Progress against priorities set for 2020-21 Our patie nts

Pre scribed information Form of s tatement

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.

28 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 hospeak 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. 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 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.

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

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Priorities w e 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.

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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

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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 affectedthe 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 affectedthe 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.

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The trust has continued to focus on reducing long length of stays for patients through collaborative w ork w iththe 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 econtinued 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 successfulw ith32 nurses recruited follow ingstudent placements at the trust and by grow ingour ow nregistered nurses w hohave undertaken an apprenticeship programme from being healthcare support w orkers toregistered nurses.

In addition, w ew elcomed 81 international nurses despite restrictions on global travel due to the pandemic, all of w hichcontributed to a band 5 vacancy rate of 5.8% in March 2021.

Our nursing w orkforceestablishments w ereuplifted in October 2020 follow ingan establishment review ,w hichincreasedthe overall number of established nursing posts by 23.64WTE, and band 5 posts by 34.27WTE. It is w orthnoting that w ithoutthe increase in establishment the overall nurse vacancy rate w ouldhave been 4.8%.

Turnover rates have continued to reduce and w ere8.65% 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 toreduce face-to-face consultations through better use of technology and redesigned

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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 rapidly , using the Attend Anyw here platform, as part of the national response to COVID-19 in April 2020,w ith 70% of spec ialties on-boarded to use the system. Template letters and proc esses es tablishe d to support the delivery of telemedicine. We are now engaging w ith operational teams to identify opportunities to increase non-face-to-fac e c apacity, 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 paperles s communic at ion f or patients . A text message generates a link for c orrespondenc e to be v iewed. This is in place f or all appointments in outpatients w ith outc ome letters due to go live in April 2021. There has been a 71% uptake of patients choosing to view their letters electronically, w hich has both cost sav ings, 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 enabling tw o w ay messaging w ith our patients . We hav e gone liv e w ith paediatric and paediatric diabetes as a tw o w ay mes saging flow f or appoint me nts. Other main outpatient services w ill be live by October 2021 and pilots are due to commenc e for gynaecology elec tive 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%.

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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

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Outcom e: Achie ved

During 2020/21, w ehave 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 virtualtow 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 esecured 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 havealso 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.

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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.

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Table 4: COVID-19 data up to 31-03-21 Inpatient spells since: 01 02 20: First w ave 01 09 20: Second w ave

Total inpatient spells (w ith a positive sw ab):

2069 Inpatients (positive) - on 31 03 21: 5 Inpatients (previously positive) - on 31 03 21: 7 1542 5

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Discharged home (w ith a positive sw ab in spell): Discharged other (w ith positive sw ab in spell): 1249

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Inpatient deaths (w ith positive sw ab in spell): 529

Transferred (w ith positive sw ab in spell): 210 1018

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330

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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 at PAHT, using national definitions

01/04/20 – 31/03/21 Q1 Q2 Q3 Q4

Patients testing positive for the first time 3-7 days after admission (indeterminate cases)

31 1 84 76

Patients positive for the first time 8-14 days after admission (probable nosocomial infection)

19 0 57 56

Patients positive for the first time >15 days after admission (definite nosocomial infection)

12 0 40 38

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 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

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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 eekdays, 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

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 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

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

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Cl ostri di um di ffi ci l e (C.di ffi ci l e) Apr-20 May-20 Jun-20 Jul -20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Hospi tal onset heal thcare associ ated: 0 2 1 4 6 4 2 1 5 7 3 8 Communi ty onset heal thcare associ ated: 1 0 0 0 2 0 1 1 0 2 2 2 Communi ty onset i ndetermi nate associ ati on: 1 1 1 2 2 2 5 1 1 1 0 0 Communi ty onset communi ty associ ati on: 0 2 1 1 1 0 1 1 0 1 0 1

 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 infe ctions Pre 48 hour cases Pos t 48 hour cases

E.coli bacteraemia

156 Klebsiella spp. bacteraemia 33 Pseudomonas Aeruginosa bacteraemia 14 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

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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 hichw 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.

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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 ingaccess 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 w ay te xt messaging

 Moved aw ay from a one-w ay messaging flow to enable tw o way 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)

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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).

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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 638 A17 - Appointments 481

A08Q Poor communication/lack of communication betw een professionals/patients 542 A03A Delay in appointment time 274 A17I Inadequate communication about an appointment 182 A08W No reply to telephone contact 192 A03B Delay in operation time taking place 126 A17J Appointments poorly organised/scheduled 116

A08I Written communication inaccurate (i.e. out of date)

37 A03F Delay in test results (i.e. X-ray results) A08Z Clarity/confusing 34 A03H Delay in referral - internal 126 A17H Cancellation of an appointment

38 A17D Long w ait for appointment 107

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A08J Written communication - delay in sending correspondence, letters, etc. 24 A03E Delay in treatment (i.e. IV Fluids) 23 A17F Delay in being seen 6

Se ction 18 re port 204 com plaints in 2020-21, incre asein 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 ereceived, 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 .

