Annual Report 2014-2015
Produced and published by: Communications, Surrey and Sussex Healthcare NHS Trust For additional copies please contact: 01737 768511 x 6199
Contents
Contents Welcome.................................................. 4 About us................................................... 7 • Activity........................................................ 8 • Clinically led................................................. 8 • Our CCGs.................................................... 8 • Our health campus...................................... 8 • Our vision.................................................. 11 • Our values................................................. 11 • Our priorities.............................................. 11
Our year.................................................. 12 • A&E four hour wait.................................... 12 • Mortality.................................................... 12 • CQC intelligence monitoring...................... 12 • Elective length of stay................................ 12 • Outpatient follow up rates......................... 12 • Friends and Family Test............................... 12 • Patient Opinion.......................................... 12 • NHS Choices.............................................. 12 • Inpatient survey......................................... 12 • Staff survey................................................ 12 • Staff Awards.............................................. 12 • Foundation Trust........................................ 14
Our safety, quality and clinical outcomes................................ 15
• PALS.......................................................... 23 • Responding to complaints...............................24 • Digital conversations.......................................26
Our people............................................ 27 • Who we are............................................... 27 • Gender profile........................................... 27 • Our volunteers........................................... 28 • Work experience students.......................... 28 • League of Friends....................................... 29 • National staff survey.................................. 29 • Developing our staff.................................. 30 • Equality, diversity, human rights................. 32 • Health and wellbeing................................. 32 • Staff engagement...................................... 33
Our Charity........................................... 34 • SASH Charity ............................................ 34 Our environment............................... 35 • Travel plan................................................. 35 • Recycling................................................... 35 • Energy efficiency........................................ 36
Our plans............................................... 37 • Strategic direction...................................... 37 • Delivery plan.............................................. 39
• CQC report................................................ 15 • Safety thermometer................................... 17 • Hospital acquired infection......................... 17 • Venous Thromboembolism (VTE) assessment on admission.................. 17 • Referral to treatment time.......................... 18 • Cancer waiting times................................. 18 • Delay on discharge to other care provider.......18 • Maternity CNST......................................... 18 • Right Care, Right Time............................... 18 • Emergency preparedness........................... 18
Our governance and assurance....46
Patient experience ........................... 20
Appendices........................................... 79
• What our patients say................................ 21 • Your Care Matters..................................... 21 • Patient Opinion.......................................... 21
• Appendix 1 – annual governance statement... 79
• Quality governance.................................... 50 • Board assurance......................................... 51 • Escalation framework................................. 51 • Making a difference................................... 52 • Putting people first.................................... 52 • Getting it right........................................... 52
Our finances......................................... 54 Putting people first.......................... 78
How to contact us.............................. 93
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Annual Report 2014-2015
Welcome – chairman and chief executive’s report
Contents
This year has been another amazing year for Surrey and Sussex Healthcare NHS Trust and a year where we have continued to see the very positive impact our clinical leaders, clinicians, staff and volunteers have on the people we care for. We are immensely proud of the success and progress our teams have enabled us to achieve during 2014-15 and which is detailed in this report. One on-going focus for us is our journey to Foundation Trust status. Our application to become a Foundation Trust took a positive step forward when we received approval, in March, from the TDA (Trust Development Authority) to move to the final Monitor assessment stage. When we started our journey we set ourselves the ambitious goal of recruiting 9,000 members from our patients, local people and staff to work collaboratively to ensure that patients remain at the centre of everything we do and also our plans for the future. We are pleased that the number of members had reached over 10,000 by the end of 2014-15 and that this number continues to grow. Heading into 201516, our members will be invited to nominate themselves for the role of Governor for their local constituency – we have opportunities for 28 Governors and elections will be taking place in June 2015. We look forward to working with our Governors and members as, together, we take our Trust from being a good organisation to an outstanding one. Our staff have a huge commitment to safety and quality and deliver high quality care and compassion every day. We are delighted that this strong focus was recognised and acknowledged by the Care Quality Commission in their independent report into our services that was published in August 2014 following an inspection in May by a large team from the CQC including doctors, nurses and senior NHS managers that looked at the standards delivered by our staff.
Thanks to the hard work and professionalism of staff across the Trust we achieved a ‘Good’ rating across the board with responsiveness in end of life care rated as outstanding. This puts us amongst the best in the country for the quality of services and the CQC said our staff should be extremely proud of what they have achieved. We know that this achievement is as a direct result of the talent, hard work and dedication of our teams and the report shows their commitment to safety and quality and provides reassurance for the community we serve. The inspectors also said our staff were the most engaged out of all of the Trusts they had visited and we know this makes a real difference to patient experience and care. They also said they would be very proud to work here and would want their family and friends to be cared for here which is a wonderful endorsement of everyone’s efforts. This year, we have also seen real steps forward in our aim to create a health campus at East Surrey Hospital that brings together centres of excellence onto one site and closer to home for local people – giving them the highly specialist care they need without the need to travel further afield. In July, the St Luke’s Radiotherapy Centre opened. A joint project between Surrey and Sussex Healthcare NHS Trust and the Royal Surrey County Hospital and costing £10 million the centre brings the best range of radiotherapy treatments available closer to home for local people. In October, the Lane Fox REMEO® Respiratory Centre also opened providing the UK’s first purpose-built weaning and home ventilation centre for patients with a wide range of respiratory conditions. The new purpose-built centre operates as a satellite to the renowned Lane Fox Respiratory Unit at St Thomas’ Hospital in central London. Medical care is provided by the specialists from
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Annual Report 2014-2015
Guys and St Thomas’ Hospitals and means that patients now have access to leading clinical expertise in ‘weaning’ from invasive mechanical ventilation and enabling them to eventually return home. Moving patients out of intensive care wards and into a multidisciplinary specialist centre also enables us to free up hospital intensive care beds for other acutely ill people. Another new facility we have opened for the benefit of local people is The Earlswood Centre, a new hub for diabetes and endocrine care. Diabetes affects three million people in the UK and the new centre means that doctors and nurses at East Surrey Hospital are able to run separate clinics for people with Type 1 and Type 2 diabetes and clinics for young adults and people using an insulin pump. We can also now treat patients with monogenic diabetes which means they no longer have to travel to Brighton or Oxford - another example of bringing care to one place and closer to home for local people. Ensuring we are at the front of developments in delivering excellent healthcare remains central to our Trust. In recent years we have been strong advocates for physicians associates (PAs) who work alongside our doctors and consultants. Trained in a number of roles, PAs support doctors in our medicine, surgery and emergency teams by taking medical histories; performing examinations and ward rounds and undertaking consultations with patients. In recognition of our history and success in developing and integrating physicians associates within our teams, Health Education Kent, Surrey, Sussex have asked us to set up a School of PAs. The School will be the first of its kind in the UK and will work in partnership with the University of Kent; University of Surrey; Canterbury Christchurch University and Brighton & Sussex Medical School. We very much look forward to seeing this exciting new initiative develop.
As chairman, I would also like to take the opportunity to mention an accolade that has been awarded to Michael this year when he was named Inspirational Leader of the Year at the NHS Kent, Surrey and Sussex Leadership Collaborative’s annual awards ceremony and summit in November. I know Michael will want me to say that the award is testament to the fantastic team at the Trust from our clinicians and his executive and Board colleagues to the porters and kitchen teams who every day go above and beyond to ensure that our patients’ experience is the best it can be. We must also mention our team of 200 volunteers who, likewise, are integral to the success and positive experience of the people we care for and congratulate Maris Codling, voluntary services manager at East Surrey Hospital, who was awarded a British Empire Medal in the Queen’s Birthday Honours list in 2014, in recognition for her services to patients and the community. It is our amazing clinicians, staff and volunteers that make our Trust such a great place to be and we are immensely proud of them and all that they do every day. Thank you.
Michael Wilson Chief executive
Alan McCarthy Chairman
About us
About us Surrey and Sussex Healthcare NHS Trust provides extensive acute and complex services at East Surrey Hospital in Redhill alongside a range of outpatient, diagnostic and planned care at Caterham Dene Hospital, The Earlswood Centre, Oxted Health Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex. Serving a population of over 535,000 we care for people living, working and visiting east Surrey, north-east West Sussex, and south Croydon, including the towns of Crawley; Horsham; Reigate and Redhill. East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit, which cares for seriously injured patients in partnership with the major trauma centres at St George’s University Hospitals NHS Foundation Trust and Royal Sussex County Hospital Brighton. East Surrey Hospital has 666 beds and ten operating theatres – along with four more theatres at Crawley Hospital in our day surgery unit. We are a major local employer, with a diverse workforce of around 3,700 providing healthcare services to the community we serve. The Trust is an Associated University Hospital of Brighton and Sussex Medical School.
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Annual Report 2014-2015
In 2014-15 we had an income of £244m and we have delivered an increase in activity across the services we provide and in the number of people we have cared for: Non-elective (unplanned) care Emergency department (ED) attendances - all
2013-14 2014-15 Change % 82,660
87,246
5.5%
Non-elective - emergencies
34,656*
32,172
-7.2%
17,872
19,481
9%
4,434
4,463
0.7%
Outpatients
299,569
319,716
6.7%
Total
421,319 443,597
5.3%
Emergency admissions – stay of two days or more Births
*In 2013-14, a counting and coding change took place that saw some of the non-elective short stay emergencies re-classified as outpatients in the figures for 2014-15
Elective (planned) care
2013-14 2014-15 Change %
Day cases
27,966
30,482
9.0%
Elective - inpatients
4,983
4,863
(2.4%)
Regular day attenders
5,135
6,850
33.4%
Total elective activity
38,084
42,195
10.8%
Outpatients
299,569
319,716
6.7%
Total
421,319 443,597
5.3%
Clinically led We are a clinically led organisation, focused on putting people first. Our services are led and managed through four divisions: Cancer
Chief
Dr Ed Dr Virach Cetti Phongsathorn
Associate Angela director Stevenson Chief nurse
Medicine Surgery Women and children
Jane Penny
Vacant Nicola Shopland
Dr Dr Barbara Deborah Bray Pullen Natasha Bill Hare Kilvington Jamie Moore
Michelle Cudjoe
Our clinical commissioning groups The services we provide are commissioned by local clinical commissioning groups (CCGs). In 2014-15 we held contracts with 11 CCGs; the co-ordinating commissioner was Crawley CCG along with four associate commissioners - Horsham and Mid Sussex CCG; East Surrey CCG; Surrey Downs CCG and Croydon CCG: • Crawley CCG: has 13 GP practices and a population of more than 120,000 people • Croydon CCG: has 61 GP practices serving a population of 350,000 people • East Surrey CCG: has 18 GP practices in south East Surrey covering Caterham; Horley; Reigate; Redhill and Oxted with a population of nearly 170,000 people • Horsham and Mid Sussex CCG: has 23 GP practices and a population of 225,000 people • NHS Surrey Downs CCG: has 33 GP practices serving a population of 290,000 people
Our health campus We have continued to develop partnerships with other leading healthcare providers and to work towards our goal of creating a health campus setting for an extended range of care for local people based in the grounds of East Surrey Hospital. This year has seen us make significant progress in achieving strong partnerships with the opening of the St Luke’s Radiotherapy Centre in partnership with Royal Surrey County Hospital NHS Foundation Trust. The Centre, linked with the St Luke’s Cancer Centre, a leading specialist tertiary cancer centre at the Royal Surrey County Hospital in Guildford, means that people living in east Surrey and West Sussex can now have their treatment closer to home.
