Paper I â Business Intelligence and Performance Report and new
Paper I March July 20152014 Health Education East Midlands Business Intelligence and Performance Report Health Education East Midlands Business Intelligence and Performance Report Page 1 of 25 HEALTH EDUCATION EAST MIDLANDS BUSINESS INTELLIGENCE AND PERFORMANCE REPORT Reporting Month Mar-15 Reporting data as at month end Feb-15 Overall status- Last Month (RAG) Green Overall Status - This Month (RAG) Green LEGEND DIRECTORATE LEVEL SUMMARY Green No issues. Progressing according to plan Amber Issues are emerging which will require corrective action in the near future Red Significant issues have arisen and urgent, corrective action is required immediately Workforce Education Commissioning and Quality 1 Workforce a Regional Workforce Numbers - Qualified Nursing and Admin/Managers (24 month trend) b Health Visitor target : Staff in post vs planned position % Variance b Apprentice target: fulfil the national apprentice training 2 Clinical Professional Education c d Pre-reg recruitment 2014/15 YTD Current Status Senior Responsible Officer +559 Qual Nursing +179 Admin and Managers 947.34 vs 956.42 Jane Johnson 630 starts (Q3) 731 (Q4 projection) vs 721 (Q4 Target) Current Status Senior Responsible Officer Contributing Author RAG Aug-14 RAG Sep-14 RAG Oct-14 RAG Nov-14 RAG Dec-14 RAG Jan-15 RAG Feb-15 Simon Woodward Green Green Green Green Green Green Green Nancy Cooke Green Green Green Green Green Amber Amber Jackie Brocklehurst Green Green Green Green Green Amber Green Contributing Author RAG Aug-14 RAG Sep-14 RAG Oct-14 RAG Nov-14 RAG Dec-14 RAG Jan-15 RAG Feb-15 2655/2495 (94%) Green Green Green Green Green Green Green Pre-reg attrition (Average of all latest completed cohorts) (Nursing) 13% Green Green Green Green Green Green Green Adult Nursing (Average of all latest completed cohorts) 15% Green Green Green Green Green Green Green Allied Health Professionals ( Average of all latest completed cohorts) 8% Green Green Green Green Green Green Green Other (inc Clinical Psychology, Pharmacy, ODP and Dental Hygiene) 4% Green Green Green Green Green Green Green RAG Aug-14 Green RAG Sep-14 Green RAG Oct-14 Green RAG Nov-14 Green RAG Dec-14 Green RAG Jan-15 Green RAG Feb-15 Green Jane Johnson Nicki Ferrin Post Graduate Medical and Quality 3 Quality and Regulation Current Status Senior Responsible Officer Contributing Author a Quality Management of Local Education Providers - (Monthly) See annex 3 b See annex 3 Red Green Green Green Green Green Green c Quality Scrutiny Board Outcomes - (Annually and Quarterly) Approval and Re-approval of GP - (Monthly) See annex 3 Green Green Green Green Green Green Green d National Trainee Survey Outcomes - (Annually and Monthly) See annex 3 Green Green Green Green Green Green Green e Local Survey Outcomes - (Quarterly) See annex 3 Green Green Green Green Green Green Green f Involvement of Lay Partners - (Quarterly) See annex 3 Green Green Green Green Green Green Green g Complaints - (Quarterly) See annex 3 Green Green Green Green Green Green Green RAG Aug-14 RAG Sep-14 RAG Oct-14 RAG Nov-14 RAG Dec-14 RAG Jan-15 RAG Feb-15 4 Post Graduate Medical Recruitment Current Status Sheona MacLeod Senior Responsible Officer Jill Guild Contributing Author a Foundation (Academic) 100% fill rate Green Green Green Green b General Practice (R1) 62% fill rate Amber Amber Amber Amber c Public Health Green Green Green Green d Secondary care (R1) 90% fill rate (81% inc LATs) Green Green Green Green e Oriel recruitment System (Assurance rating) Green - on plan to deliver Green Green Green Green RAG Aug-14 RAG Sep-14 RAG Oct-14 RAG Nov-14 RAG Dec-14 RAG Jan-15 RAG Feb-15 Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 5 Post Graduate Medical Trainee Support Services 100% fill rate Current Status a Number of new cases 16 b Number of closed cases 8 c Active Trainee Support Service (TSS) Cases Sheona MacLeod Marcia Reid Senior Responsible Officer Contributing Author Sheona Macload Nathan Jones 222 Page 2 of 25 Senior Responsible Officer a b Number of ARCP panels completed Number of trainees assessed 18 67 RAG Aug-14 Green Green 6 Post Graduate Medical Assessment Current Status Contributing Author RAG Sep-14 Green Green RAG Oct-14 Green Green RAG Nov-14 Green Green RAG Dec-14 Green Green RAG Jan-15 Green Green RAG Feb-15 Green Green c Number of outcome 2 issued 8 Green Green Green Green Green Green Green d Number of outcome 4 issued 4 Green Green Green Green Green Green Green e Number of outcome 5 issued 5 Green Green Green Green Green Green Green f Number of appeals commenced 1 Green Green Green Green Green Green Green g Number of appeals where outcome was upheld 0 Green Green Green Green Green Green Green h Number of appeals where outcome revised 0 Green Green Green Green Green Green Green i Number of active appeals 3 Green Green Green Green Green Green Green j Number of extensions to training issued (outcome 3) 7 Green Green Green Green Green Green Green k Certificate of Completion of Training (CCT) applications processed 5 Green Green Green Green Green Green Green RAG Sep-14 Green RAG Oct-14 Green RAG Nov-14 Green RAG Dec-14 Green RAG Jan-15 Green RAG Feb-15 Green Sheona Macload Senior Responsible Officer Nathan Jones a Total number of doctors who were under notice for revalidation 70 RAG Aug-14 Green b Total numbers of doctors who were under notice and have had recent ARCP 11 Green Green Green Green Green Green Green c Of these, positive revalidation recommended 11 Green Green Green Green Green Green Green d Number of deferrals 59 Green Green Green Green Green Green Green e No recent ARCP 46 Green Green Green Green Green Green Green f <1 year from CCT 0 Green Green Green Green Green Green Green g New starter 13 Green Green Green Green Green Green Green h Not assessed due to admin problem - HEEM error 0 Green Green Green Green Green Green Green i Not assessed due to admin problem - non HEEM error 0 Green Green Green Green Green Green Green j Exam failure only 0 Green Green Green Green Green Green Green k No form R submitted 0 