Additional Governor Questions submitted to the Board July 2019

1. Additional Governor Questions submitted to the Board July 2019

2. Does the Trust have a trust wide property strategy (that includes the clinical site strategy for the main site, the consolidation of community estate and a strategy to deal with ongoing issues regarding NHS Property Services NHSPS) and does this go some way to reflecting the organisation’s anticipated clinical strategy and 5 year plan? 1

3. Trust-wide property strategy (1/2) The Trust is in the process of developing its clinical services strategy, with work commencing in September. Once this work is underway work will start to develop our site strategy for the District Hospital site. We are already aware of some of the key pressure areas in relation to diagnostic and theatre capacity, as well as recognising some of our ward accommodation is in need of upgrading. However, following the outcome of the clinical services strategy work we will be able to revisit this to ensure that the infrastructure on the site aligns appropriately with our future clinical services strategy. It will also give us the opportunity to determine the future use of the Briary Wing once it is vacated by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). In relation to our community estate, the Trust is constantly exploring opportunities to rationalise the accommodation we occupy. At present we have services in 161 sites and the costs associated with these properties is approximately £3.4m We are currently undertaking a review of the podiatry estate to determine if there are options to rationalise the number of clinics and accommodation we utilise without affecting the quality of service we provide. In addition, we are in discussions with commissioners across our patch, working with them to develop business cases for new facilities. These include Catterick, Skipton and Whitby. We are also developing a Place Estates group, led by Jonathan Coulter to determine the future needs for services across the Harrogate locality. This will include the HARA estate, Primary Care Networks, Ripon Community Hospital and the District Hospital site.

4. Trust-wide property strategy (2/2) With regard to NHSPS, a significant piece of work has been undertaken to resolve the outstanding debt position and members of the Finance and Planning teams are actively engaged with colleagues at NHSPS to deal with the business as usual aspects of the estate portfolio. New processes are being put in place to monitor rent and FM spend, with quarterly meetings now in place to review finances and highlight any potential issues and options to resolve these effectively. In general relationships appear to be improving. Our focus continues to be to explore options of whether we continue to remain in NHSPS properties or look at alterative facilities.

5. It has been a year since the establishment of Harrogate Integrated Facilities (HIF) (formerly known as Harrogate Healthcare Facilities Management); part of the rationale and business case for the creation of the subsidiary company was the opportunities for income generation. How assured are the Non-Executive Directors that the Board of HIF are delivering against that ambition and how much revenue has the organisation seen to date? What is the expected revenue for the coming year? 2

6. Harrogate Integrated Facilities (1/2) The business plan for the establishment of HIF included a clear expectation that once established it would explore opportunities for wider income generation, the Board of Directors signed of the year 1 business plan which was to ensure that the services transferred safely in year 1 and that the new management arrangements would utilise the first year to establish itself. At the end of Year 1 HIF delivered the agreed financial plan (£800k surplus) before exceptional items, which related to the impact of the unexpected Clinical Waste pressure (£600k impact). This year there is an expectation that HIF will deliver a £200k surplus and in achieving its financial plan it will have delivered an absolute reduction in operating costs and continued absorb the impact of the higher Clinical Waste costs. The Trust is therefore benefitting from the establishment and performance of HIF.

7. Harrogate Integrated Facilities (2/2) . HIF have not yet set an external income generation target but have started a piece of work to scope the potential opportunities. The Trust will have an opportunity to discuss this informally with the HIF Board at an upcoming Board to Board session. However, we are keen that there is strong delivery against the key areas of service to HDFT before further expansion is considered.

8. There is a problem with lack of funding for IT and the age of the systems. Has the Trust considered looking for a sponsor for IT who might support IT development and enjoy publicity from its involvement ? Is this something that might be considered to help solve the problem? 3

9. IT(1/1) The current funding available for capital investment in general and IT investment in particular is constrained due to national funding limitations. We have an increasing reliance on IT to both deliver efficiency in service provision and improve the safety of our processes, so recognise the importance of investment in IT. It is an area which is of great importance to our colleagues working in HDFT. We are constantly seeking ways of supporting the necessary investment, focussing in particular on external bids where we have been successful in the past (for example to support the development of WebV EPR, and the introduction of patient wi-fi). To date we have not considered the identification of an IT ‘sponsor’. This is partly because sponsors normally focus on ‘enhancements’ to routinely expected NHS provision. However, we will give this idea some thought as a possible avenue to explore, but identifying such a sponsor could be a challenge!

