertaking this project to align our carbon emission reduction commitments to the NHS and UK government goal of achieving net zero by 2050. The output w ill be a defined and a measurable net zero strategy to be adopted by PAHT w ill include high-level cost-benefit analysis and an action plan pathw ay to net zero carbon emission. This project involves:     

Comprehensive assessment of the current major greenhouse gas (GHG) emission sources and emissions across PAHT, aligning to the NHS Carbon Footprint guidance including access to the Net Zero Hub for ongoing carbon reporting Baseline and technical audits including data capture, assessment of the energy performance of the hospital to inform the strategy and behavioural surveys to understand employee influence Assessment of climate-related risks and opportunities available to PAHT, including PESTLE analysis of climate change relating to operation and value chain carbon and assessment of our strengths, w eaknesses, opportunities and threats Assessment of existing and know n potential climate-related legislation and compliance schemes that PAHT are to be aw are of Scenario modelling using government, national and local data sets to assess various technical and financials approaches to net zero and informing other w orks, namely an objective settings w orkshop

 

Objective setting w orkshop to collaborate w ith PAHT to set a reasonable and achievable target for the net zero journey Production of a net zero strategy in line w ith the NHS’s Green Plan guidance, bringing together all data sources and w ork completed to compile an adoptable document supported by various technical w orkbooks.

Low Carbon Skill Fund (LCSF) and Public s e ctor decarbonisation s cheme (PSDS) Our application for the public sector LCSF grant w as successful. We received a grant of £19,140 through Salix and the department of Business Energy and Industrial Strategy (BESI). The funding enabled us to carry out surveys for applicable sustainability technologies to reduce our carbon footprint and deliver an effective PSDS grant scheme application, how ever the £1bn fund made available by the government w as oversubscribed and our £450k grant application w as not given. We are in a better position to put in another application once the government provides further funding opportunities; this is deemed to be imminent due to the government’s commitment to sustainability. Was te m anagement Due to the COVID-19 pandemic, clinical w aste generated across all healthcare settings has increased significantly; PAHT produced 608 tonnes in 2020, an increase of 128 tonnes over 2019 data. This unprecedented increase in w aste generation happened across the country and impacted on the national clinical w aste treatment infrastructure, leading to regular service disruptions and the Cabinet Office established a national emergency logistic cell to manage the situation. We remained compliant w ith the COVID-19 w aste management standard operating procedure (SOP) issued by the NHSE/I for the management of w aste during the COVID-19 pandemic. We have implemented the guidance to ensure our w aste is managed in a safe manner using appropriate receptacles and w aste bags for infectious and non-infectious w aste consignments so that our activities do not negatively affect critical national w aste disposal resources during the emergency response period. Procurement (Supply Chain) Through w orking collaboratively w ith our supply chain partners, w e currently have 75% of our electricity supply from renew able sources (not fossil) that are REGOS certified. The aim is to fully integrate sustainable and ethical procurement practices into our procurement strategies and processes for all goods and services. This is being incorporated into the procurement of our environment and sustainability related contract agreements.

We w ill continue to specify environmentally friendly practices to our supply chain partners to ensure that our contract arrangements for services that have a direct or indirect impact on the environment are managed, w ith climate risk elements mitigated. Looking ahead In addition, w e are making visible our commitment to w ork tow ards the national goal of keeping the global average temperature increase below 2°C and achieving ‘Net Zero’ by 2050. We w ill continue to review the carbon footprint of our estates and its impact on the environment, our staff, patients and our finances in line w ith our strategy to decarbonise our facilities. To achieve this w e will:  Produce achievable and measurable Green Plan (SDMP) from established site-specific baseline data, pestle analysis and defined net zero pathw ay scenarios i.e. w ith outlined programme of goals w here w e can keep track of planned actions and progress. The actions w ill include: o Proposal to change fleet and estate vans to electric vehicles o Further removal of single use plastic from our restaurant o Sw itch over to low pow er laptops w here reasonably practical o Collaboration to positively influence our supply chain partners  Drive further energy, w ater and carbon reductions in ow ned buildings and rented buildings  Achieving the BREEA M (Building Research Establishment Environmental Assessment Method) standard for all our capital projects and new builds  Maintain comprehensive measurement and reporting systems w ith external verification and publish our annual report  Challenge building contractors to propose cost-effective, low carbon solutions w hen undertaking refurbishment projects and monitor the benefits  Work w ith w aste contractors to implement the w aste hierarchy, achieve zero w aste to landfill and turn residual w aste into a resource opportunity w herever possible  Aim to increase the amount of electricity w e purchase from the national grid that is generated from renew able energy sources  Produce a Net Zero Strategy alongside partners to understand our current position and actions required to w ork tow ards Net Zero w ithin the NHS’s timeframe, no later than 2045  Implementation of our green travel plan to ensure that all travel options and impacts are taken into consideration w hen planning new premises and for off-site/local community healthcare services Conclusion against our sustainable development goals We are constantly striving to understand fully and reduce the environmental impact created through delivering quality healthcare services. We are also looking at how sustainable principles can help provide a better environment for our people, patients and the local and global community.