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Table 9: Themes from complaints

Com munication M e dical care Nurs ing care

Lack of information shared w ith relatives Poor communication/lack of betw een professionals/patients No telephone contact w ith relatives Conflict of information betw een professionals Lack of information shared w ith the patient 31 Missed diagnosis 27 Inadequate monitoring

29 Inadequate treatment provided 19 Poor standard of care provided 19

19

13 Poor treatment provided 9 No treatment provided 9 Failure to refer to another speciality 19 Poor pain control 17

15 Poor nutrition 14

10 Lack of assistance w ith personal and oral hygiene 13

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 :

 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 hichhas 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 ithour 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 tw o

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.

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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 esadly 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 orkfrom 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-facemeetings  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

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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 hichwas 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 hichhas 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.

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Working with our patients and their carers

We introduced a w eekly carers group and revised the carer’s card, w hichallow 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, investigationsand changes im plemented

Patient safety is a key trust priority, w econtinually strive to ensure incidents are managed effectively and most importantly that w elearn 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 ereported 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 hencompared w ith2019-20 other than death graded harm, w hichhas increased from 0.06%, attributed to hospital onset COVID-19 infection, a recognised national issue.

1200

1000

800

600

400

200

0

Apr 2020 May 2020 Jun 2020 Jul 2020 Aug 2020 Sep 2020 Oct 2020 Nov 2020 Dec 2020 Jan 2021 Feb 2021 Mar 2021 Apr 2021 May 2021

None Minor Moderate Severe Death

This year saw c hanges in the incident management proc ess 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 s erious incident group meetings. IMG activity for the year resulted in the management of 785 incidents of w hich 141 required internal inv es tigation.

Incide nt themes

• Doc umentation not fully completed or missing • Time ly as sessment and allocation to the correct speciality team first time • Number of falls in patients requiring clos e observation • Staf f unaw are their patients requested radiologic al inves tigat ions have been ref us ed, therefore patients ex periencing delays • Patient medication pods at each bedside noted not all to be locking

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• Two c ritical medications (insulin) not prescribed/given af ter unplanned admis s ion. This w ill be part of the patient safety priorities in the coming y ear • Compliance w ith the recording and es calation of observations • Care of the deteriorating adult w ith COVID-19 outside of the critical c are 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 ingexamples illustrate the approach to learning.

What w e have changedfollow ingincidents this ye ar

• Paper based ris k ass essment transferred onto Nervecentre, allow ing trans parenc y of results and the es calation of non-completion • Speciality rev iew and treatment of patients w ith abdominal pain pathway developed in consultation betw een the emergency department (ED), paediatrics and surgery • Enhanced care proc ess implemented • Radiology c onsultants provide a clinical rationale on the electronic request f or radiology investigation if it is declined • Trus t w ide review of all bedside lockers undertaken and new pods provided • Improvements to medicine reconciliatio n by daily pharmacist pres ence in the ac ute admiss io 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 respons e team during wave one of the COV ID-19 pandemic to support 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 es calation of the sick child • Changes to PAHT policies (f alls, GI bleed policy, maternity related policies) as a result of learning and embedding changes into prac tice

Im proving medicine safety

Over the last 12 months, the pharmacy team have w orkedcollaboratively w ithcolleagues across the w holeorganisation 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 ardmoves, w ritingand validating clinical guidelines and support for home delivery of medication to patients w ithcancer.

De ve lopingthe roles of our pharmacists

We have specialist pharmacists w orkingin critical care, anticoagulation, gastroenterology, rheumatology and dermatology; these individuals provide expert advice and guidance to support patient care. In addition, w enow havea specialist neurology pharmacist w hoprovides expert pharmaceutical support to this group of

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patients. We are also developing our integrated w orkforcew ithinthe Integrated Care Partnership (ICP) by having tw ojoint posts w ithWest Essex Clinical Commissioning Group (CCG). One of these posts is a lead frailty pharmacist.

M e dicines optimisationto acute assessment

As part of new models of medicine optimisation care and to support the new ly opened medical assessment unit, pharmacy staff w illbe providing support to the unit 12 hours a day, seven days a w eek.This w illsupport safe management of medication and patient flow .

Antim icrobials 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 effectivecourse 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 ecanmonitor our practices and ensure that our patients are receiving safecare.

Ele ctronicPrescribing and Medicines Administration(EPM A)

The EPMA team have implemented automatic stop dates for antibiotics, based on the indication selected w henthe 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 ereinitiated over the past year, all of w hichwere configured on EPMA. This has facilitated prescribing and management of the trials through reporting available in EPMA.