About us
We have also opened the UK’s first Lane Fox REMEO® Respiratory Centre, also based at East Surrey Hospital in partnership with Guy’s and St Thomas’ Hospital NHS Foundation Trust. The purpose-built centre operates as a satellite to the renowned Lane Fox Respiratory Unit at St Thomas’ Hospital in central London. It provides specialist expertise for respiratory patients in ‘weaning’ them from invasive mechanical ventilation and enabling them to eventually return home. This means that local people can now have specialist treatment much closer to home in a relaxing and purpose built environment. Continuing the growth of our health campus in 2015-16 will be the addition of a £1.3m East Surrey Macmillan Cancer Support Centre in partnership with Macmillan Cancer Support charity. In October, our planning application was approved to build to build a state-of-theart support centre, which will provide specialist help for cancer patients in a friendly, nonclinical environment. An appeal to help raise funds towards the Centre was launched in January 2015. The site was cleared and ready for the building works to begin in April with the aim of the Centre being completed at the end of year - putting to an end the added stress on cancer patients who currently have to travel to the nearest cancer support centre in Crawley, or even further afield to Guildford or Purley.
All I can say is that the whole team acted in a truly professional manner and that I couldn't have asked for any better treatment than I had on the day. I am unable to give individual names as I can't remember them. But they were all MARVELLOUS…
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Annual Report 2014-2015
This was the NHS at its very best – everyone we dealt with was hugely helpful and professional.
About us
Our vision Safe, high quality healthcare that puts our community first.
Our values • Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour • One team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth • Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care • Safety and quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care
Our priorities This year, as part of our ongoing development of our Trust, we reviewed our strategic objectives to align them with the five domains of the new Care Quality Commission (CQC) inspection standards and to focus our priorities as: • Safe: Deliver safe services and be in the top 20% against our peers • Effective: Deliver effective and sustainable clinical services within the local health economy • Caring: Ensure patients are cared for and feel cared about • Responsive: Become the secondary care provider of choice for our catchment population • Well-led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model
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Our year Surrey and Sussex Healthcare NHS Trust continues to improve and is proud to be one of the best performing Trusts in England. In the past year, 2014-15, we have succeeded in meeting clinical standards and delivering high quality care and a positive experience for our patients through a number of elements, including.
Friends and Family Test score: we are consistently the best in the region and among the highest scoring nationally for our emergency department and above average for our inpatient wards
A&E four hour wait (Type 1): we have consistently achieved this target and rank in the top 10% of acute hospitals nationally. In 201415 we admitted or discharged 95% of patients within four hours. Although we did not achieve the ED (emergency department) standard in Q3 or Q4 we still remained in the top quarter of emergency departments nationally
NHS Choices: our overall and latest ranking on NHS Choices is four out of five stars – with infection control and cleanliness and somewhere recommended by staff ranked as among the best along with high scores for privacy and dignity, same-sex accommodation and overall care
Mortality: the Trust SHMR (standardised hospital mortality rate) continues to improve and is consistently below the national average, Currently at 88 our standardised hospital mortality indicator is ranked 27th out of 137 Trusts Care Quality Commission Intelligent Monitoring: we are rated as the equivalent as Band 6 for the whole of 2014-15, which means we are low risk and rated as one of the safest hospitals in the country Elective length of stay: we are ranked 19th out of 32 acute Trusts in our peer group for elective lengths of stay and 9th our of 32 for day case rates Outpatient follow-up rates: we rank 3rd out of 32 acute Trusts in our peer group
Patient Opinion: a respected national online forum that also links to NHS Choices, views us as an exemplar organisation in patient satisfaction and our proactive approach to seeking and actively encouraging our patients to provide feedback
Inpatient survey: the 2014 survey ranked us ‘as expected’ across all ten subject areas for which a sample of our patients were surveyed Staff survey: 56% of staff responded to the 2014 staff survey. The results, published March 2015, rated us in the top 20% of acute Trusts for motivation and as a place to work and receive care for the third year running
Annual staff awards Every day of the year our staff are responsible for delivering high quality care to the communities we serve. We know just how much the people they care for appreciate their compassion and commitment through the feedback we receive. Each year we make sure that we celebrate this hard work and dedication at our annual Staff Awards of Excellence.
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Over 100 staff were nominated in 11 categories for our 2014 awards along with those recognised for long service – the categories are: • Innovation and Service Improvement • Frontline Employee of the Year • Behind the Scenes Employee of the Year • Compassion (team award) • Compassion (individual ward) • Your Care Matters • Volunteer of the Year • Frontline One Team • Behind the Scenes One Team • Dignity and Respect • Safety and Quality
I am really proud of our staff. Our growing reputation is due to their commitment. Many congratulations to all our winners and everyone who was nominated. Alan McCarthy Chairman
We have many staff working on our wards and behind the scenes delivering exceptional standards of care every day. The awards are a wonderful opportunity for us to share these stories of excellent care and to be inspired by our colleagues who go over and above in their jobs. Michael Wilson Chief executive
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Foundation Trust – our journey
I thank everyone who has signed up to be a member so far – it is fantastic to know we have the support of the people in the communities we serve and that, importantly, our members are already sharing their views at focus groups and events. Michael Wilson Chief executive
The last year, has seen us make strong progress on our journey to become a Foundation Trust. A Foundation Trust is made up of members who can help shape the future development of health care in the area. Membership is free and members can get involved as little or as much as they like. Foundation Trusts are different from existing NHS Trusts as they are more accountable to local people through the membership and less accountable to central Government. However, NHS Foundation Trusts remain part of the NHS and remain free at the point of use and are subject to NHS standards, performance ratings and systems of inspection. Our application to become a Foundation Trust has successfully completed a number of key milestones: • November 2014: Formal Board-to-Board with the Trust Development Authority (TDA) • March 2015: The TDA Board gives approval for us to move to the final Monitor assessment stage • April 2015: Monitor assessment begins We set ourselves an ambitious goal of recruiting 9,000 members. In March 2014 we had successfully recruited around 1,000 members. As we reached the end of March 2015 we are delighted that we now have over 10,000 members and this number continues to grow.
March 2014:
1,000
members
March 2015:
10,000
+
members
Safety, quality and clinical outcomes
Safety, quality and clinical outcomes This year we have continued to focus on delivering on-going improvements in the quality of our services as detailed in our Quality Account. All our quality improvement work will be based on benchmarked quality performance through locally generated metrics and those provided through accepted agencies (Dr Foster, national and regional data sets) based on the Trust’s five strategic objectives: SO1: S afe – Deliver safe services and be in the top 20% against our peers SO2: Effective – Deliver effective and sustainable clinical services within the local health economy SO3: C aring – Ensure patients are cared for and feel cared about SO4: R esponsive – Become the secondary care provider for the catchment population SO5: Well led – Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model We remain focused on providing high quality care and a positive patient experience, including:
Care Quality Commission report Last rrat ated ed 6 August 2014
Surr Surrey ey andatSussex Healthcare e NHS Everyone SurreyHealthcar and Sussex Trust Healthcare NHS Trust has a huge commitment to safety, quality and Overall Inadequate Requires Good Outstanding providing care improvement and compassion rating and this focus on excellence was endorsed in 2014-15 by the Care Quality Ar Aree ser servic vices es Commission (CQC) team of Safe? doctors, nurses and senior NHS managers who completed an Effective? inspection in May 2014. Good
Good
Caring?
Good
Their report, published in August, by the Chief Good Responsive? Inspector of Hospitals focused on five key questions about the healthcareGoodservices we Well led? provide, are they: • Safe The Care Quality Commission is the independent regulator of health and social care in England. You can read our inspection report at www.cqc.org.uk/provider/RTP We would like to hear about your experience of the care you have received, whether good or bad. Call us on 03000 61 61 61, e-mail enquiries@cqc.org.uk, or go to www.cqc.org.uk/share-your-experience-finder
• Effective • Caring
• Responsive to people’s needs • Well-led Thanks to the hard work of our staff, we achieved a ‘Good’ rating across the board in all five areas - to put this context nationally at the time of the most recent (31) inspections only four other Trusts achieved an overall ‘Good’ rating and only two of these were green in all domains. This puts us amongst the best in the country for the quality of services and the CQC said that our staff should be extremely proud of what they have achieved.
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Annual Report 2014-2015
The report highlighted several areas of outstanding and good practise, including: • End of life Care achieved an ‘Outstanding’ in the responsiveness category • The excellent care and facilities on the midwife-led birthing unit and the neonatal intensive care unit • The pre-assessment clinic at Crawley Hospital, which has been extended in the evening in response to feedback and local demand • Staff focus groups: best attended – more staff than they had seen in any other Trust • Clear ambition across the Trust to be the best – from catering staff through to the chairman • Staff willingness to go the extra mile and work together to meet individual pastoral needs
patient experience and care. They also said they would be very proud to work here and would want their family and friends to be cared for here which is a great endorsement of everyone’s efforts and commitment.
Last rrat ated ed 6 August 2014
Surr Surrey ey and Sussex Healthcar Healthcaree NHS Trust Overall rating
Inadequate
Requires improvement
Good
Outstanding
Ar Aree ser servic vices es Safe?
Good
Effective?
Good
Caring?
Good
Responsive?
Good
Well led?
Good
• Strong desire to be clinically-led • Large number of specialist nurses with a strong focus on learning and development The report recommended some areas where improvements could be made – the majority of which were in our out-patients areas. These included a need to ensure adequate capacity to meet demand and improvements to the quality of service including waiting times and cancellations. We have made significant progress in addressing these points - the refurbishment of the out-patients department at East Surrey Hospital and improvements to seating and signage; the opening of the Earlswood Community Diabetes and Endocrine Centre and the involvement of our patients in focus groups to help us to gather feedback and to co-design and shape the service as we plan for the future, are just some of the ways we have moved forward and focused on putting people first. We know that this will help us to improve the experience we provide for our patients and also for the teams involved. The inspectors said our staff were the most engaged out of all of the Trusts they had visited and we know this makes a real difference to
The Care Quality Commission is the independent regulator of health and social care in England. You can read our inspection report at www.cqc.org.uk/provider/RTP We would like to hear about your experience of the care you have received, whether good or bad. Call us on 03000 61 61 61, e-mail enquiries@cqc.org.uk, or go to www.cqc.org.uk/share-your-experience-finder
I am very proud of our staff – this is their story and I am glad their talent, hard work and dedication has been recognised. The report also makes for reassuring reading for the community we serve and shows our commitment to safety and quality. Michael Wilson Chief executive
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Safety, quality and clinical outcomes
Safety thermometer The NHS Safety Thermometer is a monthly prevalence study which measures the level of harm from pressure damage, falls, catheter acquired urinary tract infections and VTE (venous thrombo-embolism) acquired by the Trust inpatients. It is a high priority for nursing teams and is regularly discussed at all levels across the organisation. Data collection allows for specific ward based analysis and interventions. The measurement is calculated as ‘new harms’ (those acquired as an inpatient) and ‘all harms’ (harm that the patient acquired before their admission for example pressure damage). The national target is that 95% of patients will receive harm-free care. We are currently achieving between 94-97% harm-free care for ‘new harms’ and 90-93% for ‘all harms’ monthly. The ‘all harms’ performance is influenced by community acquired pressure damage and following a revision to the Datix reporting system we are now able to capture additional data on patients admitted with pressure damage including whether they came from their own home, another acute provider or a nursing or residential home. This allows for much more effective information sharing and we are now working with our Clinical Commissioning Groups (CCGs) and community providers as part of a system wide approach to supporting a reduction in these instances. This collaborative approach includes community providers attending our pressure damage board where cases are discussed; equipment is reviewed; patients and carer information is developed and polices are revised. We also lead on undertaking multidisciplinary team deep-dives into individual cases so that we can all share expertise and learning.