We w ill continue to analyse the environmental, social and economic impacts of our activities; covering the three approved global Greenhouse Gas (GHG) emission scope protocols (scopes one, tw o and three) w ith the aim of fully embedding sustainability themes, throughout the w hole organisation in compliance w ith the target set by the Climate Change Act (2008), Net Zero by the year 2045 and to fulfil our moral responsibilities of ensuring a better environment for future generations.

State ments from stakeholders

State ment from West Es sex Clinical Com missioning Group and Eas t and North He rtfordshire Clinical Commissioning Group West Essex Clinical Commissioning Group and East and North Hertfordshire Clinical Commissioning Group are responsible for the commissioning of acute health services from The Princess Alexandra Hospital NHS Trust for the citizens of w est Essex and east and north Hertfordshire. Both West Essex and East and North Hertfordshire CCGs w ould like to commend and thank all the staff and volunteers that w ork for The Princess Alexandra Hospital NHS Trust in relation to their response to the COVID-19 pandemic. Staff responded w ith professionalism, energy and adaptability. Their teamw ork and continued energy has enabled the care of patients to continue during the challenging time of the pandemic. The production of this year’s Quality Account has been challenging for all providers, the Department of Health and Social care considered an extension to the publication deadline of 30.06.21 (a significant extension w as enabled in 2020), how ever confirmation w as received in May that there w ould not be an extension this year. The trust has identified eight priorities for 2021/22 that are fundamental elements of their five P strategy: our patients, our people, our performance, our places and our pounds. This includes continuing the w ork to reduce the mortality rate and to support staff affected by their experiences during the pandemic and improve w ellbeing. All priorities that w ere not fully achieved last year have been extended into 2021/22. These priorities w ill be monitored through the PAHT Quality and Safety Committee. During the last year, PAHT has faced significant challenges due to the COVID-19 pandemic; very unw ell patients, changes to w ard locations due to infection , prevention and control requirements, staff w orking in full PPE, increased admissions of patients requiring higher levels of care than usual, redeployment of staff to intensive care and high dependency units, maintaining care services throughout. All staff have had to w ork differently and adapt to an ever-changing position w ith differing requirements for the management and testing of patients. Support mechanisms for staff are in place and w ill continue into the next year. The trust has w orked w ith partners w ithin the local health economy, independent sector hospitals, to continue the surgical care of patients w ith cancer. Unfortunately, the pandemic affected PAHT’s ability to achieve the requirement to treat 85% of patients w ith cancer w ithin 62 days; how ever there are plans in place to improve the position and treat patients quickly as capacity increases.

The trust has reported against last year’s quality priorities (2020/21), it is clear from the narrative w hether these priorities w ere fully achieved or not. Those not fully achieved have been rolled over to continue into 2021/22, it is clear that all priorities have been affected by the pandemic. The trust has provided a full and transparent account of the CQC inspections they have had in year, w hat this has meant for services and how concerns are being addressed. The trust has identified many departments and speciality teams w ithin w hich improvements have been made in the last year, notably the w ork of: the infection control team and their w ork during the pandemic to support patients and staff, the teams caring for patients w ith dementia, case studies in relation to learning from complaints and the w ide ranging and constructive w ork of the Patient Panel, w ho have continued to w ork together virtually throughout the year. The integrated w orking w ith staff and the high esteem w ith w hich the Patient Panel are view ed is very clear in the Quality Account. Maternity services have been the focus of national scrutiny follow ing the publication of the Ockenden report. PAHT has responded to the requirements of the report and is actively w orking to improve services for w omen and their families. The trust is part of the Local Maternity and Neonatal Service netw ork (LMNS) w ith acute trusts in Hertfordshire – best practice and learning from clinical incidents is shared across the LMNS. In year, the trust has invited peer review of some maternity incidents, to ensure that an external view is part of the investigation, this demonstrates a transparent approach to learning and improvement. The peer review identified a significant amount of good practice and made recommendations for changes w hich are being taken forw ard by the teams. We confirm that w e have review ed the information contained w ithin the Account and checked this against data sources w here these are available and it is accurate in relation to the services provided. Some of the data that is required to be included for example, a comparison of the trust results to the highest and low est scores of other organisations has not been included, w e expect this w ill be addressed in the final version.* The draft has some missing information (audit data, statement from the CEO) w e understand that this w ill be updated in the final version. We have review ed the content of the Account; it complies, on the w hole, w ith the prescribed information as set out in legislation and by the Department of Health and Social care. We believe that the Account is a fair, representative and balanced overview of the quality of care at the trust. We w ill continue to collaborate w ith and support the trust to achieve good quality care and treatment for the people of w est Essex and east and north Hertfordshire. The CCGs w ould like to extend their thanks to all the staff at The Princess Alexandra NHS Hospital for their dedication and commitment to the people they care for and how they have provided compassionate, supportive care to people through the pandemic.