Green Green Green Green Green Green Green l Other reason Concerns/ ongoing investigation 0 Green Green Green Green Green Green Green 0 Green Green Green Green Green Green Green RAG Aug-14 Green RAG Sep-14 Green RAG Oct-14 Green RAG Nov-14 Green RAG Dec-14 Green RAG Jan-15 RAG Feb-15 Green Green Green Green Green RAG Aug-14 Amber RAG Sep-14 Amber RAG Oct-14 Amber RAG Nov-14 Amber RAG Dec-14 Amber RAG Jan-15 Amber RAG Feb-15 Amber Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green RAG Aug-14 Green RAG Sep-14 Green RAG Oct-14 Green RAG Nov-14 Green RAG Dec-14 Green RAG Jan-15 Green RAG Feb-15 Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 1 Green Green Green Green Green Green Green 19.9 WTE Green Green Green Green Green Green Green RAG Aug-14 Green RAG Sep-14 Green RAG Oct-14 Green RAG Nov-14 Green RAG Dec-14 Green RAG Jan-15 Green RAG Feb-15 Green 7 Post Graduate Medical Revalidation m 8 Post Graduate Educator and School Development a b Curriculum Study Leave applications awaiting approval Educator Vacancies Current Status Current Status 10 14 Sheona MacLeod Contributing Author Nathan Jones Senior Responsible Officer Contributing Author Sheona MacLeod Gerard O'Reilly Senior Responsible Officer Contributing Author Karen Rutter/David Farrelly Belinda Hales Finance and Enabling 9 Finance Current Status a Future Workforce £334.8m (£334.7m in M10) b Education Support £9.6m (£9.9m in M10) c Running Costs £5.4m (£5.4m in M10) d National Activities £0.4 m (£0.4m in M10) e Workforce Developments 10 Human Resources £13.7m (£13.5m in M10) Current Status a Workforce Employed vs Establishment (WTE) b Current active vacancies (WTE) 17.1 WTE c Sickness Absence (Monthly %) 3.49% d Number of Temporary Staff (Headcount) e Leavers (2014/15 year to date) (WTE) 11 Communications Senior Responsible Officer Contributing Author David Farrelly Emma Heyhoe 177.11 vs 195.44 Current Status a Twitter Follower Count b External newsletter open rate 34.0% c Website Visits 6239 d Average Staff Weekly Update Readership 49.0% Senior Responsible Officer Contributing Author David Farrelly Carole Appleby 2,434 (1st ranked LETB) Green NA NA NA NA Green Green Amber Green Green Green Green Green Green Green Green Green Green Green Green Green Contributing Author RAG Aug-14 RAG Sep-14 RAG Oct-14 RAG Nov-14 RAG Dec-14 RAG Jan-15 RAG Feb-15 Sue Betts Green Amber Amber Amber Green Amber Amber Risk Overview 12 Risk Management a HEEM Corporate register: 14 risks in total, 2 Red, 11 Amber, 1 Green Current Status - Senior Responsible Officer PageKaren 3 of 25 Rutter HEALTH EDUCATION EAST MIDLANDS EXECUTIVE SUMMARY (FOR SUPPORTING MATERIAL SEE ASSOCIATED ANNEX) Reporting Month Feb-15 Workforce Education Commissioning and Quality 1 Workforce Health Visiting Workforce Information (see attached GB Health Visiting Paper) The latest available data (December 2014) shows a total of 947.34fte Health Visitors employed across the region. The December plan for the region is 956.32fte, the region is below the plan by a total of 9.18fte, which can be attributed to a number of unforeseen extensions to studies and a delay in the NMC registration process for some students. A total increase for the region of a total of 393.5fte from the original May 2010 baseline is noted. The distance to the April 2015 target is 63.16fte, which is a further growth in the workforce of 6.7%. The data source used for the staff in post is the ESR data warehouse unless otherwise stated. 101 Students have recently qualified and all have been offered Health Visitors posts in the East Midlands, early indications show that there are around 84 FTE commencing employment within the Health Visitor workforce in January and February 2015 Apprentice Target Current Q4 projections are estimating a figure of 731 apprenticeship starts vs a planned figure and final year end target of 721. (see annex 1) Ongoing activity: 1 On-going collation of apprentice data from NHS providers 2 Where capacity allows cold calling – Primary Care contacts 3 Liaison with Educational Providers to ensure all apprentices within the NHS are being recorded 4 Refocus efforts to count current workforce on apprenticeship frameworks not than just new starters – some areas not currently collecting this data 5 Encourage organisations to support full apprenticeships rather than stand alone NVQ/QCF units 6 Liaison with UNISON / HEE to commence new Apprenticeship Project Role 7 To facilitate a LETB GB discussion at a future development session on Talent for Care and Widening Participation 2 Clinical Profession Education Please see Annex 2 for detail of the latest recruitment vs commissions information. Post Graduate Medical and Quality 3 Quality and Regulation See annex 3 4 Post Graduate Medical Recruitment ORIEL Recruitment: The East Midlands is on plan to deliver within the timescales. 5 Post Graduate Medical Trainee Support Services Post Graduate Medical:- Training Support Services.-- Total cases for TSS stands at x222. Referrals to TSS during February 2015 were slightly reduced vs. last month; down from x20 to x16, which is a -20% decline. This was following an increase last month due to ARCP panels. However, referral numbers for Feb are static year on year. The new referrals were spread across 10 different specialties, with no significantly high numbers from any. The number of cases closed during February was x8. Of these x7 continue in Training Programme and x1 left the training programme. Page 4 of 25 6 Post Graduate Medical Assessment This months data represents activity from December. We undertook 18 panels during January assessing 67 trainees . We are currently managing 3 appeals within the team. The Certificate of Competency Training (CCT) application figures detailed are average for this period. 7 Post Graduate Medical Revalidation (1) Assessments & Revalidation team participated in the HEEM Healthcare Educators Training Day to (a) improve quality of ES reports which contribute directly to ARCP and Revalidation, and (b) to develop educators' understanding of the wider Revalidation process. 