Hospital acquired infection The management of hospital acquired infection continues to improve with only one MRSA (contaminant) case. 2011-12 Q1
Q2
Q3
Q4
Total
MRSA
1
1
2
1
5
CDiff incidents
7
16
16
17
56
Q1
Q2
Q3
Q4
Total
MRSA
1
0
1
1
3
CDiff incidents
8
4
6
7
25
Q2
Q3
Q4
Total
2012-13
2013-14 Q1 MRSA
0
1
2
0
3
CDiff incidents
6
10
6
1
77
Q1
Q2
Q3
Q4
Total
MRSA
0
0
0
1*
1*
CDiff incidents
5
5
5
9
24
2014-15
* (Contaminant) this sample was contaminated due to blood culture technique and this contamination was not bloodstream infection. Our blood culture competency programme continues to be implemented.
Venous Thromboembolism (VTE) assessment on admission Performance of VTE assessment on admission has improved steadily over the last three years and remains consistently 95% or above.
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Annual Report 2014-2015
Referral to treatment time (RTT) The national standard is that patients that are referred for treatment should receive their treatment within 18 weeks of the referral. The Trust continues to aim to treat all patients within 18 weeks and has worked as part of a national drive to reduce long waiters over the course of the year
Cancer waiting times Our performance in relation to cancer waiting times has been good across the year with all quarterly access standards achieved except for The 62 Day Screening Standard which was not achieved in Q2. Our cancer services are now under the leadership of a new chief consultant along with lead nurse and associate director.
Delay in patients being discharged to another care provider In light of an increase in the number of delays in patients being discharged to another care provider and the increase in people who need to be admitted to hospital we have continued to focus on arranging the packages of care that will support our patients to leave hospital. Often, people leaving hospital have different needs to their needs and how they were living before they became unwell and were admitted to hospital. We continue to work in closer collaboration with our community partners to help support our patients when they return home.
Maternity CNST (clinical negligence scheme for Trusts) Our maternity department scored 47 out of 50, achieving Level 2 in the CNST (clinical negligence scheme for Trusts) assessment. The assessment process focuses on how the hospital manages the safety of women and their babies.
Right care, right time At the start of 2014-15 we put in place a plan to operate our inpatient wards with a bed occupancy rate of 95% - with the intention that this would ensure we were able to care for new patients on the most appropriate ward for them. However, as a consequence of the intense pressure being felt across the NHS nationally our bed occupancy in the past year has consistently been at around 99%.With a growth in attendances at the emergency department (ED) and in admissions we have not always been able to place patients in the most ideal ward for them. However, we have met this challenge in a number of ways including ensuring that the specific nursing and therapy needs of patients continue to be centred on the patient to ensure a positive patient experience. We also bring specialist care to them from our specialist teams from across the hospital – for example, our intensive therapy unit teams along with respiratory, cardiac and gastro-intestinal teams visit patients in all wards bringing their specialisms to the patient. We have also opened additional beds in new areas to support the increase in demand. Ensuring our patients continue to receive the right care and the right time is central to everything we do and making this happen in challenging times is a reflection of the commitment of all our staff in putting people first.
Safety, quality and clinical outcomes
Emergency preparedness The Trust has a legal obligation, as a Category 1 responder, under the Civil Contingencies Act 2004 to plan and prepare for emergencies. Emergencies may include incidents that present a serious threat to the health of the community, disruption to services, or causes such numbers or types of injury as to require special arrangements to be implemented. In order to meet this responsibility, the Trust has a major incident plan built on the principles of risk assessment, emergency planning, business continuity, co-operation with partner agencies, sharing information and communicating with the public. The current Major Incident Plan 2013-16 was approved in September 2013. The Trust also has a resilience policy 2013-16, which also covers business continuity. This is currently being reviewed to ensure that any disruption to service provision causes minimal disruption and is resolved as quickly as possible. Emergency planning is one of the core subjects on the statutory and mandatory training programme provided to all staff across the Trust. More specialist training is delivered to those key departments or personnel with a specific role to play within the major incident plan.
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Annual Report 2014-2015
Patient experience
The NHS will actively encourage feedback from the public, patients and staff; welcome it and use it to improve its services. NHS Constitution
Hear the patient voice at every level – even when that voice is a whisper. Berwick Report
Patient experience
What our patients say We know that excellent patient experience is vital in delivering safe, high quality care. This year we have continued to maximise the ways in which our patients and the people we care for can let us know their views, comments and suggestions through a range of feedback options designed to meet the needs of our patients. Our bespoke Your Care Matters patient survey is available across all services and offers patients, their family and carers the opportunity to tell us how they think we did, both good and not so good. We also have our Patient Advice and Liaison Service (PALS) and online Patient Opinion website, which provides us with a range of feedback that we have continued to use to review the views of patients to help to inform what we do and to make improvements where we can. As a result of comments made by patients we have made changes – from the small things that make a difference at ward or clinic level, to changes that apply across the Trust, including: • A pilot customer care training programme for all front facing non-clinical staff to ensure that our patients and visitors are greeted and assisted in a way that reflects our Trust values • Revising and improving the quality and consistency of patient appointment letters • Increasing the number of visitor car parking spaces to help avoid congestion and subsequent delays • Introducing free parking for patients who regularly attend our chemotherapy suite • Adding a contact email to our outpatients appointment letters • Introducing a new system to check patients into our emergency department that helps to increase the level of privacy • Replacing the chairs in the surgical assessment unit with more comfortable ones • Increasing the number of reclining chairs in the post-natal ward
• Developing a baby checks training plan for midwives to help make the discharge process faster • Extending pre-assessment appointment times into the early evenings • Introducing a bleep system to allow patients to leave the clinical area and still be contacted
Your Care Matters We receive around 1,000 responses a month to our Your Care Matters patient feedback survey. Patients are encouraged to take part and can do so on-line, by using a Freephone number or, for some services, completing a paper copy. As well as monitoring performance on key issues such as dignity and respect, communication, the discharge process and levels of care and compassion, the survey also gives respondents the opportunity to make comments or suggestions on things that they feel could be improved. The Your Care Matters survey also provides patients with an opportunity to thank individuals or groups of staff when they feel they have received exceptional care. These commendations are shared with team and senior managers and also the chief nurse.
Patient Opinion Patient Opinion is an independent website that provides an online option for patients to tell their story about their experiences and about the level of care they have received. We have been a subscriber to Patient Opinion since its launch in 2012 and are seen as an exemplar organisation as a result of our proactive approach to seeking and actively encouraging our patients to tell their stories. We are also one of only a handful of organisations across the country to have a live-feed of comments about Surrey and Sussex Healthcare NHS Trust from Patient Opinion on the homepage of our website. We encourage our staff to respond in a timely, open and honest way. All comments made about the care we provide and our responses are available for anyone to read,
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Annual Report 2014-2015
In the past 12 months
346
and their comments were viewed more
67,100
patients have told their story
than times
The nursing staff were helpful and kind and at each stage introduced themselves and explained the tests and procedures. Comment posted on Patient Opinion
I have to say that I was overwhelmed by the care provided by the NHS at East Surrey hospital. They were so helpful, kind, loving, compassionate and professional. They saved my wife's life and I can't thank them enough. Comment posted on Patient Opinion
Patient experience
Patient Advice and Liaison Patient experience forum During the past year the patient Service (PALS) Patients, relatives or carers may sometimes need to turn to someone for on-thespot help, advice or support - the Patient Advice and Liaison Service (PALS) is there to help them. The PALS team will provide prompt and confidential support to resolve any queries or concerns about the care provided and can also guide people through the different services available from the NHS. The PALS acts independently, liaising with hospital staff and managers to ensure prompt response and resolution – it remains committed to ensuring that the best possible experience is enjoyed by everyone using the services provided by Surrey and Sussex Healthcare NHS Trust. It has remained focused on continuing to improve the experience of the people we care for. Feedback received from patients is taken seriously and the care of patients raising concerns is not affected in any way and continues to be of the very highest priority. Among the many services and support provided by the PALS team are: • a central source of information/early warning on areas where patients and the public perceive problems • support for patients with learning disabilities and their carers • assistance in arranging interpreters for hearing impaired patients and nonEnglish speakers • text translation services for non-English speaking patients • information about the Trust’s complaints process • access to independent complaints advocacy services During 2014-15 the PALS team has continued to provide a high standard of service to patients, relatives and visitors to Surrey and Sussex Healthcare NHS Trust.
experience forum has met on a bi-monthly basis to discuss patient feedback and services provided by the Trust. Managers from across the organisation have presented to the forum on recent developments in areas such as infection control; theatres and the hospital and Boots pharmacies. The subsequent discussions have led to refinements in procedures such as changes in criteria for dispensing medications prescribed in outpatient clinics. Members of the forum have regularly represented the view of the patient on a wide variety working groups and committees at the Trust - ensuring that our hospital services always consider patient experience when planning changes and monitoring standards. The work undertaken by other hospital committees, including oral hydration and nutrition, maternity services and end of life care is now being consolidated into a report to be provided for the members of a successor committee in June 2015. Patient focus remains a high priority in the Five Year Forward View published by NHS England in October 2014 and it is clearly recognised that this means putting patients at the centre of everything we do. The patient experience forum plays a strong role in helping the Trust achieve this goal and its contribution is valued and appreciated.