Jane Kinniburgh Director of nursing and quality Hertfordshire and West Essex Integrated Care System June 2021 Dr Rob Gerlis, chair Dr Jane Halpin, chief officer *noted with partial comparisons included in the published version

Re s ponse to Princess Alexandra Hos pital Trust (PAHT) Quality Account 2020-21

Healthw atch Hertfordshire values the relationship w ith The Princess Alexandra Hospital NHS Trust and looks forw ard to continuing to w ork closely w ith the trust to help improve services for patients including supporting the quality priorities outlined in this Quality Account.

Ste ve Palmer Chair, Healthw atch Hertfordshire June 2021

Glos s ary of te rms Acute bowel obstruction - Significant mechanical impairment of the passage of contents through the intestine (bow el) due to a blockage of the bow el Allie d he alth practitioners - Healthcare professionals w orking in dietetics, occupational therapy, physiotherapy, operating department assistants, radiography and speech and language therapy. This is distinct from nursing, medicine, pharmacy and healthcare scientists Am bulatory care - Medical care provided on an outpatient basis, includes diagnosis, observation, consultation, and treatment Ante natal – This is the care you receive from health professionals during your pregnancy Anticoagulation - Medicines that help prevent blood clots Antim icrobial resistance - The ability of a bacteria to resist the effects of medication (antibiotics) that once could successfully treat the infection Antim icrobial s tewardship - A coordinated intervention designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration Audiology - The study of hearing and balance Bacte rae mia – An infection of bacteria in the blood Cardiac arrest – Sudden loss of blood flow from failure of the heart to pump effectively Cardiac cathe te r lab – Procedures of placing catheters (small tubes) into the blood stream to access the heart and blood vessels Cardiology - The branch of medicine that deals w ith diseases and abnormalities of the heart Care Quality Commission (CQC) - CQC is an executive non-departmental public body of the Department of Health United Kingdom. Established in 2009, it is the independent regulator of all health and social care services in England Che mical pathology – A branch of pathology dealing w ith biochemical basis for disease Che motherapy - The treatment of disease by the use of chemical substances, especially the treatment of cancer by cytotoxic and other drugs Chronic obstructive pulmonary disease (COPD) - The name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airw ays disease

Clinical audits - A process aimed to improve quality of patient care and outcomes through systematic review of care against explicit criteria and the implementation of change Clinical coding - The process by w hich patient diagnosis and treatment is translated into standard, recognised codes that reflect the activity that happens to patients Clinical Commissioning Group (CCG) - NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England Clinical nurse specialis t (CNS) - A nurse w ho has advanced know ledge and competence in a particular area of nursing practice Clostridium difficile (C.difficile) - Clostridium difficile, also know n as C. difficile, or C. diff, is a type of bacterial infection that can affect the digestive system Colorectal care - Treatments for patients w ith symptoms of the gastrointestinal tract including colorectal cancer and inflammatory bow el disease Colposcopy and hys teroscopy services - A procedure used to examine the cervix and inside of the w omb (uterus) CQUIN - Commissioning for Quality and Innovation is a system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care Datix - Softw are used in healthcare to collect patient safety incidents and for reporting adverse events De lirium - Is a state of mental confusion that can happen if you become unw ell. It is also know n as an acute confusion De m entia cham pions - A group of staff w ho have had specific training in dementia care. Their aim is to make other colleagues more understanding of w hy a patient may be more challenging and encourages them to tailor therapies accordingly De rmatology - The branch of medicine concerned w ith the diagnosis and treatment of skin disorders Diagnos tics - Tools used to help identify disease and illness Die te tics – A branch of healthcare concerned w ith the diet and its effects on health, especially w ith the practical application of a scientific understanding of nutrition Dys phagia – Medical term for sw allow ing difficulties