A new chemotherapy prescribing systemcalled ChemoCare has been implemented w hich w illsignificantly 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 een1 October 2019 and 31 March 2020, show edthat the proportion of reported incidents that w eremedication 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 ).

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M e dication safetyprogramme

Other areas w heregood progress has been achieved includes:  Our medicines optimisation group meets monthly to review anddiscuss 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 ideor 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 safestorage and use of medicines and compliance w ithgovernance requirements  There is regular communication betw eenthe medication safety officer and the EPMA team to see how JACcan 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

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 Staff are made aw areof national medicine shortages and receive advice about alternative medicines that can be prescribed  Air handling units are now in place across the w holeorganisation 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 :

People KPI 2019-20 targe t Ye ar to date pe rformance

Vacancy rate Sickness absence 8.6% 8% 4.3% 3.6%

Voluntary turnover Statutory and mandatory training Appraisal Flu 10.7% 9.7% 92% 87% 89% 71% 80.1% 81%

Time to hire 31 days 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 :  Lookingafte 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 deliveringcare – 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

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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 wellbeing

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

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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 orkingat 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-facedrop 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

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 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 oof 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 apoignant 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).

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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 tw o: 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.

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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 ereexplored 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 orkfor 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 committee and trust board meetings. Externally, the trust is held to account for its operational performance by NHS England/Improvement.

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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 hichallow ed us to continue cancer and urgent elective surgery, along w ith associated diagnostics. The consequent impact on the 18-w eekRTT 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.

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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.

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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 oaudits due to local softw are issues. A summary of this information is in table 11.

There w ere nine national confidential enquiries, w hichthe 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.

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Table 11: Nam e of audit programme –project name (providers) Did PAHT participate ? Stage / % of cas e s s ubmitted

Antenatal and New -bornNational Audit Protocol 2019 to 2021 Yes 100%

British Spine Registry (British Spine Registry) Yes All procedures Case Mix Programme (CMP) (Intensive Care National Audit and Research Centre (ICNARC)) Yes 100% Cleft Registry and Audit Netw ork (CRANE) (Clinical Effectiveness Unit, The Royal College of Surgeons of England) Not applicable Elective Surgery (National PROMs Programme) (NHS Digital) Yes 92% Emergency Medicine QIPs - Fractured Neck of Femur (Care In Emergency Departments) (Royal College of Emergency Medicine) Yes 117 cases Emergency Medicine QIPs - Infection Control (Care In Emergency Departments) (Royal College of Emergency Medicine) Yes 94 cases Emergency Medicine QIPs - Pain in Children (Royal College of Emergency Medicine) Yes Data submission period extended Falls and Fragility Fracture Audit Programme (FFFAP) - National Audit of Inpatient Falls (Royal College of Physicians (RCP) Yes 100% Falls and Fragility Fracture Audit Programme (FFFAP) - National Hip Fracture Database (NHFD) (Royal College of Physicians (RCP)) Yes 352 cases = 100% Falls and Fragility Fracture Audit Programme (FFFAP) - Vertebral Fracture Sprint Audit (Royal College of Physicians (RCP)) Not applicable Inflammatory Bow el Disease (IBD) Audit Biological Therapies Audit (IBD Registry) - IBD Yes 189 cases Inflammatory Bow el Disease (IBD) Audit – IBD Service Standards (IBD UK) Not applicable LeDeR - Learning Disabilities Mortality Review (NHS England and NHS Improvement) Yes 100% Mandatory Surveillance of HCAI (Public Health England) Yes 100% National Adult Diabetes Audit (NDA) Core Diabetes Audit (NHS Digital) - National No National Adult Diabetes Audit (NDA) - National Diabetes in Pregnancy Audit (NHS Digital) Yes 71% National Adult Diabetes Audit (NDA) - National Diabetes Transition (linkage w ith NPDA) (NHS Digital) Partial Automatic data linkage from NDA and NPDA (not

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Table 11: Nam e of audit programme –project name (providers) Did PAHT participate ? Stage / % of cas e s s ubmitted

National Adult Diabetes Audit (NDA) - National Diabetes Foot Care Audit (NHS Digital) Yes

National Adult Diabetes Audit (NDA) - National Diabetes Inpatient Audit Harms (NaDIA-Harms) (NHS Digital) 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

National Adult Diabetes Audit (NDA) - NDA Integrated Specialist Survey (NHS Digital) Yes National Asthma and COPD Audit Programme (NACAP) - Adult asthma secondary care (Royal College of Physicians (RCP) ) Paused due to COVID-19

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) Paused due to COVID-19

Paused due to COVID-19

Not applicable

Yes 100%

National Audit of Cardiac Rehabilitation (University of York) Not applicable

National Audit of Care at the End of Life (NACEL) - (NHS Benchmarking Netw ork) Round 3 data collection cancelled to due impact of COVID-19