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Annual Report 2014-2015
Responding to complaints
7%
>
During 2014-15, we received 466 complaints, which is a decrease of
Alongside other ways we receive feedback from our patient, complaints are an important indication of how patients and relatives feel about the care and treatment we provide. It also helps us to identify where services would benefit from changes and improvements. As part of our robust governance structure, complaints are discussed at divisional governance meetings and more widely at the patient experience committee so that learning from complaints is not limited to ward or service level and is shared across the organisation. Sharing gives us the opportunity to make changes – for example: • the introduction of portable phones on each ward so patients may receive calls from relatives or friends without having to leave their bed • 24-hour access to medical records, which helps our emergency department staff provide a better service outside standard office hours Anonymised complaints are regularly shared in staff meetings, encouraging staff to reflect on their practice and consider how they may enhance patient experience. In response to national feedback, where people have expressed concerns about the difficulties in making complaints, we will be introducing an online form which can be populated and submitted directly from our website.
from the previous year
The majority of complaints are received by post, and increasingly by email or by phone. We also meet people making a complaint face to face and may use translation services to ensure equitable access is available to everyone who wishes to raise concerns. We remain keen to reassure patients that making a complaint will not affect the clinical care they receive. All formal complaints are managed under the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. We aim to acknowledge complaints within three working days, either by phone or by letter and provide a response, usually within 25 working days. Following a full complaint investigation, our response provides an explanation about what happened and is our opportunity to apologise in those instances where the service received did not meet expected standards. We use the Parliamentary and Health Service Ombudsman and Patient Association good practice guidelines to ensure our complaints process is centred on the needs of the person making a complaint. The majority of people have told us that in raising a concern they hope their own experience is not repeated by other patients or relatives. We are working hard to achieve the optimum patient experience and continue to evaluate the detail from complaints to further improve our services in the coming year.
Patient experience
I wasn't just treated as a number or a patient, was treated like a human being in pain and needing help. Made exceptional efforts to keep me informed all the time of what was happening and about to happen. To them, probably just doing their job but to me it was greatly appreciated.
Impossible to single out any employee, it was just a well-run unit with friendly and down to earth staff that made a very stressful day less stressful.
All the nurses involved in our care were fantastic. They provided excellent care and reassurance to both patient and mum at what was a very frightening time for both. Heartfelt thanks to all of you.
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Annual Report 2014-2015
Digital conversations
The staff looked after my mother (and me) with dignity, empathy and the utmost professionalism. When she finally passed away the nurse was an example to us all in his humanity.
From reception to physician via cleaners; nurses; a phlebotomist; a radiographer and porters everything was superb.
Informal feedback and engagement has continued to grow through our website and social media sites – giving the people we care for and the community we serve an immediate and direct way of making comments, sharing their views and recognising the care they have received.
Visit us at: www.surreyandsussex.nhs.uk @sashnhs The majority of our digital conversations are through Facebook and Twitter – our Twitter followers have increased to almost 7,500 this year. We have used Twitter to promote special days at the Trust with our teams using the day to update our followers – for example at the open day for our new Earlswood Diabetes and Endocrine Centre and Nutrition and Hydration Week 2015. Website traffic from social media April 2014 – March 2015 11%
1% 0%
88%
Facebook (5,425) Twitter (648)
LinkedIn (57) Other (9)
Our people
Our people Who we are Surrey and Sussex Healthcare NHS Trust
3,768 31%
Just under a quarter of our workforce are from black and minority ethnic backgrounds
employed staff
are nurses & midwives
14% are doctors or dentists
5%
are allied health professionals
Gender profile Our workforce is predominately female (77%) and this is the predominant gender in all of the staff groups except for estates and facilities and medical and dental staff where the position is the reverse. This balance is fairly typical of NHS acute trusts and does not present any significant issues for us.
27%
are administration, estates and facilities staff
3%
are healthcare scientists and technicians (including pharmacists) of our staff are female
77% Staff Group Professional Scientific and Technical Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered Total
Female % 76 80 85 89 43 64 48 92 77
Male % 24 20 15 11 57 36 52 8 23
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Our volunteers
Work experience students
We also have the support of around 260 volunteers who each year donate approximately 41,600 hours - the equivalent of 5,500 days of their time to support our teams and the people we care for:
The Trust has a long history of offering a wide-ranging work experience programme and opportunities to students looking for a chance to gain an understanding of working life within a healthcare environment.
58
volunteers support Radio Redhill based at East Surrey Hospital Our oldest volunteer is
92 16
years old
Our youngest volunteer is
years old
Volunteers run a fundraising trolley shop that visits the wards twice a week selling toiletries and sweets to patients and their visitors – in 2014-15 they successfully raised over £3,000. We also have four Pets As Therapy (PAT) dogs who visit the hospital with their owners providing therapeutic visits to patients. The generosity and commitment of our volunteers ensures that, together, we make sure that we continue to provide the best experience we can.
We thank each and every one of our volunteers who help us to put people first.
Last year the success of the programme grew even further – giving 101 students of all abilities a work experience placement during the programme calendar period of May – November 2014. Our programme supports all students and the efforts of individuals and teams in supporting placements for students with a disability was acknowledged and celebrated by Surrey Choices EmployAbility who awarded Surrey and Sussex Healthcare NHS Trust their Making a Difference Award 2014. The award recognises employers who are making a difference by supporting people with disabilities to achieve their potential.
Our people
League of Friends
National staff survey
The teams of volunteers from East Surrey Hospital’s League of Friends continue to make an invaluable contribution to the hospital and enables Surrey and Sussex Healthcare NHS Trust to enhance the positive experience of the people we care for.
In 2014-15, a total of 56% of staff from across the organisation responded to the annual national NHS staff survey with the results showing a significant increase in the numbers of staff reporting good communications between senior management and staff and in those who would recommend the Trust as a place to work or receive treatment. This very positive response from our staff also put Surrey and Sussex Healthcare Trust in the top 20% nationally for:
In 2014-15, they hit a significant milestone of raising a total of £3 million since the League of Friends’ charity moved to East Surrey Hospital in 1983. This success has been possible through the commitment of the volunteers in running the Friends' Coffee Shop situated at the east entrance of East Surrey Hospital.
• Job satisfaction and motivation • Effective team working
Donations from the League of Friends over the years have paid for:
• Fairness and effectiveness of incident reporting procedures
• WiFi across the hospital
• Job related training, learning and development
• heated baby mattresses
• Support from senior managers
• extra televisions for patients
• Using feedback from patients and service users to make informed decisions about the care they provide
• earphones for patients to listen to Radio Redhill and many more invaluable items.
• Staff recommending the Trust as a place to work or receive treatment Our staff rated engagement and their opportunity to be involved in the Trust as one of the top scoring areas making them feel more motivated and part of a wider team delivering excellent healthcare.
We were seen very quickly and efficiently and all the staff including the tea lady were delightful, professional, respectful, kind, funny, friendly.
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I am delighted that the results show just how positive our staff feel about being part of the Trust as there is good evidence of a strong link between a high level of staff engagement and the delivery of high quality care and a positive experience for our patients. Michael Wilson Chief executive
The results also provided an insight into areas where we need to focus – specifically through levels of appraisals. We have experienced some busy periods – however it is encouraging that those appraisals which were completed were well-structured. The survey results will be used to develop an action plan to make further improvements for the year ahead. NHS Staff Survey results – summary 2013 The overall staff engagement score The overall staff motivation score** The overall satisfied at work score I feel able to contribute to improvements My role makes a difference Recommend my place of work to friends and family for care or job I need to work longer hours to get my job done Experience bullying, harassment or abuse from other members of staff Staff feeling pressure to attend work when feeling unwell Staff getting an appraisal Staff having access to health and safety training Staff knowing how to report concerns
2014 Rating
3.83*
3.86*
P
3.99*
3.93*
N
3.69*
3.72*
P
69%
70%
P
92%
92%
P
3.75*
3.93*
N
69%
72%
P
21%
20%
P
21%
22%
N
77%
78%
P
76%
76%
P
88%
92%
P
P: Positive N: Negative * Scale measures the extent to which respondents feel motivated and engaged with the work of the Trust. Possible scores range from 1 to 5 with 5 indicating that staff are enthusiastic by their work and highly engaged with their work, their team and the Trust. ** A lthough we have a slight reduction in this score we retain our position in the top 20% of acute trusts nationally.
Developing our staff Developing our staff remains central to the learning and education opportunities we offer to our staff to continue to grow their knowledge and skills and to ensure that they have the competencies needed to support and deliver high quality care.
Our people
New staff have a tailored local induction programme supported by a package of statutory and mandatory training covering a wide range of topics from infection prevention and control to safeguarding and information governance. This is supported by on-going development to meet the needs of individuals – with our training and education plan designed to meet our strategic objectives and to ensure that all staff, have access to comprehensive training and development opportunities that enables them to develop and progress their career through the organisation.This also includes offering secondment opportunities along with the chance to undertake academic programmes that lead to qualifications and professional registration. Our essentials of management programme continues to develop the skills of our managers and equip them to manage and lead their teams. The programme, designed to enable managers to network in a multi-professional setting, allows learning and innovation to come together and for the development of leadership skills that support new ways of working and sharing of best practice across the organisation.
In 2014-15
84%
of staff have received job-relevant training, learning or development. This year we have continued to implement and embed our SASH Plus: accelerating success programme, in partnership with GE Healthcare Finnamore. The programme supports us in our aim to be a clinically led and managerially enabled organisation by developing clinical leadership skills through a programme of five workstreams, which are designed to build the leadership skills and capability needed to continue to evolve our leadership approach within the organisation – these are:
Sometimes, it is necessary for the Trust to make use of the skills of external contractors rather than employed staff – at these times, we ensure that the arrangements comply with our standing financial instructions and offer good value for money. We also ensure that our contracts ensure that contractors have complied with the relevant tax and national insurance requirements.
• Values and behaviours: translating SASH values into clear behavioural statements that will help inform and guide the behaviours of all employees
Off-payroll engagements: In 2014-15 there were 11 members of staff on off-payroll engagements for more than £220 per day and more than six months were in place. These contracts were reviewed to enable the Trust to seek assurance as to their tax obligations.
• Performance management: aligned, rationalised and streamlined performance review/appraisals processes and detailed action plans for implementation
• Goals and objectives: ensuring that there is line of sight, clarity and alignment between Trust strategic objectives and individual goals and objectives
• Change leadership: building the capability of clinical leads to lead and sustain change • Embedding clinical leadership and stakeholder management: low touch programme management and stakeholder management support
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Annual Report 2014-2015
Appraisals are a key opportunity for managers to review and assess progress through individual and team achievements and performance and they underpin the development of skilled and motivated staff with the competencies to deliver high quality care. In 2014-15, 78% of staff reported that they had received an appraisal and 42% stated that they received a well-structured appraisal. We continue to seek to increase the number of people receiving an annual appraisal and recognise the impact that the pressures during busy periods will have on achieving this. In line with our SASH Plus programme, during 2014-15, we have developed and redesigned our appraisal process to include assessment against our values: • Dignity and respect • One team • Compassion • Safety and quality The new achievement review programme was launched in March 2015 and takes effect from April 2015.
Equality, diversity and human rights During 2014-15 we have continued to work in partnership with Surrey County Council and Employability to provide work experience to young adults with epilepsy through a partnership programme, which aims to provide work placements to people with disabilities that will enable them to apply for paid work in the future. We are two ticks accredited by the Job Centre Plus for our support in employing people with a disability and we continue to offer a guaranteed interview scheme, provision of reasonable adjustments and ongoing support by our managers and from the organisation. We raise awareness of the principles of equality, diversity and human rights at our mandatory
training sessions and through a number of communications including our regular eBulletin updates and Staff News newsletter. Our equal opportunities policy is also available to all staff online through the Intranet and published on our website for the public to view. An equal opportunities statement is included in our job adverts and our annual equality data is reviewed to ensure the ongoing effectiveness of the policy at recruitment, development and progression points and in employee relations cases. Through a simplified process called equality analysis we continue to analyse all policy documents to consider any potential impact on groups or individuals - this is one way in which we meet the needs of the Public Sector Equality Duty for public bodies.