Endocrinology - The branch of physiology and medicine concerned w ith endocrine glands and hormones Endos copy - A procedure that allow s a view the inside of a person's body ENT clinics – An area w here diagnosis and treatment is provided to conditions of the ear, nose and throat Epide m iology – The study (scientific, systemic and data driven) of the distribution, frequency and pattern of health related states and events in specific populations such as neighbourhoods, schools, countries and globally Escherichia coli (E.coli) bacte raemia - Type of bacterial infection and a blood stream infection Frailty s e rvice – Review s frail older people using a holistic assessment of physical, mental and social needs Frie nds and Fam ily Te st (FFT) - Test aimed at providing a simple headline metric w hich, w hen combined w ith follow -up questions, is a tool to ensure transparency, celebrate success and galvanize improved patient experience. It asks “How likely are you to recommend our services to friends and family if they needed similar care or treatment?” w ith answ ers on a scale of extremely likely to extremely unlikely Gas troenterology - The branch of medicine w hich deals w ith disorders of the stomach and intestines Ge nito-urinary - The branch of medicine relating to the genital and urinary organs Gove rnance - Establishment of policies, and continuous monitoring of their proper implementation, by the members of the governing body of an organisation Gram ne gative blood s tream infections (GNBSIs ) - Type of bacterial infection and a blood stream infection Gynae cology - The branch of physiology and medicine that deals w ith the functions and diseases specific to w omen and girls, especially those affecting the reproductive system Hae m atology - The branch of medicine involving the study and treatment of the blood He althcare associated infections (HCAI) - Infections that are acquired as a result of healthcare. The burden of healthcare-associated infections has mainly been in hospitals w here more serious infections are seen He alth Education England - Is the new national leadership organisation for education, training and w orkforce development in the health sector

He alth Ove rview and Scrutiny Committee – Local authority committees that scrutinise health issues and care in their area He althw atch – Obtain the view s of people about their health needs and experiences of having care and social services Hos pital Standardised Mortality Ratio (HSM R) - Calculation used to monitor death rates in a trust Inflam m atory bowel disease – The name for a group of conditions that cause the digestive system to become inflamed Inte rventional radiology - Is a sub-specialty of radiology w hich utilises image-guided procedures in order to diagnose and/or treat diseases using the least invasive techniques Intrave nous – Giving fluids or drugs directly into a vein Klebsiella bacte remia - Type of bacterial infection and a blood stream infection Laparotomy - A surgical incision into the abdominal cavity, used for diagnosis or in preparation for major surgery M ate rnal and Fe tal As sessment Unit - Outpatient Antenatal Unit offering planned appointments for assessment of the mother and unborn baby in pregnancy M axillofacial de partment – An area w here diagnosis and treatment is provided to conditions of the mouth, face and adjacent structures M e dical e xam iner – senior medical doctors w ho are contracted for a number of sessions a w eek to undertake medical examiner duties outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes M e dicines optimisation - Is the process of ensuring patients are on the most effective and few est medications Methicillin-Resistant Staphylococcus Aureus (M RSA) / Methicillin-Sensitive Staphylococcus Aureus (M SSA) – A specific bacterial infection M orbidity and m ortality (M &M) - Meetings established to review deaths as part of professional learning M yocardial infarction - Commonly know n as a heart attack M yocardial is chaemia - When blood flow to your heart is reduced, preventing the heart muscle from receiving enough oxygen

National Confidential Enquiries (NCEPOD) - National Confidential Enquiry into Patient Outcome and Death National Re porting and Learning System (NRLS) - A central database of patient safety incident reports Ne onatal (NICU) - New -born children and new -born intensive care unit Ne urology - The branch of medicine or biology that deals w ith the anatomy, functions, and organic disorders of nerves and the nervous system NHS Digital – the national information and technology partners to the health and social care system NHSE/I - NHS England and Improvement is responsible for overseeing trusts and NHS services, as w ell as independent providers that provide NHS-funded care NICE - The National Institute for Health and Care Excellence provides guidance, w hich supports healthcare professionals and others to make sure that the care they provide is of the best possible quality and offers the best value for money Non-invas ive positive pressure ve ntilation - uses a ventilator breathing machine to help move air into and out of the lungs. Delivered through a tight fitting facial or nasal mask and pressure assists to keep the airw ays open. Norovirus - A type of viral infection that can affect the digestive system Obs te trics - The branch of medicine that deals w ith the care of w omen during pregnancy, childbirth, and the recuperative period follow ing delivery Oe s ophago-gastric care – Treating patients w ith problems of the gullet (oesophagus) and stomach Oncology - The study and treatment of cancer and tumours Ophthalm ology - The study of the structure, functions, and diseases of the eye. Orthopaedic - The branch of medicine that deals w ith the prevention and correction of injuries or disorders of the skeletal system and associated muscles, joints, and ligaments Pae diatrics - The specialty of medical science concerned w ith the physical, mental and social health of children from birth to young adulthood Palliative care - An approach that improves the quality of life of patients and their families facing the problems associated w ith life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