8 Post Graduate Educator and School Development Finance and Enabling 9 Finance (Page 14-15) We continue to report the achievement of all 3 HEE financial targets and the local financial target to increase flexible investment in local workforce development need. To date we are reporting an under spend of £4.2m against plan mainly due to lower than expected GP trainee numbers on placement in GP for the 11 month period to date, attrition/under recruitment to university education programmes and reduced student grants costs. To hit the breakeven target we have put in place a pre GP training programme and a round 3 recruitment starting in February 2015 to reduce the under recruitment to the training programme from August 14. We've over recruited against commissions to the 3 year midwifery education programme to offset the under recruitment to the shortened 18 month midwifery course and have over recruited to health visitor commissions in September in order to meet our national target by 31 March. We are also planning to reinvest the current projected slippage against our investment plan (£9.7m) focusing on additional future workforce and local workforce development priorities and we have approved plans totalling £9.7m which are being implemented. Our reinvestment plan will also mitigate the following financial risks: • To reinvest in the same HEE budget category that slippage occurs where possible to achieve the £3.6m future workforce under spend target set by HEE in M8 • Attrition on healthcare education courses may vary from plan including under recruitment to planned commissions in the last quarter • Reconciliations currently taking place of actual clinical placement activity for medical and non medical students may vary from the prospective plan funded through the LDA and lead to additional payments to providers . • The number of GP trainees on placement in general practice is lower than forecast in March • Increased vacancies across Running Costs and Education Support due to Beyond Transition programme: HEE budget increased by £92k this month due to HEEoE redistribution of postgrad medical SRH post funding to LETBS. HEEM annual budget has increased by £5.7m in total to date. 10 Human Resources (Page 16) There have been a total of 23 (headcount) leavers in financial year 2014/15. The current FTE of 177.11 is 18.33 FTE below the workforce establishment figure of 195.44 . Sickness absence has risen to 3.49% following the low of 1.32% in May 2014. The number of temporary staff being utilised by HEEM (Agency and Consultancy) has fallen to 1 staff compared with a figure of 13 in August 2013. 11 Communications (Page 17-18) Twitter: Since last month's return we have increased our Twitter follower count to 2,302, and remain as the LETB with the highest number of followers. Website: Figures for visits during January have increased by over 1,000, primarily due to local media activity promoting the 'Come Back to Nursing' (Return to Practice) campaign and the hyperlinks to a range of stories within the Spring external stakeholder newsletter. Staff Weekly Update: Open rates for the HEEM weekly update readership remain at a higher rate than any other LETB as well as readership of HEE Matters. External stakeholder newsletter: Delivered to 1,055 stakeholders at the end of January 2015, to date this has been read by 32.90%. This figure has been steadily increasing compared to previous newsletters. Risk Overview 12 Risk Management (Page 19) HEEM's risk management process continues to have its emphasis at project/function/team level. Updates to the HEEM RR were formally requested at end-Feb15. Continuous confirm and challenge exercising required of team/project risk registers to determine risk tolerance levels, mitigation plans, monitoring/measuring effect of mitigation activity, forecasted dates to have achieved required tolerance level. Page 5 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Feb-15 1a Workforce Page 6 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Feb-15 1b Workforce Health Visitor recruitment target Page 7 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 1c Workforce 1500 1,442 Q4 estimate 1400 Actual Starts 1300 1200 2014/15 target 1100 2015/16 Target 1000 900 800 Q4 estimate, 731 2014/15 target, 721 700 713 600 461 500 400 306 300 236 195 195 230 200 100 0 98 49 Derbyshire EMAS Leicestershire Lincolnshire Northamptonshire Nottinghamshire Actual Starts 135 27 126 163 64 198 2014/15 target 153 25 118 97 98 230 721 2015/16 Target 306 49 236 195 195 461 1,442 Q4 estimate East Midlands 731 Page 8 of 25 713 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 2 Education East Midlands Attrition Modelling Programme Attrition factor Completed Cohort Attrition (Oct 14 numbers) 0.8% Apr-14 17% Oct-14 13% Change Midwifery FT Midwifery PT Midwifery Shortened 4.6% 23% 23% 0.6% 0.1% 2.9% 3.5% 18% 23% 30% 14% 15% 24% 7% h i i i 0.1% 1.1% 5.6% 0.0% 23% 13% 15% 6% 28% 0.9% 0.3% 10.0% 3.7% 13% 17% 17% 10% 24% 40% 19% Nursing Learning Disabilities 0.2% 1.9% 17% 33% 24% 2% Nursing Learning Disabilities Total 1.9% 33% 2% Midwifery - Total Nursing Adult Nursing Adult - CFP Masters Nursing Adult - Graduate Entry Nursing Adult - Total Nursing Child Nursing Child - CFP Masters Nursing Child - Graduate Entry Nursing Child - Total Nursing Mental Health Nursing Mental Health - CFP Masters Nursing Mental Health - Graduate Entry Nursing Mental Health - Total Attrition factor Completed Cohort Attrition Live Attrition i i i 11% i h h h h i i Live Attrition Apr-14 11% 33% -2% Oct-14 4% 42% 2% 10% 6% 18% 0% 6% 4% 12% 6% 7% 5% 18% 0% 4% 4% 13% 3% 7% 10% 27% 0% 5% 6% 16% 0% 10% 6% 6% 4% 6% 0% Comment Change i h h i i i h i i i h i i i g i i i Course discontinued - rolling out Course discontinued - rolling out Course discontinued - rolling out Course discontinued - rolling out Course discontinued - rolling out Shows the Percentage effect of 1 student leaving the cohort (refers to completed attrition) Average of all cohorts who have completed within one year of reporting date Average of all active cohorts as at the reporting date Page 9 