Health and wellbeing We continue to focus on encouraging staff to look after their health and recognise the positive impact of the wellbeing of our staff on both their quality of life and also on the experience of the people they care for. Our health and wellbeing strategy underpins our activities across the year along with the monitoring trends identified through our confidential sickness absence reporting system. During 2014-15 our activities included: • a successful Wellbeing Day held at East Surrey Hospital with a wide range of invited experts and exhibitors, both internal and external, on hand to give advice and information on developing and maintaining a healthy lifestyle • flu vaccination clinics and occupational health campaigns • 24-hour confidential free advice line for staff and their immediate family • our workplace choir, which has an established programme with weekly sessions and performances • fast-track physiotherapy referrals
Our people
• counselling service • regular updates in our Staff News newsletter on health and wellbeing activity linked to national health promotion awareness campaigns • Active Wellbeing group with members from across the organisation
Further achievements in 2014-15 were recognised in our annual Staff Recognition Awards ceremony, which celebrates and acknowledges the valuable contribution made by individuals and teams nominated during the year and staff involvement and engagement in service improvements.
Staff engagement Our established staff engagement strategy supports our ongoing work to develop the connection that our staff have with the vision and values of the organisation and this work is further supported by a framework to ensure that key areas of focus continue to have a positive impact: • Health and wellbeing • Supporting personal development • Management and leadership • Involvement of staff in decision making • Ensuring every role counts We continued to embed our schedule of staff engagement activities and provide staff with opportunities to find out more and to share their views and suggestions including through our regular schedule of: • All staff update briefings • Senior leaders’ briefings • Back to the floor – members of the executive team spend time working in a team from across the organisation • Executive drop-in sessions – open to all staff • Board to ward – briefing from the Board chair shared with all staff
Our staff work tirelessly to provide quality care to our patients and to be able to do this day in day out it is important they look after themselves - we want to support them in whatever way we can.
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Annual Report 2014-2015
Our charity SASH Charity SASH Charity is the new name for the Surrey and Sussex Healthcare NHS Charitable Fund (registered charity no.1054072). Established in 1996, the charity was rebranded and re-launched in December 2014 to reflect our renewed focus on proactive fundraising to invest in enhancing patient care. SASH Charity has a dedicated website, www.sashcharity. com and we have a fundraising co-ordinator to manage the charity’s fundraising and community engagement. The charity relies on donations as its primary source of income. In 2014-15, voluntary income totalled £63k and its expenditure was £144k. During 2014-15, funds have been spent on additional resourcing to care for our elderly patients, including securing both a dementia nurse and falls nurse.
Funds have also been invested in Your Care Matters, to improve our understanding of patients’ experience. SASH Charity supported our staff awards ceremony held in late 2014 which recognised individual staff and team achievements where they were presented with awards and gift vouchers and in recognition of their contributions towards improving the care patients receive. The charity has also supported the introduction of a workplace choir which aims to boost morale and raise the profile of the Trust at public events. SASH Charity is managed by the Trust’s Charitable Funds Committee, which is responsible for ensuring that donations given to the hospital are spent wisely and appropriately, in accordance with the Charities Commission and NHS regulations. Each year, the charity is independently audited and these accounts can be found on the Charity Commission’s website.
We are very grateful for the generous contributions and the fundraising efforts of our staff, patients and the community to support SASH Charity.
Our environment
Our environment We take pride in respecting the environment and continue to seek ways to ensure we help reduce any impact on the world we live in through:
Travel plan We have launched our travel plan and continue to encourage the use of more sustainable ways to travel - our actions include: • An additional 49 cycle lockers installed with a grant awarded by Surrey County Council
To enable us to do more we are developing a waste reduction action plan that aims to increase recycling rates.
Each month we recycle:
3tonnes of our general waste
• A dedicated changing room and shower is now available for staff who walk, run or cycle to work or exercise in their break times
7tonnes
• Continued participation in the national Cycle to Work scheme
of cardboard waste
• Installing new power points for recharging electric cars free of charge • A trial of the use of an electric van as part of our transport fleet • A display of a range of demonstration electric vehicles at our staff wellbeing day • Securing a long-term loan from Surrey County Council of six bicycles - two electrically assisted and four traditional style, for staff to try out and borrow • Encouraging staff to use EASIT for discounted local bus and rail travel • Increasing the number of car parking spaces for visitors and staff at East Surrey Hospital
Recycling We continue to review how we manage the waste we create with the aim to reduce the overall environmental and financial costs. Currently, at least 25% of the general waste generated is recycled and we have dedicated recycling bins in our offices and staff areas.
All our used toner cartridges and batteries
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36 Quality AnnualAccount Report 2014-2015
Energy efficiency Whilst not always visible, this year we have continued to maximise savings in both environmental and financial terms through a number of initiatives, projects and changes. This has included: • Expansion of gas driven air conditioning system, including waste heat recovery, in Copthorne and Charlwood wards and our new theatre suite. Valuable savings are made in the electricity needed to drive the refrigeration compressor where a small gas driven internal combustion engine is used saving both on the cost of the fuel - gas is cheaper than electricity and emissions - point of use gas Co2 emissions are lower than imported electricity ones. Additionally, the recovered heat is used to pre heat the air supplied to the theatres when needed. • A replacement window programme started with new units that have much greater thermal efficiency, which also allow additional natural ventilation during the summer months. Last year, we piloted a trial by installing a test window in a side room in Outwood children’s ward for staff to use to ensure that it does provide what we need before beginning the replacement programme. The pilot has led to a three year rolling update programme that will focus on ward and patient areas as a priority. • Use of LED lighting to replace traditional fluorescents during updates and projects in out-patients; birthing pool suites; the new theatres and wards and parts of Trust HQ. LED lighting provides a better light quality with much lower running costs and less maintenance.
• Use of inverter driven motors and fans for new installations – predominately in air handling units, for example in our new and refurbished theatres. Unlike traditional motors and fans, which are generally either on or off the new versions turn as fast or as slow as it need to meet the conditions it is set up to achieve – saving electricity and creating further CO2 and financial savings. • Designated parking and electrical supply installation for electric vehicles introduced for staff using electric vehicles to support their use of greener transport and a positive impact on the environment. We also have loan electric bicycles for staff to use.
Our plans
Our plans Strategic direction As we develop our plans for the future, we will maximise the advantages and benefits of becoming a Foundation Trust by continuing to develop our engagement with our local community and ensuring that the voice of our patients, carers and the public is at the centre of everything we do. To do this effectively we know how important innovation, integration and partnership working across the health and social care system including other NHS providers and commissioners as well as organisations from both the third and independent sectors will be to us. Going forward our strategic aims and plans will be based on four central themes:
Our core themes will enable us to measure our achievement; our progress in meeting our strategic objectives; that our plans are aligned to national priorities and that we are meeting the needs of the people we care for. Each theme is underpinned by a defined set of actions and measures against we can evaluate our success:
Excellence Excellence will be our ability to deliver services that are: Safe: To deliver excellent quality of services in the top 20% against our peers by ensuring that we: • consistently meet national patient safety standards in all specialties and across divisions
• Excellence
• achieve an outcome of good or better from the Chief Inspector of Hospitals inspection
• Locally based services
• avoid preventable harm
• Affordability
• are open and transparent
• Leadership
Effective: To deliver effective and sustainable clinical services within the local health economy by ensuring that we:
For us, these four themes form a central thread through our business plans as well as each of our core and supporting strategies creating a point of measurement and assurance as we look to the future and implement plans that will move us from a good organisation to an outstanding one. We know that to ensure we continue to develop and deliver high quality services to the people we care for it is vital that we further develop our partnerships across the whole health and care economy, with both providers and commissioners, working to the shared aim of delivering high quality, safe and affordable care.
• achieve the best possible clinical outcomes for our patients • deliver services differently to meet the needs of patients, the local health economy and the Trust Caring: To ensure patients are cared for and feel cared about by ensuring that we: • deliver high quality care around the individual needs of each patient • treat patients and their families with dignity, respect and compassion • listen to patients and their families
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Annual Report 2014-2015
Responsive: To become the secondary care provider of choice for our catchment population by ensuring that we: • deliver access standards • use feedback to shape and improve the services patients receive • deliver local services as appropriate at East Surrey Hospital, other Trust sites and in the community • value staff Well led: To become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model by ensuring that we: • are an organisation that is clinically led and managerially enabled
Affordability We will provide affordable services to the health system by: • delivering excellence as defined previously • reducing harm, variation and waste and getting it right first time • continually improving productivity • using technological advances appropriately • work with partners to ensure only those patients with an appropriate medical need attend, are admitted to and remain in hospital • achieving economies of scale by working in partnership with other providers
Leadership
• have appropriately qualified and competent staff always working to the highest stands of professionalism and ethics
We will be an organisation that is clinically led and managerially enabled. Within the hospital this will mean:
• are a well-governed organisation working in partnership with others
• lead clinicians taking full responsibility over the delivery of excellent and affordable services
• have a visible leadership team who are engaged and play a valuable part in the local health and social care system to ensure the development and delivery of safe and sustainable services
Locally based services Where appropriate we will provide services close to where people live by: • Partnering with other organisations to provide services at East Surrey Hospital that would otherwise be provided for the people we care for outside our area meaning often very lengthy journeys for treatment
• ward sisters and charge nurses taking responsibility for the day to day management of wards • delivery of specialty based clinical indicators • leaders identified, supported and empowered to act at all levels within the organisation Outside the hospital this will mean: • senior managers engaged across the system to ensure the Trust achieves clinical and financial sustainability
• Providing services closer to peoples’ homes in other health venues or at the patient’ home where appropriate and affordable.
• hospital clinicians working alongside GPs and other clinicians to design appropriate pathways of care
• Continuing to develop partnerships with other organisations that provide specialist services, which cannot be provided locally
• playing a full part in ensuring an excellent and affordable health and care system
Our plans
Delivery plan Our delivery plan continues to underpin our progress in meeting our strategic objectives. Our strategic objectives will be used to define team and individual objectives for the year enabling a clear connection with the impact everyone across the Trust has in enabling us to succeed. The delivery plan, which outlines the strategic responsibilities and executive director ownership, is detailed in the following pages. Monitoring: The delivery plan forms part of the annual plan, which outlines how the actions will be delivered. Progress to the plan is monitored through the annual operating plan and this is presented to our Board each quarter.
All the staff were very helpful, approachable, friendly and uplifting at a time that can be quite worrying. It was clear they all worked as a team together very well.