Pathology - The scientific study of the nature of disease and its causes, processes, development and consequences Patie nt Advice and Liais on Service (PALS) - Offering confidential advice, support and information on health-related matters. Provides a point of contact for patients, their families and their carers Patie nt Pane l - A group of volunteers w ho represent patients, families and carers of The Princess Alexandra Hospital NHS Trust Patie nt Safe ty Ale rts - Issued by NHS Improvement to rapidly w arn the healthcare system of risks. They provide guidance on preventing potential incidents that may lead to harm or death Pe rioperative medicine - care of patients from the time of contemplation of surgery through the operative period to full recovery. Pe rsonal protective e quipment (PPE) - w ill protect the user against health or safety risks at w ork Polym erase chain reaction (PCR) te s ting - a method w idely used to look for genetic code of the COVID-19 virus, this involves taking a sw ab of the throat and nose. The test w ill confirm if a person w ith symptoms has the virus currently Pos t Anaesthetic Care Unit (PACU) – An area in theatre w here patients are taken directly after surgery so they can w ake up from their anaesthetic and w ill remain until w ell enough to go to a w ard for ongoing care Pos tpartum haemorrhage – A complication w here there is bleeding heavily after the birth of a baby Ps e udomonas aeruginosa - A specific bacterial infection Public He alth England - A government body w ith the role to protect and improve the nation’s health and w ellbeing and reduce health inequalities Pulm onary embolism (PE) - A sudden blockage in a lung artery Rapid As sessment and Treatment (RAT) - A treatment model used in emergency care to provide an early senior assessment and early treatment Radiology - The branch of medicine that deals w ith the use of radioactive substances used in diagnosis and treatment of disease.

Re fe rral to Treatment (RTT) – A constitutional standard that trusts are measured against in w hich a person’s w aiting time starts on the day the hospital receives the referral letter from a GP to the time of first appointment or treatment Re s piratory medicine – The branch of medicine that deals w ith the act of breathing Rhe umatology - The study and treatment of arthritis, autoimmune diseases, pain disorders affecting joints, and osteoporosis Se psis and septicaemia - Sepsis is a serious blood stream infection. A serious complication is septicaemia, w hich is w hen inflammation occurs throughout the body, w hich can be life-threatening Se rious Incidents (SIs ) - An unexpected or unplanned event that caused harm or had the potential to cause harm to a patient, member of staff, student, visitor or contractor Stak e holders - A stakeholder is anyone w ith an interest in a business. Stakeholders are individuals, groups or organisations that are affected by the activity of the business. They include ow ners who are interested in how much profit the business makes Standard Operating Procedures – A set of step-by-step instructions compiled to help w orkers carry out complex routine w ork, aimed to achieve efficiency and uniformity of performance Standardised M ortality ratio (SM R) and Summary Hos pital-level M ortality Indicator (SHM I) - Ratio betw een the actual number of patients w ho die follow ing treatment at the trust and the number that w ould be expected to die, based on average England figures given the characteristics of the patients treated there Sus tainability and Transformation Partnerships (STP) - Bringing together local health and care leaders to plan the long-term needs of local communities and how care w ill be delivered Trauma Audit and Research Ne twork (TARN) – An audit w here information is collected and analysed for patients w ho are moderately or severely injured after an injury. Data is submitted by trusts and a comparison can be undertaken Urology - The study of urinary organs in females and the urinary and sex organs in males Vas cular surgery – Specialists that treat people w ith diseases of the circulation, w hich can be conditions affecting arteries, veins and w here there are blockages to the flow of blood. Ve nous thromboembolism (VTE) - A condition w here a blood clot forms in a vein, most commonly in a leg w here it is know n as deep-vein thrombosis (DVT), a blood clot in the lungs is called a pulmonary embolism (PE) VTE prophylaxis - The giving of a medicine or treatment to prevent a VTE

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