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 2 Education 2014/15 Non medical recruitment v Commissions Apr-14 May-14 Aug-14 Sep-14 Oct-14 Jan-15 Mar-15 Total for 2014/15 % YTD Comment Comms Starters Comms Starters Comms Starters Comms Starters Comms Starters Comms Starters Comms Starters Comms Starters Clinical Psychology Dental Hygiene & Therapy Diagnostic Radiography Dietetics Health Visitor Hospital Pharmacy Midwifery Midwifery Shortened Nursing Adult Nursing Child Nursing Learning Disabilities Nursing Mental Health Occupational Therapy Operating Department Practitioner Paramedic Physiotherapy Podiatry Speech and Language Therapy Therapeutic Radiotherapy Scientists (STP) Scientists (HSST) Scientists (Gr. Dip) IAPT Total Nursing Dual Reg 12 28 28 62 30 105 64 30 73 117 12 850 97 67 217 130 23 44 102 26 45 28 115 10 850 103 68 232 131 22 44 104 27 46 27 12 40 26 26 30 12 26 26 40 16 15 206 20 17 200 21 63 25 65 25 15 14 21 31 21 6 5 12 13 39 39 18 31 16 4 5 30 2014 0 118 54 4 Page 10 of 25 334 161 28 12 62 30 118 40 138 27 1174 117 67 298 155 80 44 117 26 45 28 21 6 5 30 28 12 64 30 89 39 115 27 1050 124 68 297 156 79 44 118 27 46 27 16 4 5 30 100% 100% 103% 100% 75% 98% 98% 100% 99% 106% 101% 107% 101% 99% 100% 102% 104% 102% 96% 76% 67% 100% 100% 2668 2495 94% 0 4 Additional No.s not paid for Recruited additional cohort in Jan placements limited recruitment Looking into overrecruiting 2nd cohort Additional No.s not paid for Additional No.s not paid for Additional No.s not paid for Additional No.s not paid for Comms increased, actually 5 over original Additional No.s not paid for Additional No.s not paid for Additional No.s not paid for Recruited to actual numbers. Shortfall due to non starters. These are included in above HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month Quality & Regulation – Enhanced Monitoring / Visit Process 3 Quality and Regulation Trust Issue United Lincolnshire Hospitals NHS Trust FY2 in General Surgery The planned visit on the 7th of January 2015 to Lincoln County Hospital with the GMC as part of the enhanced monitoring process for General Surgery was postponed due to the Trust Black Alert status which required all non-emergency activity to be cancelled. This will now take place on the 31st March 2015 with the GMC. University Hospitals of Leicester NHS Trust Acute Internal Medicine & Emergency Medicine Awaiting news on whether Renal Medicine and Emergency Medicine will be de-escalated from enhanced monitoring by the GMC. United Lincolnshire Hospitals NHS Trust (Grantham) Core Medical Training & Emergency medicine Feedback from February CMT committee reported a number of concerns relating to training and education. At the quality review meeting in February the DME explained that due to staffing levels and activity of service this had had a recent six week negative impact. The Trust are managing the situation and the quality department are working closely with the DDME to monitor this. Leicestershire Partnership NHS Trust Child & Adolescent Psychiatry No further update. A forum took place on the 12th November 2014. An action plan has now been agreed around faculty development and this will be taken forward to the Chief Executive and Medical Director level. LETB Wide Ophthalmology Ophthalmology (region-wide) remains under enhanced monitoring at least until the round of visits has concluded early in the 2015. Visits to Derby and Kings Mill to carry out. University Hospitals Activity Renal Medicine Quality Management of Leicester NHS Trust Status Awaiting news on whether Renal Medicine will be de-escalated from enhanced monitoring by the GMC. First review meetings are taking place to all Trusts following the Quality Management visits to review the action plans. Visit dates are also being identified with the Trusts for the 2015 Quality Management Visits and lead visitors are being agreed. Page 11 of 25 Status HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 3 Quality and Regulation Trust Issue University Hospitals of Leicester The visit to O&G (originally planned as part of the October visit), was postponed until December. The visit raised significant concerns about education and training and its sustainable delivery, mainly (but not exclusively) as a result of medical staffing levels. A formal visit report has been completed and agreed with the Trust. HEEM will revisit, with School and external College representation on 12th June 2015 to assess progress. Concerns about training in T&O at the LRI have been raised via the specialty school. Investigations are on -going but will link into a wider programme review of T&O in January/February 2015. Leicestershire Partnership Trust CAMHS locally and regionally remains a focus of attention from HEEM. This is being led by Adrian Brooke. Dr Brookes has met with the Medical Directors and Directors of Medical Education at Nottinghamshire Healthcare Trust and Leicester Partnership Trust to discuss ways to improve the education and training environment in both centres as well as their reputation to improve recruitment. A key element of the action plan is faculty development and how trainees are allocated to supervisors. Dr Jones is organising a workshop for early May 2015 for all CAMHS educators. She is also seeking support from the Royal College. The planned implementation of new on-call arrangements from February 2015 will be closely monitored, as well as progress towards a new education facility. An interim review meeting is being set up to assess progress against the November QMV recommendations and requirements. LOROS Nothing to update Derbyshire Healthcare Royal Derby Hospital Interim meeting to be scheduled Chesterfield Royal Hospital United Lincolnshire Hospitals Interim meeting to be scheduled. QM interim meeting being scheduled. Further visits to Lincoln County Hospital to see both Elderly Care and Surgery departments was due to take place th 7th January 2015; this was cancelled due to a black alert, further visits have been arranged for the 4 March 2015. Return night visits have been arranged for both