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Annual Report 2014-2015
Delivery plan: 2014-19 Safe: Deliver safe services and be in the top 20% against our peers Overall lead: Medical director Priority
High level actions
High level measures
Lead director
Consistently meet national patient safety standards in all specialities and across divisions
Chief operating The safety of patients comes first Year 1 - 5: 100% compliance officer and chief in all we that we do Patient safety performance nurse standards benchmark Trust in the top 20% against peers
Outcome of Chief Inspector of Hospitals Inspection to be rated as good or better
Regular mock CQC Inspections and speciality deep dives
Chief nurse and Years 1 - 4: Achieve a rating of good or better with ongoing medical director improvements to ratings from mock inspections and deep dives Year 5: be in top rated category
Avoid preventable harm
Year 1-5: Compliance with Work in partnership with community partners to deliver a safety thermometer and as few safety first and personalising care as possible never events culture Every member of staff has relevant patient safety goals included in their annual objectives and can demonstrate how they achieve organisational quality goals
Year 1: 100% of clinical staff appraisals include safety goals
Chief nurse and clinical chief
All directors and clinical chiefs
Year 2: 75% of non-clinical staff appraisals records include safety goals Year 3: 100% of all staff appraisals include safety goals Year 4& 5: 100% of all staff appraisals include safety goals
Actively participate in national Patient Safety Collaborative in Kent Surrey & Sussex area
Years 1-5: Agree and deliver standards as agreed
We are open and transparent Share good practice; learn from Year 1: Baseline established incidents, complaints and poor using audit test approach and realistic improvement levels practice. Triangulate themes targets agreed for complaints Develop a culture of openness and serious incidents and candour in handling and Years 2-5: Deliver agreed responding to complaints, year on year incremental serious incidents including improvements which communication with patients are sustained and their families in harmony with the principles of the NHS Constitution
Medical director
Chief nurse and clinical chiefs
Our plans
Effective: Deliver effective and sustainable clinical services within the local health economy Overall lead: Medical director Priority
Deliver services differently to meet need of patients, the local health economy and the Trust
High level actions
High level measures
Lead director
Year 1: Baseline against CQC indicators established and incremental improvement plan agreed
Chief nurse and clinical chiefs
Right patient, right place, right time through ring-fenced beds, fast-tracking and ambulatory care programmes
Years 2 – 5: Deliver incremental improvement plan
In partnership with other organisations identify new ways of working e.g. integrated care pathways
Years 1 – 5: Delivery of service developments detailed in integrated business place
Chief operating officer
Timely review, assessment and where relevant implementation NICE guidance across Trust and outcomes monitored
Year 1: Establish process for review, assessment and implementation
Medical director
Where guidelines are not implemented have clear, evidence based, reasons for the decision
Years 2 - 5: Process embedded
Effective working with partners in the local health economy
Chief executive Years 1 - 5: Year on year improvement in partnership development and relationships across the local health economy
Essential, mandatory and speciality based ongoing training and development programmes for all staff
Year 1:Baseline established and incremental improvement plan agreed Years 2 – 5: Deliver incremental improvement plan
Director of HR
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Annual Report 2014-2015
Caring: Ensure patients are cared for and feel cared about Overall lead: Chief nurse
Priority
High level actions
High level measures
Lead director
Deliver high quality care around the individual needs of each patient
Regularly review and audit working practices to ensure patients feel cared about
Year 1: Audit programme and process developed. Build on information from in-patient survey, Your Care Matters and Friends and Family Test
Medical director and director of information and estates
Years 2 - 5: Implement programme with evidence of year on year improvements Effective and competent multidisciplinary working in all areas
Year 1: Nursing and midwifery Strategy embedded within Trust
Chief nurse
Baseline established for each specialty and incremental improvement agreed Year 2 - 5: Nursing review and assessment reflects individual needs Deliver incremental improvement in all specialities
Treat patients and their families with dignity, respect and compassion
Explore and establish new methods of gaining patient and carer input into care delivery
Year 1: Develop and implement a scheme based on the concept of: You said… We did… to demonstrate responsiveness to patients’ views
Chief nurse
Implementation of the SaSH Plus values and behaviours across the whole organisation delivering the Trust’s ambition to deliver excellent and compassionate patient care.
Year 1: Embed nursing and midwifery strategy within the Trust
Chief nurse and director of HR
Engender a culture that expresses commitment and pride in the quality of care provided, whilst monitoring and assessing performance to provide supportive challenge and to learn from successes and when things go wrong
Listen to patients and their families
Continually work with patient and carers representatives or champions part of the on-going patient experience strategy Involve families in the care and planning of patients where appropriate
Customer care training developed and begin implementation Implement workforce and organisational development strategy Year 2: Establish and undertake programme of patient listening events Years 2 - 5: Develop and embed values based recruitment Year 1: Develop and implement a scheme based on the concept of: You said… We did… to demonstrate responsiveness to patients’ views Years 2 - 5: Use scheme to listen to and respond to patients’ views
Director of information and facilities
Our plans
Responsive: Become the secondary care provider of choice for our catchment population Overall lead: Chief operating officer
Priority
High level actions
High level measures
Lead director
Deliver access standards
Work in partnership with CCGs and ambulance services to ensure referrals are appropriate through education workshops, patient profiling etc
Years 1 - 5: Compliance with annual plan objectives and standards and NHS England standards
Chief operating officer
Work in partnership with CCGs and other providers to identify alternative healthcare provision for non acute emergencies Use feedback to shape and improve the services patients receive
Develop local services as appropriate at East Surrey Hospital, other Trust sites and in the community
Alternative providers for frail elderly step-up and step-down facilities
Take steps to ensure meaningful engagement with the local community including minority groups ensuring that through its membership and the Council of Governors, the communities it serves are able to influence the future development of services.
Years 1 - 5: Demonstrate that Director of information services are shaped through patient and member feedback and estates and director of Year 2: Macmillan Cancer corporate affairs Information Centre
Active engagement of members, patients and carers in service review and development
Year 1: Develop mechanism for engagement eg quarterly patient/ member forums
Support CCGs to repatriate activity from out of area providers
Years 1-5: Repatriated services Chief operating / activity to SaSH e.g. 80% of officer catchment area (on campus and/community)
With local partners increase community beds and capacity of Hospital at Home
Years 2 - 5: Programme of engagement activities with patients and members
Chief nurse and clinical chiefs and director of corporate affairs
Achieve bed occupancy of 95%
Planned services developments Deliver planned service as described in the integrated developments business plan
Value staff
Develop and implement recruitment & retention strategy to attract and retain high calibre staff which demonstrate and display Trust values
Years 1 - 5: Year on year improvement in partnership development and relationships across the local health economy
Director of HR
Essential, mandatory and speciality based ongoing training and development programmes for all staff
Year 1: Quality assured appraisals - 90% of staff have a PDP
Director of HR
Turnover rate: 12% Staff engagement in the top 20% of Trusts
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Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Overall lead: Chief executive
Priority
High level actions
High level measures
Lead director
Live within our means to remain financially sustainable
Deliver non-elective/elective balance
Years 1 – 3: 100% compliance with annual plan targets
Chief finance officer
Increase productivity prepare two year CIP plan including efficiency gains
Minimal cancellation or delays to timing of planned operations in theatre due to lack of beds/ recovery space
Outline longer term areas for productivity gains for year 5; 3-5 Years 4-5: Reduction in waste for inclusion in next two year CIP eg opened theatre packs etc and repatriation/local referrals Standardisation of processes across Trust Agency bill reduced by 50% We are an organisation that is clinically led and managerially enabled
Embed a clinically led divisional/ service structure and develop an appropriate framework of decision making and accountability
Medical director Year 1: Establish clinical lead and clinical roles - recruit to them and establish talent management and chiefs. accountability process Year 2: Decision rights around specified areas allocated to clinical areas and agree implementation plan over next three years Years 3-5: Implement devolvement of decision rights
Implement an effective pro-active management and appraisal process
Year 1: Implement new performance appraisal system that accounts for behaviours against agreed outputs below clinical leads and agree metrics and targets for monitoring
HR director
Years 2-5: Effectively operate the appraisal system, delivering metrics and standards Continuously improving and a learning organisation which supports Trust values Appraisals of all staff to demonstrate compliance with Trust values
Year 1: Establish periodic (twice every five years) programme of 360 multisource feedback for doctors
Medical director and clinical chiefs
Year 2: Establish multisource feedback programme for all other staff
Chief nurse and director of HR
Years 2-5: Multisource feedback for all staff used in staff appraisals
Our plans
Priority
High level actions
High level measures
Lead director
Have appropriately qualified and competent staff always working to the highest standards of professionalism and ethics
Embed leadership development by implementation of the SASH Plus values and behaviours across the whole organisation delivering the Trust’s ambition to deliver compassionate excellence
Year 1: Ongoing implementation of GE clinical leadership programme and Foresight Board development programme
Director of human resources, medical director and chief nurse
Implementation of National Quality Board guidance on nursing, midwifery and care staffing capacity and capability along with similar guidance for medical staff
Ensure IT and estate support Optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication
Staffing review cycle and elements agreed and undertaken Ensure staff work to professional codes of conduct. Promote and undertake staff listening events Years 2 – 5: Deliver incremental improvement plan Years 1 – 5: Ward refurbishment Director of information programmes and estates New outpatient facilities Re-procurement of electronic patient record (EPR) Implementation of electronic prescribing and medicines administration (EPMA)
We are a well governed organisation working in partnership with others
In partnership with key stakeholders in health, social care and others, respond positively and pro-actively to challenges and opportunities posed by the economic environment, allowing rapid adoption of new ways of working
Years 1 – 5: Achieve planned partnership programme
Chief executive
Ensure the right governance systems and internal control mechanisms are in place and working effectively at all levels
Year 1: Audit review of governance provides strong assurance
Director of corporate affairs
Year 2: Governance processes adapted to support clinical leadership model and remain effective Years 3-5: Steady state and agile enough to adapt
We will have visible leadership team who are engaged and play a valuable part in the local health and social care system to ensure the development and delivery of safe and sustainable services
In partnership with other stakeholders in the health and social care system develop and deliver flexible and sustainable models of care
Chief executive Year 1-5: Year on year improvements to feedback from key stakeholders which is positive and inline with principles of good partnership working. Evidence of joint working to achieve safe and sustainable services
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Our governance and assurance We remain committed to ensuring that our governance systems and arrangements are cohesive and ensure that our approach is co-ordinated and combined.
Our Board of Directors Our Board of Directors consists of five voting executive directors and six non-executive directors (including the Chair) and meets every month in public. The minutes and papers are made freely available and this includes publishing them on our website:
Other senior employees attend as the Board of Directors considers appropriate. The Board of Directors provides proactive assurance and leadership of the Trust towards the achievement of corporate objectives and oversight of the framework of sound internal controls, risk management and governance in place to support their achievement. The Board of Directors is responsible for: • setting the Trust’s strategic aims
www.surreyandsussex.nhs.uk/ boardpapers
• setting the Trust’s values and standards
The Board also meets for Board Seminars in intervening months.
• holding the organisation to account for the delivery of the strategy and through seeking assurance that systems of internal control are robust and reliable
There are three additional executive directors who are non-voting - voting rights apply should the Board be unable to reach a consensus on a specific issue.