10. What is the Trust’s policy about collecting fees for treatment from non EU citizens? Does the Trust actively seek payment for those not eligible for NHS treatment? 4

11. Non-EU citizens(1/2) The national policy and regulations in respect of non-eligible patients states that wherever community and secondary care services are provided by National Health Service (NHS) Trusts to non-eligible patients that aren’t exempt, that they are chargeable unless the service itself is a free to all service. The policy requires that all providers of NHS funded secondary care, where no exemption applies, recover an estimate of the charges in advance unless doing so would prevent or delay the provision of immediately necessary or urgent services. There are key processes that we are expected to have in place. Our policy therefore aims to provide a clear and unambiguous processes that reflect this guidance for all staff regarding the management of those patients who are not entitled to free NHS treatment. It also aims to ensure all patients are treated fairly and equitably whilst meeting the requirements of the Department of Health (DH) regulations and safeguarding Trust finances to ensure appropriate charges are recovered.

12. Non-EU citizens(2/2) To support this work internally we have recently had a visit from NHS Improvement (NHSI) to test our procedures and as a result have introduced an Overseas Visitors working group (chaired by the Finance Director) to monitor the systems we have in place. A one day workshop was held in June that involved people from across the Trust (clinical, finance, IT and communications staff), facilitated by specialists from NHSI, to redesign our systems and processes for identification of non-eligible patients and our fee collection. This includes an initial focus on European Health Insurance Card fee recovery, which was identified as a ‘quick win’ for the Trust. By way of context, historically we have recovered between £50k and £100k per year from patients not eligible for free NHS treatment, and historically most charges that are due have been recovered. The analysis undertaken recently with NHSI has suggested that the financial opportunity each year for the Trust could be up to £300k, and this is the focus of the work we are undertaking at the moment.

13. With the move of the acute stroke service away for the Trust, how are things progressing and can the Trust update us on any impacts from the change of service provision on the patient experience? Has a review been undertaken or is one planned? 5

14. Acute stroke service (1/2) The centralisation of hyper acute stroke services went live on April 1st 2019. The national drivers for this were multifactorial, not least concentration of expertise, equity of access to innovative therapies in acute stroke and manpower pressures in stroke services. Whilst Harrogate had performed well by national data standards, the average stroke admissions of 300 per year fell well short of the 600 threshold for a sustainable hyper acute stroke unit. Thus it was well known for some time (not least the regional review of stroke services) that hyper acute stroke care in Harrogate would change. Patients are transported directly to either York or Leeds, depending on their point of origin. It is important to emphasise that Harrogate still provides stroke care in the acute phase of the illness. This happens either because patients are admitted here directly with another suspected illness, but are subsequently diagnosed as a stroke and it is felt clinically inappropriate to transfer them elsewhere.

15. Acute stroke service (2/2) Another scenario would be that patients transferred directly to the larger hyper acute units are found not to need specialised hyper acute care and are repatriated to Harrogate quickly, often in 24hrs where there ongoing care is taken over. Major service delivery and logistics problems have been few and far between. Some patients who present with symptoms of stroke will have other conditions (known as Stroke mimics) or who do not need specialised hyper acute care. These patients are transferred back to Harrogate, often within 3 days. Whilst the arguments for taking a patient directly to Leeds and York transfer are well known and have a sound clinical evidence base, it can be disruptive for a small proportion of patients. There have been no adverse outcomes for patients taken to Leeds or York, but a proportion of patients might feel “inconvenienced “ by what may be perceived as unnecessary transfers by patients and their relatives. We will continue to assess this with the Stroke network