Lincoln County and Pilgrim Hospitals. Concerns have been raised by a trainee concerning supervision and training in Trauma & Orthopaedics at Lincolnshire County Hospital and their outpatient work at County Hospital Louth. HEEM has decided to visit County Hospital Louth to review the training and education resources and to ensure there is adequate clinical st supervision. This visit is due to take place on 31 March 2015. Interim visits to all three sites have been arranged. Page 12 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 3 Quality and Regulation Trust Issue Sherwood Forest Hospitals Trauma and Orthopaedics The Quality Team and TPD met again with trainees on February 10th with trainees reporting improvements: improved rigour relating to consenting procedures (although the team were not reassured about informed consent), morning trauma meetings, engagement in the training process, involvement in the audits about consent procedures, support for teaching and behaviours. One trainee described the improvements as a “sea change”. Concerns continue to exist about patient care in ED, inappropriate referrals and lack of X-rays post procedure. New issues were raised about being rostered to undertake Consultant list acute clinics with Consultants being absent. The Trust were required to investigate the new concerns and submit an action plan by March 2 nd and the issues of patient flow from the Emergency Department and inappropriate referrals be escalated to the Medical Director for immediate action planning. The final report has been shared with the CQC and Head of School. Foundation Year 2 Trainees On February 19th 2015 the Director of Foundation Training and Quality team met with Foundation trainees to follow up with them reported actions taken as a result of the Quality Management visit. We heard of concerns relating to a lack of senior review of patients, this appeared to be a theme particularly in the areas of Medicine, Surgery, O&G and Urology. The Trust have been required to urgently review the model of senior review of patients We heard concerns about their experiences of the Emergency Department out of hours (quality of locums, lack of leadership in the department, inappropriate referrals, lack of Consultants, reluctance to take responsibility by the middle grade doctors, being placed in situations beyond competence). The Trust was required to immediately investigate the concerns and escalate the issues to the Medical Director and Chief Executive. An urgent action plan is due to be submitted on March 2 nd. Emergency Department In light of the feedback from trainees in T& O and Foundation, combined with confirmation from the Trust that these issues have been raised recently via Junior Doctor Forums and information from the School about the intensity of the Core trainee rota the Quality team feel there has been a marked deterioration in feedback. We intend to submit the report and the action plan to the General Medical Council to request escalation to enhanced monitoring for Emergency Medicine. HEEM were aware of proposals to include Foundation Year 1 trainees as part of the Hospital at Night team. As a result of the above concerns the Trust have been advised that HEEM would not presently support their inclusion in the Hospital at Night team. Page 13 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Feb-15 3 Quality and Regulation Trust Nottingham University Hospitals Issue Dermatology Implications for education and training of the planned closure of adult Dermatology service discussed with Deputy Directors of Medical Education at the interim review in February. Head of School is discussing individual trainee training and education plans. ENT Meeting date with trainees awaited from the Trust. Ophthalmology Visited as part of the enhanced monitoring process to review the region-wide training programme. The outcome was that in general, trainees reported a good training experience. However, induction and handover appeared to be unstructured and informal and the strategic leadership around education and training within the department was unclear. Neurology Monitoring continuing. Will meet again with trainees on 16th April 2015. Radiology- A full response to the report submitted has been received and the Quality team will meet in March with the TPD, Head of School, College Tutors and Quality Lead to discuss outcomes and future plans. Respiratory The Quality team intended to visit Respiratory trainees once the departmental move from QMC to the City Hospital was complete. However we have received a concern relating to HST at QMC and senior support. The Quality lead for the School and the Quality Manager are arranging to meet with trainees at both sites to discuss the concerns in more detail. Spinal Surgery Two items relating to spinal surgery remain on the Dean’s return, the GMC have been updated in consultation with the Trust and the Quality Team will visit the department in March to seek assurance that the original concerns have been addressed. Nottinghamshire Healthcare Awaiting confirmation of meeting date with recently appointed DME to discuss quality agenda. Page 14 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 3 Quality and Regulation Trust Issue Northamptonshire Healthcare A concern has been raised relating to St Mary’s Hospital by a GP Trainee which has been investigated by the Trust, GP Academy and Quality Team. A visit to St Mary’s hospital is likely to take place in March (date currently being agreed) where representatives from the GP Academy and Quality Team will meet with trainees based at St Mary’s to gather feedback around their experience. Kettering General Hospital A concern has been raised regarding Stroke Medicine at KGH in particular clinical supervision, which has been investigated by the DME and the Department. The DME has liaised with the Head of School for Medicine and the Quality Team are currently planning a date to visit the department to gather feedback from trainers and trainees. A night visit has now been booked and will take place during April and will