Membership of the Board of Directors • A Non-executive Chair with a second and casting vote if necessary; • Five non-executive Directors • Non-executive Director Designate (non-voting) • The Chief Executive and Accountable Officer; • Chief Operating Officer • Chief Financial Officer • Medical Director • Chief Nurse • Director of Information and Facilities (non-voting) • Director of Corporate Affairs (non-voting) • Director of Human Resources (non-voting)
• the safety and quality of services
• ensuring that the necessary financial, human and physical resources are in place to enable the Trust to meet its priorities and objectives and periodically reviewing management performance • ensuring that the Trust complies with these Rules of Procedure, Standing Orders, Standing Financial Instructions, Scheme of Delegation and statutory obligations at all times.
Board members and declarations of interest Non-executive Directors (NEDs) Non-executive directors are from all walks of life and have a wide variety of experience in the voluntary, public and private sectors. They are all part-time. Their declarations of interest for 2014-15 are:
Our governance and assurance
Alan McCarthy, Chair Chair of The Basement Charity (Chair of Charity Commissioning Performance for ‘Sick’ Festival – part of Public Health strategy in Brighton & Hove) Trustee of Brighton Dome and Festival Board Vice Chair Brighton Aldridge Community Academy Trustee of Albion in the Community Yvette Robbins, Vice-chairman Director, Galaxy Investment Ltd Company Secretary in Galaxy Homes; Galaxy Land; Galaxy Investments and Galaxy Property (all businesses owned by partner) Owner, Guideon Ltd: consulting for a healthcare company from June 2014 , which has included contact with NHS organisation outside of the South East Coast Alan Hall Director of Network Planning – Open Reach (A division of BT Group Plc) John Power (until August 2014) No declarations Richard Durban Magistrate (Justice of the Peace) on SW Surrey Bench Richard Congdon (until May 2014) Member National Information Governance Board Chief Executive Arthritic Association Richard Shaw No declarations Paul Biddle (from July 2014) Non-Executive Director W&J Linney Ltd Non-Executive Director CAF Bank Trustee, Macfarlane Trust Pauline Lambert Clinical part-time Safeguarding Children’s Specialist Nurse for Sussex Community Trust
Executive Directors The executive directors are all full-time employees of the Trust. Details of their remuneration can be found in the remuneration report section of this report.. Michael Wilson, Chief Executive Special Advisor for the Care Quality Commission (CQC) Honorary President of the East Surrey Branch of the NHS Retirement Fellowship CEO representative on the Programme Board for Health Education England Visiting Professor at Surrey University Paul Simpson, Chief Finance Officer No declarations Desmond Holden, Medical Director Medical director of Kent, Surrey & Sussex Academic Health Science Network (1 day per week) Non-executive director (NED) of South East Health Technology Alliance Fiona Allsop, Chief Nurse Specialist Advisor, Care Quality Commission (CQC) Paul Bostock, Chief Operating Officer No declarations Gillian Francis-Musanu, Director of Corporate Affairs (non-voting member) Home Office Authorised Person (Marriage Registrar) – for London Borough of Hounslow Yvonne Parker, Director of Human Resources (non-voting member) No declarations Ian Mackenzie, Director of Estates and Facilities (non-voting member) No declarations Our four clinical chiefs of service are members of the executive committee to ensure the right clinical balance of decision making.
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Key committees
The key functions of the Board committees are:
The Board of Directors has authorised a number of committees to scrutinise aspects of the work of the Trust. Each committee is chaired by a non-executive director with a membership that (apart from Charitable Funds and the Audit and Assurance Committee which is a nonexecutive membership) always includes the Chief Executive.
Audit and Assurance Committee: Meets a minimum of five times a year to conclude upon the adequacy and effective operation of the Trust’s overall internal control system which includes financial and clinical assurance. It is the role of the executive to implement a sound system of internal control agreed by the Board of Directors. The Audit and Assurance Committee provides independent monitoring and scrutiny of the processes implemented in relation to governance, risk and internal control. The Committee shall also review and challenge the Trust’s Information Assurance Framework to ensure that there are appropriate controls in relation to data quality.
The terms of reference of each committee sets out the remit of responsibility delegated by the Board of Directors and sets out the information requirements of the committee, how it should interact with the information it receives and use this to reach a conclusion about assurance. Where assurance cannot be robustly established the Chair of the Committee reports this to the Board of Directors. The Board of Directors receives a report from each chair at every public board meeting. On receiving a report that identifies a lack of assurance in relation to an aspect of the business the Board of Directors can either hold the Chief Executive to account (managerial aspects) or seek independent assurance by referring the matter to its Audit and Assurance Committee.
Core committee structure Board of Directors Audit and Assurance Comitee
Finance and Workforce Commitee
Safety and Quality Commitee
Nomination and Remuneration Commitee
Charitable Funds Commitee
Nomination and Remuneration Committee: To appoint and, if necessary, dismiss the executive directors, establish and monitor the level and structure of total reward for executive directors, ensuring transparency, fairness, consistency and succession planning. The Committee shall receive reports from the Chairman of the Board of Directors on the annual appraisal of the Chief Executive, and from the Chief Executive on the annual appraisals of executive directors, as part of determining their remuneration. The committee meets at the request of the Chair of the Board and at least twice per year. Safety and Quality Committee: Meets monthly and has delegated authority to ensure the on-going development and delivery of the Trust’s Safety and Quality Strategy and that this drives the Trust’s overall strategy. The duties of the Committee shall ensure the implementation, delivery and monitoring of the Trust’s Quality and Clinical Strategies. The committee shall also be responsible for managing the safety of patients through ensuring compliance and the implementation of effective internal controls. Finance and Workforce Committee: meets monthly to provide oversight of the Trust’s business planning, investment policies, and capital programme. The Committee is responsible for the following key areas:
Our governance and assurance
• business planning including strategic financial and workforce planning; • approving investment decisions; and • monitoring delivery of significant projects and investments, and any potential business combinations. Charitable Funds Committee: Meets three times a year to oversee the generation, management, investment and disbursement of charitable funds within the regulations provided by the Charities Commission.
The Executive Committee and Executive Committee for quality and risk The Executive Committee meets weekly and a twice monthly Executive Committee for Quality and Risk which is supported by series of subcommittees to consider, on a rolling basis, managerial delivery of the Board of Directors’ strategy, quality of services provided and the effectiveness of risk management, the delivery and management of all performance and the management of each clinical division. Five
Executive sub-committees have been formed to both guide management decisions and provide assurance for Safety, Responsiveness, Clinical Effectiveness, Patient Experience and Workforce.
Significant Risk Register Details all risks on the Trust risk register system that are recorded as significant and the inks to the Board Assurance Framework. The Executive Committee oversees (through the Corporate Governance Manager) the maintenance of and reviews the Assurance Framework. It is then discussed and challenged at the Trust Board prior to its acceptance. The Assurance Framework and Significant Risk Register are presented at each public Board meeting. Each director confirms that he or she has taken all the steps that ought to be taken as a director in order to make them aware of any relevant information that should be shared with the Board and its Auditors.
Directors’ membership of core committees – 2014-15 Audit & Assurance Committee
Nomination and Remuneration Committee
Safety & Quality Committee
Finance & Workforce Charitable Funds Committee Committee
Chair Richard Congdon (until May 2014)
Chair Alan McCarthy
Chair Richard Shaw
Chair Richard Durban
Chair Yvette Robbins
Members All NEDs
Members Richard Durban (until August 2014)
Members John Power (until August 2014)
Members John Power (until August 2014)
Yvette Robbins
Richard Congdon (until May 2014)
Richard Congdon (until May 2014)
Alan Hall
Pauline Lambert (August 2014)
Paul Biddle (from July 2014) Members John Power (until August 2014) Richard Durban Richard Shaw Yvette Robbins (from September 2014)
In attendance Chief Executive Director of HR
Pauline Lambert (from August 2014) Chief Executive
Paul Biddle
In attendance Chief Financial Officer
Chief Nurse
Chief Executive
Chief Medical Officer
Chief Finance Officer
Director of Corporate Affairs
Chief Operating Officer
Director of HR
Other members of the Executive and Non Executive team are invited to attend as and when required
Chief Finance Officer Clinical Chiefs of Service
Paul Biddle (from July 2014) Chief Finance Officer
Chief Nurse Director of Information Director of Corporate and Facilities Affairs Director of Corporate Director of Information Affairs and Facilities Chief Nurse (from November 2014) Medical Director
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Working with our regulator The Care Quality Commission (CQC) regulates the Trust as a provider of NHS care. We are required to register with the CQC and our current registration status is that we are fully licenced to provide NHS Services. We have no conditions on our registration. The Care Quality Commission has not taken enforcement action against the Trust during 2014-15. The CQC completed an inspection in May 2014 – report published in June 2014) and has not conducted a physical inspection during this period. See the Care Quality Commission (CQC) section for details of the CQC’s Intelligent Monitoring assessments. Thanks to the hard work of our staff, we achieved a ‘Good’ rating across the board in all five areas - to put this context nationally at the time of the most recent (31) inspections only four other Trusts achieved an overall ‘Good’ rating and only two of these were green in all domains. This puts us amongst the best in the country for the quality of services and the CQC said that our staff should be extremely proud of what they have achieved.
Quality governance This year our Board has made many significant improvements to quality governance and this is reflected in the Chief Inspector for Hospitals’ inspection report published in August 2014 which rated the Trust as good across all inspection domains. Our Board and executive team are responsible for ensuring the divisional capability to manage clinical governance and also for building Board level ability to scrutinise and gain assurance of quality governance. In 2014-15 we have implemented quality improvements to resources and infrastructure, which we expect to deliver significant improvements to quality governance, including: • The appointment of a clinical nonexecutive director • The appointment of a new non-executive director bringing experience from an established and performing Trust
• An increase in clinical presentations and patient stories to the Board • The refresh of the safety and quality committee • The restructure of quality governance systems and reporting from divisions through the executive committee for quality and risk through to the Board • Executive led specialty deep dives • Building capability within the divisions to manage risk, audit and complaints • Serious incident reports presented and discussed at public board meetings We have reviewed our quality governance framework and developed a system that is aligned with the Care Quality Commission (CQC) five domains of quality: • Safe • Effective • Caring • Responsive • Well-led The changes to quality governance allow staff at divisional level, through the divisional governance meetings, to escalate any concerns relating to quality to the Board through the executive committee for quality and risk. The Board, through the safety and quality committee chair’s monthly report, can ask for further work or seek further clarification on issues raised or supporting agenda items such as patient stories. This simpler process is supported by the Trust’s incident reporting system and, when necessary, our whistleblowing policy. The appointment of a non-executive director with clinical experience has already had a positive impact by: Skilled knowledge and robust clinical challenge at Board meetings and at Board sub-committees including the safety and quality committee. • The ability to translate clinical conversations and discussions at the Board into experience from a clinical frontline as well as from a strategic perspective with clearly articulated examples
Our governance and assurance
• Significantly improving the diversity of our Board that would not otherwise be present. This has already been verified by external partnership working with regulators and from a Board development perspective • Highlighting issues of assurance to the Board detailed in the annual safeguarding report and worked with the chief nurse to ensure assurances are robust • Reviewing the actions taken for the management of oral methotrexate following the second never event and provided the Board with assurance that plans where sound and fit for purpose
Board assurance The Board Assurance Framework (BAF) and Integrated Performance and Quality Report are fundamental tools for Board level management of risk and performance and quality governance. The IPQR includes the presentation of quality data, supporting information on performance, actions that the executive team are taking and qualitative feedback from patients relating to specific examples of patient care. It focuses the data on key issues of strategic importance and quality assurance and provides a 13 month trend analysis. It also provides a focus on long-term strategic risks which have been identified as part of the implementation of strategy. The BAF includes significant operational risks where they pose an unacceptable level of risk to long-term strategy. The Significant Risk Register (SRR) details significant operational risks which have either been identified by the executive team or divisional management. The link between the SRR and the BAF has become a very visible element of quality governance and the Trust’s escalation framework at Board level.