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) Not applicable Data collection suspended due to COVID-19 Data collection suspended due to COVID-19

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Table 11: Nam e of audit programme –project name (providers) Did PAHT participate ? Stage / % of cas e s s ubmitted

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)

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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 ? Stage / % of cas e s s ubmitted

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 Not applicable

Not applicable

Postponed due to COVID-19

Postponed due to COVID-19

Yes 14 cases

Yes Data submission period still open

Yes

Yes

Continuous data submission (submitted annually and retrospectively – 1 year behind) Continuous data submission (submitted annually and retrospectively – 1 year behind) Yes 89%

National Lung Cancer Audit Programme (Royal College of Physicians (RCP)) Yes 100% National Maternity and Perinatal Audit (NMPA) - (Royal College of Obstetricians and Gynaecologists) Yes 100% National Neonatal Audit Programme (NNAP) (Royal College of Paediatrics and Child Health (RCPCH)) Yes 100% National Ophthalmology Audit (NOD) - Adult Cataract Surgery (The Royal College of Ophthalmologists ) No

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Table 11: Nam e of audit programme –project name (providers) Did PAHT participate ? Stage / % of cas e s s ubmitted

National Paediatric Diabetes Audit (NPDA) (Royal College of Paediatrics and Child Health (RCPCH)) Yes 135 cases

National Prostate Cancer Audit (NPCA) (Royal College of Surgeons of England) Yes 100% National Vascular Registry Surgeons of England) - (Royal College of Yes Data submission period still open (extension given)

Neurosurgical National Audit Programme (Society of British Neurological Surgeons) Not applicable

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

Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) Registry - (University of Warw ick) Not applicable

Paediatric Intensive Care Audit Netw ork (PICANet) - (Universities of Leeds and Leicester) Not applicable

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 Start delayed due to COVID but part of PAHT research restart programme

Not applicable

Not applicable

Yes 100%

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Table 11: Nam e of audit programme –project name (providers) Did PAHT participate ? Stage / % of cas e s s ubmitted

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) Not applicable Yes 100%

Not applicable

Not applicable

Not applicable

Not applicable The Trauma Audit and Research Netw ork (The Trauma Audit and Research Netw ork) Yes UK Cystic Fibrosis Registry - (Cystic Fibrosis Trust) Not applicable

UK Registry of Endocrine and Thyroid Surgery (British Association of Endocrine and Thyroid Surgeons) Yes Not complete for w hole of year due to impact of COVID-19

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)) Yes 100%

Not applicable

Not applicable Not applicable

Table 12: Nam e of confidential enquiry Did PAHT participate ? Stage / % of cas e s submitted

Child Health Clinical Outcome Review Programme - Transition from child to adult Not yet started

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Table 12: Nam e of confidential enquiry Did PAHT participate ? Stage / % of cas e s submitted

health services (National Confidential Enquiry into Patient Outcome and Death (NCEPOD))

Maternal, New -bornand Infant Clinical Outcome Review Programme - Maternal mortality surveillance and confidential enquiry (MBRRACE-UK led from the University of Oxford) Maternal, New -bornand Infant Clinical Outcome Review Programme - Perinatal confidential enquiries (MBRRACE-UK led from the University of Oxford) Maternal, New -bornand 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

Yes

Yes

Yes

Not applicable

Not applicable Delayed due to COVID-19

Delayed due to COVID-19

Delayed due to COVID-19

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Table 12: Nam e of confidential enquiry Did PAHT participate ? Stage / % of cas e s submitted

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) 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 edeployed 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

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 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

13

Commercial 2020/21

74 70

Non Commercial 2019/20 Non Commercial 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 erein 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.

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2020/21 PAHT Accrual Figures

1500

1000

500

0

1

Commercial Studies Recruitment Non-Commercial Studies Recruitment 1289

Table 13: Re s earch recruitment per speciality

Recruitm ent Speciality Dire ctorate Com m ercial/Non com m ercial Portfolio activity

777

5 Cancer Cancer, cardiology and clinical support services Non-commercial

Gastroenterology Medical Non-commercial

3 Emergency department Urgent and ambulatory Non-commercial

16 Critical Care Surgery Non-commercial 369 People Corporate Non-commercial 64 Respiratory Medical Non-commercial

10 Maternity Family and women’s services Non-commercial

3 35 Ophthalmology Medical Musculoskeletal Medical Non-commercial Non-commercial

6 Diabetes Medical Non-commercial

1 Cancer Cancer, cardiology and clinical support services Commercial

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.

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 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

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 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.

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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%

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5000

4000 3000 2000 1000 0

Quarterly GHG Emissions by Category (tCO2e)

FY20-21 Q1 FY20-21 Q2 FY20-21 Q3 FY20-21 Q4

Building N atural 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:

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 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 w aste 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

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 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 scheme (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.

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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.

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