provide the opportunity to shadow medical trainees working out of hours. A meeting took place with the Education Team, the GP Academy and the Quality Team to agree the delivery of half day release for GP trainees to enable them to attend to GP Teaching. The Education Team are working with GP Programme Directors to affect this change. Northampton General Hospital A concern has been raise with regards to Orthopaedics training and the experience of Core Surgical Trainees, the DME has reviewed faculty reports, which have not raised concerns. An internal review has been planned and the team have met with a small number of trainees. The Review team are planning to meet with all trainees and are hoping to achieve this as a matter of urgency. A night visit has now been booked and will take place during April and will provide the opportunity to shadow medical trainees working out of hours. During the recent update meeting between the Trust Education and Quality teams, the issue of releasing GP trainees for half day teaching was discussed and the Trust are in contact with the GP Programme Directors to decide how to facilitate this change. Page 15 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 3 Quality and Regulation HEEM Quality & Regulation – Quality Scrutiny Board Activity Chair of QSB has submitted a report to QPED. An Status evaluation morning has been arranged for the 25th March 2014. HEEM Quality & Regulation –Activity Activity Status 14 Lay Partner involvement including School Boards, interviews and ARCPs. 10 GP Trainer re approvals took place during February Trainer Recognition – Five year strategy currently being drafted. Showcase event sharing good practice across the region taking place on the 13th March 2015. National Training Survey – Preparation is taking place for the 2015 NTS. Quality Team along with Programmes and Recruitment have reviewed programmes data and submitted to the GMC approvals team. HEEM Quality & Regulation –Complaints Activity Status KGH - A concern has been raised regarding Stroke Medicine at KGH in particular clinical supervision, which is being investigated currently by the DME and the Department. The DME is liaising with the Head of School for Medicine and the Quality Team. NHFT - A concern has been raised relating to St Mary’s Hospital by a GP Trainee relating to supervision which is being investigated by the Trust, GP Academy and Quality Team. NGH - A concern has been raise with regards to Orthopaedics training and the experience of Core Surgical Trainees, the DME has reviewed faculty reports, which have not raised concerns. An internal review has been planned and the team have met with a small number of trainees. The Review team are planning to meet with all trainees and are hoping to achieve this as a matter of urgency. Page 16 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION Feb-15 Reporting Month 5 Post Graduate Medical Trainee Development Training Support Service School new referrals closed cases ongoing cases 2 1 1 3 2 1 0 2 1 0 1 2 0 0 0 0 16 0 1 1 3 0 0 0 1 1 1 0 0 0 0 0 0 8 20 12 7 65 25 3 3 15 8 20 3 4 9 1 8 3 206 Paediatrics Trent Foundation school Psychiatry General Practice Medicine Emergency Medicine Pathology Anaesthetics LNR Foundation School Surgery Public Health O&G Radiology Broad Base Training Medical students Dental Total total cases in % of total trainees system end Jan 15 in school 22 13 8 68 27 4 3 17 9 20 4 6 9 1 8 3 222 11.8% 2.0% 4.5% 10.5% 5.0% 7.7% 8.8% 6.8% 2.9% 6.5% 10.7% 5.0% 12.3% N/A N/A N/A Appeal Status Ongoing (from previous month) 2 Original outcome revised Original outcome upheld New requests Continuing to next month 0 0 1 Surgery Paediatrics Medicine TOTAL Panels Trainees Outcome 2s Outcome 4s Outcome 5 Extensions to training Appeals 2 1 7 1 6 1 18 18 2 11 1 9 26 67 5 0 1 0 0 2 8 0 0 0 0 4 0 4 3 0 0 0 0 2 5 1 0 1 0 1 4 7 2 0 1 0 0 0 3 ARCP=Annual Review of Competency Progression. This is a review of progression for all traineesPage from17 FY1 of to 25 final year of training. 3 1 1 5 CCT= Certificate of Completion of Training. i.e number of doctors now qualified specialists No of ARCP Panels held General Practice Anaesthetics Medicine Paediatrics Psychiatry Surgery TOTAL 3 No of CCT Applications Processed School Assessments Team School Number HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION 5 Post Graduate Medical Assessment FEBRUARY 2015 : Business Intelligence Data for Revalidation Reporting Month Under notice range 01/02/2015 01/02/2015 28/02/2015 28/06/2015 (1) Doctors under notice during this period: 0 0 70 ALL SCHOOLS as % of (1) (2) Of these, doctors deferred : ...Administrative - no recent ARCP - anticipated (incl. o/c 5) …Administrative - < 1 year from CCT …Administrative - New Starter 59 84.3% 46 0 13 65.71% 0.00% 18.57% : : : …Administrative - unanticipated problem : 0 (a) Not assessed due to admin problem - HEEM error : 0 (b) Not assessed due to admin problem - not HEEM error : 0 (c) Exam failure: only 0 FEBRUARY 2015 Business Intelligence Data for: Revalidation (d) No Form R : 0 Reporting Month (e) Other reason (see 4 below for detail ) : 0 …Concerns - Ongoing Investigation (see 5 below for detail) 01/02/2015 0 28/02/2015 : (1) Doctors under notice during this period: dation Programme mber Feb-15 Reporting Month as % of All Schools 0.00% (2) General Practice Number as % of All Schools 19 doctors 32.20% Of these, deferred School of Medicine 12 20.34%: 459 23.91% : : :7.69% 4 46 0 13 Number : 8.70% as % of All Schools Number as % of All Schools Number as % of All Schools Number as % of All Schools 4 6.78% 0 0.00% 2 3.39% 0 0.00% 19 32.20% 12 20.34% 4 4 8.70% 1 2.17% 0 0.00% 14 30.43% 11 23.91% 4 1 7.69% 5 38.46% 1 7.69% 'recent' ARCP to be one that has happened within 6 months of the time of the revalidation submission the GMC. School of of Pathology School oftoPsychiatry FacultyofofEmergency Public Health School Anaesthetics Broad-based Training School Med 5 2 10.87% 77.97% 0.00% 15.38% 22.03% 0 0 0 11 0.00% 0.00% as % of (3) 0.00% 0.00% 0.00% 0.00% 0 0.00% 0.00% 0 Number 0 …Concerns - Ongoing Investigation (see 5 below for detail) : 'recent' ARCP to be one that has happened within 6 months of the time of the 65.71% 0.00% 18.57% revalidation submission to the GMC. Of these, positive revalidation recommended: 11 15.7% 2 4 1 1 4 as % asas%%ofofAll asof % ofthese, All All recommended: as as % % of of All All OfAll positive revalidation Number Number Number Number Schools Schools Schools Schools Schools Schools 3.39% 6.78% 2.17% 8.70% 15.7% School of Radiology Foundation Programme % of of All All as % Number11 Schools Schools 4 as % of (3) School ofPractice Surgery General School of Medicine as%%ofofAll All as as % of All 15.7% 100.0% Number Number Number Schools Schools Schools S Num 12 1.69% 3.39% 0 0.00% 0.00% 4 19 6.78% 32.20% 12 20.34% 4 8.70% 1 2.17% 0 0.00% 142 4.35% 30.43% 11 23.91% 4 Planned action/action undertaken (if required) 1 15.38% 52 38.46% 7.69% 11 7.69% 7.69% None These deferrals were made due to unresolved/potential concerns evidenced to the Responsible Officer/HEEM (5) Detail of concerns and planned/current actions Action undertaken (if any required) Nature of concern None (6) Missed required submissions: Page 18 of 25 Action undertaken (if any required) Numb 6.78% 0.00% None These deferrals were made due to unresolved/potential concerns evidenced to the Responsible Officer/HEEM None 40 Reason for deferral 7.69% Planned action/action undertaken (if required) (5) Detail of concerns and planned/current actions None 11 (4) Detail of deferrals for 'other' (uncommon) reasons: None Nature of concern as % of (1) None 100.0% (4) Detail of deferrals for 'other' (uncommon) reasons: Reason for deferral Number Doctors under notice during this period recent** ARCP: (3) with ** For the purposes of Revalidation, the Responsible Officer and her team consider 0.00% 0.00% as % of (1) 0.00% 0.00% 0.00% 0.00% 15.7% 0 Doctors under notice during this period recent ARCP: (3) with ** For the purposes of Revalidation, the Responsible Officer and her team consider None Number 0.00% 11.86% Sc as % of All Schools as % of All as % of All as % ofNumber (1) as % of All SchoolsNumber Number Schools Schools 6.78% 84.3% 7 School of Medicine Number 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% School of O&G ALL SCHOOLS School of Paediatrics as % of All Schools …Administrative - unanticipated problem (a) Not assessed due to admin problem - HEEM error : (b) Not assessed due to admin problem - not HEEM error : (c) Exam failure only : (d) No Form R : (e) Other reason (see 4 below : ** for detail ) 01/02/2015 0.00% 28/06/2015 General Practice as % of All Schools 77.97% 0.00% 22.03% 0.00% 0.00% 0.00% 0.00% Under 0.00% notice range 0.00% Broad-based Training School of Emergency Med Foundation Programme Number 70 Number 0.00% ...Administrative 14 - no recent 30.43% 11 o/c 5) ARCP - anticipated (incl. …Administrative - < 1 year from CCT 5 - New Starter 38.46% 1 …Administrative School of Anaesthetics as % of All Schools Number as % of (1) 0 0.0% HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 8 Finance Key Performance Indicators Target Current Month Previous Month Core Business Targets HEEM to manage MPET expenditure in line with investment plan approved by HEE (£3.55m) (£3.631m) (£3.631m) HEEM to meet running costs target set by HEE £5.732m £5.369m £5.359m £8.1m £13.464m £13.489m £4.36m £7.33m £7.33m HEEM to meet Workforce Development investment target set by HEE HEEM to increase its flexible Workforce Development budget to invest in local need Travel Comments to March 2015 HEE target now equal to M7 reported under spend against running costs and future workforce. Main risk continues to be under recruitment to the PGMed GP training programme - costs are £2.9m lower than expected for the year. A pre GP training programme and 3rd round recruitment intiatives are in place to mitigate this risk. Student grant forecast now reflects the October forecast provided by HENW overall costs are £2.1m lower than expected for year. Salary support costs for health visitor, midwifery, public health and PG med specialty training are £1.8m lower than expected in total. Non medical tuition costs are £1.7m lower than expected. Education support costs are £0.9m lower than expected. Overall we are forecasting £9.7m (£9.4m last mth) slippage on our approved investment plan. Reinvestment plans totalling £9.7m (£9.2m last month) now approved and being implemented. HEEM budget has increased by £92k this month (£5.7m in total to date). HEE target now equal to M7 reported under spend against running cost budget. HEE shared services budget and spend to be managed centrally from 2014-15 reducing HEEM running costs plan by £184k and dental deanery transfer from HEY&H has increased HEEM running costs by £138k. Includes continuing savings due to the Beyond Transition vacancy control process which is helping to offset cost pressures on legal costs and local WF team accom set up costs Our £9.2m approved investment plan for Workforce Development exceeded the target set by HEE. Received additional £3.15m HEE budget in M8 to offset overspend.The business cases for the HEEM re-investment plan are now confirmed and HEEM is now planning to reinvest £4.7m (£4.5m last mth) of its forecast under spend on workforce development initiatives to support meeting future workforce demand. LETCs were allocated £4.36m flexible budget in the approved investment plan. A further £2.97m has been confirmed through the approved reinvestment of slippage. Page 19 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 8 Finance Key Performance Indicators Target Current Month Previous Month Travel Comments to March 2015 Recruitment and Education Commissioning Investment To meet the East Midlands share of the national GP expansion target 262 184 184 Actual trainees in GP placements Apr to Feb lower than expected down by 9% (approx 36 per mth). Budget set at a recruitment target of 262 - confirmed recruitment of 164 starting Aug 14. A further 10 trainees have started on the pre GP training programme from August 14 and another 10 recruited through 3rd round to GP training programme starting in Feb 15 to help offset this under recruitment. To meet the East Midlands share of the national health visitor expansion target 188 179 179 In order to achieve the HEEM share of this target we would need to fund an average of 188 health visitor trainee WTEs this year. Recruitment in the last quarter of 2013-14 was below planned numbers but we over recruited against plan for September intake. 38 38 33 To meet the East Midlands target of an additional 250 apprenticeship starts across the region 250 250 250 Each local health community team putting plans in place to secure 50 additional starts in each locality To meet the East Midlands target of an additional 250 adult nurse return to practice starts across the region 250 125 125 Plans being put in place at a regional level to secure additional 250 RTP starts additional 14 commenced the programme in February (44 starts in total this year) To meet the East Midlands share of the HEE adult nursing return to practice target Work ongoing to attract additional starters to meet the local target for additional starters below ACHIEVING PLAN - performance has improved NOT ACHIEVING PLAN - performance improving ACHIEVING PLAN - performance has stayed the same NOT ACHIEVING PLAN - performance has stayed the same ACHIEVING PLAN - performance risk being addressed NOT ACHIEVING PLAN - performance deteriorating Page 20 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Feb-15 Reporting Month 8 Finance Previous Years HEE Category Sub Category 2014/15 Forecast For Year 2011/12 2012/13 2013/14 Approved Revised Outturn £000s Outturn £000s Outturn £000s Plan £000s Plan £000s 2014/15 Position To Date Variance Out Turn £000s Over/(Under £000s Variance Plan £000s Actual £000s Over/(Under £000s Future Workforce Non medical Tuition Salary support Bursaries Clinical placements funding Postgraduate medical Salary support Clinical placements funding Dental F1 foundation training (VTS) Primary care training Undergraduate medical Clinical placements funding Bursaries Tariff implementation transition Workforce Development Non medical Postgraduate medical All Leadership Local Priorities Innovation and Research MPET Other ASE001 Education Support Non medical Postgraduate medical Undergraduate medical Running Costs Multiprofessional National Activities Non medical Paramedic Postgraduate medical Non MPET Total HEE Budget 58,194 16,263 42,951 1,756 60,311 16,664 41,662 1,756 57,707 16,907 33,610 12,910 58,695 16,370 33,183 10,159 58,880 16,422 33,301 10,194 57,777 16,222 31,398 12,411 -1,103 -200 -1,903 2,217 53,963 15,186 30,223 9,331 52,437 14,904 29,410 10,283 -1,526 -282 -813 952 104,701 3,810 0 30,318 109,189 3,810 6,244 33,078 104,813 4,822 6,159 35,212 62,247 36,365 6,221 41,581 62,807 36,384 6,771 41,581 61,749 38,086 6,589 38,715 -1,058 1,702 -182 -2,866 57,465 33,403 6,148 38,264 56,594 34,113 5,948 35,429 -871 710 -200 -2,835 75,970 0 0 75,160 0 0 66,465 4,236 -1,254 65,164 4,663 2,233 65,164 4,663 2,233 65,164 4,461 2,233 0 -202 0 59,768 4,274 2,047 59,777 4,210 2,048 9 -64 1 13,180 1,277 0 0 0 0 9,818 850 740 6,600 0 0 8,660 262 600 5,911 420 0 4,154 79 250 4,360 338 0 4,229 79 250 4,365 388 3,186 4,154 66 600 7,947 960 40 -75 -13 350 3,582 572 -3,146 3,808 72 250 4,075 168 262 4,044 64 600 5,270 622 (26) 236 -8 350 1,195 454 -288 73 9,709 710 1,757 7,969 586 359 7,995 802 333 8,792 727 333 9,433 727 312 8,552 727 -21 -881 0 308 8,576 666 287 7,719 666 -21 -856 0 7,789 5,996 5,639 5,778 5,731 5,369 -362 5,242 4,950 -293 75 0 2,622 75 0 2,678 237 0 0 130 0 0 434 0 0 435 21 0 1 21 0 435 0 0 435 21 0 0 21 0 384,943 372,472 Page 21366,072 of 25 377,950 0 361,822 361,823 0 367,553 367,553 -64 363,924 -64 -3,629 0 333,934 -105 329,700 -105 -4,234 369,398 372,132 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month 9 Feb-15 LETB Human Resources No. of Starters 2014 01 1.30 2 2014 02 2.4 3 2014 03 0 0 2014 04 2.74 3 2014 05 2.13 3 2014 06 5.43 6 2014 07 2 2 2014 08 2 2 2014 09 3 3 2014 10 0 0 2014 11 1.00 1 2014 12 1.00 1 2015 01 1.00 1 2015 02 0.00 0 2014 01 0 0 2014 02 0.8 1 2014 03 1.6 3 2014 04 2 2 2014 05 0.15 1 2014 06 0 0 2014 07 1.6 3 2014 08 1.75 2 2014 09 2 2 2014 10 4.4 5 2014 11 2.00 2 2014 12 4.00 4 2015 01 1.00 1 2015 02 1.00 1 Employed in Post (excluding Lay Reps, NEDs and duplicate assignments) 2014 01 984 East Midlands LETB (WTE) 171.9 985 East Midlands LETB (Headcount) 210 2014 02 174.75 213 2014 03 172.8 210 2014 04 176.4 211 2014 05 176.7 213 2014 06 179.2 217 2014 07 180.2 220 2014 08 179.87 218 2014 09 182.36 229 2014 10 179.27 227.00 2014 11 179.75 227.00 2014 12 179.30 226.00 2015 01 177.55 224.00 2015 02 177.11 224.00 2014 01 11.86 2014 02 9.01 2014 03 10.96 2014 04 10.14 2014 05 9.84 2014 06 7.34 2014 07 6.34 2014 08 6.67 2014 09 10.88 2014 10 16.10 2014 11 16.10 2014 12 15.10 2015 01 16.10 2015 02 17.10 2014 01 183.76 2014 02 183.76 2014 03 183.76 2014 04 186.54 2014 05 186.54 2014 06 186.54 2014 07 186.54 2014 08 186.54 2014 09 195.44 2014 10 195.44 2014 11 195.44 2014 12 195.44 2015 01 195.44 2015 02 195.44 2014 01 11 2014 02 8 2014 03 8 2014 04 7 2014 05 7 2014 06 7 2014 07 9 2014 08 5 2014 09 4 2014 10 4 2014 11 1 2014 12 1 2015 01 1 2015 02 1 2014 01 1.82% 2014 02 2.39% 2014 03 1.80% 2014 04 1.46% 2014 05 1.32% 2014 06 1.88% 2014 07 2.39% 2014 08 3.11% 2014 09 3.93% 2014 10 2.45% 2014 11 2.12% 2014 12 1.86% 2015 01 3.17% 2015 02 3.49% 984 East Midlands LETB (WTE) 985 East Midlands LETB (Headcount) No. of Leavers 984 East Midlands LETB (WTE) 985 East Midlands LETB (Headcount) Vacant Posts 985 East Midlands LETB (WTE) HEEM Establishment WTE 984 East Midlands LETB No. of Temporary Staff (i.e. Agency and Consultancy) 984 East Midlands LETB Sickness Absence Rate (FTE) 984 East Midlands LETB Page 22 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Feb-15 10 Communications Page 23 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Feb-15 10 Communications Page 24 of 25 HEALTH EDUCATION EAST MIDLANDS SUPPORTING BUSINESS INFORMATION FOR REFERENCE Reporting Month Mar-15 11 Risk Management Page 25 of 25
© Copyright 2024