Escalation framework Recommendation was made, following a review of the quality governance framework, for an alternative structure comprising of an executive quality committee supported by a series of sub-
committees aligned to the domains of quality described by the CQC. This new framework was adopted at the start of 2014 and forms the quality governance and escalation framework for the Trust (appendix 2). For those closely involved in the system this has been a step change in governance and communication systems. There are now many clear formal, routes from divisional governance to the safety and quality committee and the Board and this provides a formal channel of escalation to our public Board that is both timely and managed by appropriately senior and competent staff. The risk management system has also been aligned with this framework meaning that any risk agreed by divisional governance will be discussed by the relevant sub-committee of the executive committee for quality and risk and, if appropriate, is included in the Trust’s significant risk register at public Board within a month of it being recorded. The framework is now the main formal escalation framework for quality matters and facilitates greater responsibility for quality governance within the divisions and meets the expressed need to have greater control and integration of the quality agenda and of resources to better manage the governance issues at source. This has delivered a great deal of improvement in the Trust’s quality governance, the clearest example of which has been clinical attendance at all levels of quality governance forum and the ability to articulate and manage issues which would previously have been left to the corporate team and is highlighted, in particular, at the safety and effectiveness sub-committees, which are regularly attended by medical staff who openly discuss problems, share best practice and provide appropriate challenge and agree solutions which are monitored on a regular basis. We continue to develop the framework to address some remaining opportunities for further improvement including clinical audit and the management of serious incidents.
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Making a difference – patient safety The patient safety sub-committee reviews incident trends and serious incident management. This year the number of serious incidents, related to falls with a fracture, were identified as an unacceptably high rate, the executive committee for quality and risk considered and added the issue to the significant risk register and resolved to review the Trust’s strategy for reducing falls with significant harm. In response, the executive team, following a review of information included in the annual patient falls report to Board, recruited a consultant nurse falls specialist who joined the Trust in December 2014.
Putting people first – patient experience The patient experience sub-committee continues to be a source of patient commentary that is reviewed and reported to public Board – in 2014-15 this has included patient commentary and reviews from our Friends and Family Test (FFT) scores. The Trust’s FFT scores for the emergency department and inpatient scores benchmark positively, however, the sub-committee was also aware of lower than national average scores reported by post-natal cases. As a result of this knowledge, the sub-committee is conducting focus groups with patients to try to understand better the issues linked to these scores.
Getting it right – assuring quality The workforce sub-committee has developed a reporting system which receives regular reports from each division, this has been a particularly useful source of shared learning and discussion of specific workforce issues and the impact they have. This has allowed the executive committee for quality and risk to request information and seek assurance whilst systems for recording and reporting information improve to meet the needs of the finance and workforce committee. The best examples of this are reviews of nursing staff without PIN numbers and nursing turnover highlighted by issues recorded in the CQC intelligence monitoring risk profile throughout 2014.
Our governance and assurance
All the nurses and doctors that were involved in my treatment were superb, I cannot praise their compassion and skill highly enough.
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Annual Report 2014-2015
Our finances The year in context
The Trust did not receive non recurrent (one-off) support for its overall financial position, but the 2014/15 position includes non-recurrent funding from NHS England to pay for additional 18 week activity (to meet referral to treatment 18 week targets) and “A&E resilience” to support the management of emergency activity in the winter (covering some of the additional cost referred to above). This funding totalled £3.1m.
2014-15 was another difficult year financially, and the Trust ended the year with a small deficit of £2.4m. We delivered our £11m savings programme, delivered our capital programme within the resource limit and we have managed our cashflow well in the year. The deficit was driven by emergency activity above plan (more people were turning up at A&E and so more people were admitted). That brought a triple problem of additional cost, more income paid at only 30% (the “marginal rate emergency tariff”) and we could not do as much planned work, resulting in a further loss of income.
Income and expenditure performance is described in the chart below, which provides a view back to the creation of the Trust in 1998/99.
Chart: Trust financial performance from its creation in 1998/99
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2014/15
2015/16 plan
0.9
(5.0)
(4.6)
(0.2)
(0.0)
(12.8) (26.4) (27.8) (12.2)
(2.6)
(2.7)
(0.2)
(2.2)
(11.9)
(9.2)
(4.3)
(5.2)
1.6
Net surp (def)
0.9
(5.0)
(4.6)
(0.2)
6.7
(4.1)
0.0
7.0
7.6
1.0
(6.1)
0.3
0.3
(2.4)
1.6
(26.4) (10.8) (12.2)
2013/14
2002/03
2006/07
2001/02
2005/06
2000/01
2004/05
1999/00
Underlying surp (def)
2014/15 plan
2003/04
Underlying surp(def) Net surp(def)
adverse
1998/99
54
Our finances
The journey to 2014/15 – a brief financial history As the graph above describes, the Trust has experienced dramatically fluctuating financial fortunes. We went into deficit very soon after the Trust’s creation (from the merger of the hospitals in East Surrey and Crawley) and after a deceptive respite in 2002/03 the Trust went into a very serious financial decline. At the peak of those problems, in early 2006, the Trust was placed in “formal turnaround” by the Department of Health. This initiated significant structural change (notably the divestment of Crawley Hospital to the Primary Care Trust and the transfer “in-house” of what was the Redwood Diagnostic and Treatment Centre previously run by a private company). A more stable management team was created and in September 2007 a major review was completed by Ernst & Young, paving the way for the loan repayment plan implemented in early 2008. In the period after 2007 the chart describes a fragile, but notable, financial recovery, and the delivery of the loan repayment plan. During this time the local Primary Care Trusts (predecessors of Clinical Commissioning Groups) provided non recurrent funding to allow the net surpluses and which, in turn, provided the Trust’s contribution to its accelerated loan repayments. This allowed the success of being able to repay most of the £56.0m loan in just three years and in 2008/09 the Trust’s categorisation as “financially challenged” was formally lifted. However, underlying operational and quality issues had not been dealt with, and in 2010/11 they became very visible. The Trust failed to deliver its full savings plan in this year and just at the point when the financial environment got much colder. There was a management team change in October 2010 (when Michael Wilson joined the Trust as interim CEO). The new team prioritised
patient safety and performance improvement, and the 2011/12 savings plan was set at the lower end of the expected level while the Trust invested heavily in clinical staff. It is this and the tightening of Government spending (seen through the reduced tariff (price) for payment by results income in that year) that contributed most to the Trust’s 2012/13 underlying deficit. In the last couple of years, financial performance has been given a significant boost by the improved quality of our services, operational performance and the improved reputation with patients and the public all of that brings. More patients are coming, and want to come, and we are able to provide them with better care and a better experience. Planned care services have become much more productive, and the Trust’s income has increased while its reference costs (see later) have continued to improve. Noting that the Trust is part of the health system, the only negative has been the health system’s continued, and shared, difficulty to deliver the intended reduction in emergency activity. The Trust’s current financial strategy builds on the improvement in our services. The mantra in the organisation about quality, experience, safety and clinical effectiveness links to the money as well, as it reduces waste, drives productivity and encourages patients to want to come to the hospital. The financial plan is therefore about further productivity improvement, repatriating activity lost to the Trust in its “difficult” years, coping with the increased emergency demand and allowing reasonable levels of financial savings. In 2014/15 the Trust remains within its financial strategy and the deficit has been driven by emergency activity above plan. Directly that had two impacts: a) higher costs from temporary capacity, additional doctors and nursing staff, and; b) as this activity is paid at the 30% “marginal rate emergency tariff” a £7.2m loss of income to the Trust, which is retained by Clinical Commissioning Groups. Indirectly, this volume
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meant that beds had a high occupancy rate (minimal empty beds at any one time) and we couldn’t do as much planned work, resulting in a loss of income.
period, and suggests that we have managed the investment in services without markedly increasing our unit costs. Table: Trust reference cost indices
It should be noted that as the Trust goes into 2015/16 the “marginal rate emergency tariff” will be adjusted for this Trust to a 70% payment and the Trust is in discussions with Clinical Commissioning Groups over the setting of the threshold at which this improved, but still reduced, payment kicks in.
Reference costs
Underlying surp(def) Net surp(def)
Reference costs
adverse
2006/07
116
2007/08
95
2008/09
86
2009/10
94
20010/11
97
2011/12
89
2012/13
92
2013/14
92
2014/15 plan
2013/14 NHS reference costs (the most recent) describe an average unit cost for the number of patients treated (correctly health resource group episodes) and are translated into an index.
Index
The loan and the statutory breakeven duty
The national average is an index of 100 and the Trust’s index score has changed as described in the table below. The 2013/14 figure, is 92. This describes cost management over a long
Surrey and Sussex Healthcare NHS Trust secured its £56.0m loan at the end of 2006/07 to cover debts from its poor financial performance up
Loan outstanding
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
Loan repayment schedule Loan repayment plan Loan 250.0 outstanding
Conversion to PDC
2007/08 (£m)
2008/09 (£m)
2009/10 (£m)
2010/11 (£m)
2011/12 (£m)
2012/13 (£m)
2013/14 (£m)
2014/15 (£m)
2015/16 Plan (£m)
(55.9)
(53.7)
(20.7)
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.7)
7.9
0.3
0.2
0.2
0.2
0.2
0.2
(4.8)
(4.5)
(4.3)
(4.1)
(3.9)
(3.7)
(3.5)
Total income 26.0 Rec income
Trust repayment
2.2
7.0 Non rec income
Loan carried forward
(53.7)
(20.7)
8.0
Our finances
to that time. This was, and probably still is, the largest loan allowed for any NHS Trust. The current position on the loan is described above, with only £3.7m left outstanding. The Trust is now making the scheduled payments required by its 25 year loan agreement against that balance. The loan repayment plan had been acting as a proxy for “meeting” the statutory breakeven duty, which the Trust has been in breach of since 2007/08. The statutory breakeven duty is set out in Schedule 5 of the NHS Act 2006 and case law states that a surplus of an equal size to any past deficits needs to be accumulated in a period of 5 years after the deficit was recorded. However as this does not take account of any loan arrangement and the repayment the Trust has achieved, the Trust is still technically in breach. Section 19 of the Audit Commission Act 1998 requires the auditor to advise the Secretary of State of any breach of the duty or the potential the Trust may incur illegal expenditure. The Auditor did so in a “Section 19 letter” at the start of the 2011/12 financial year and issued another letter, at the request of the Audit Commission, with the 2013/14 financial accounts. As the Trust’s “breach” is a technical one, there is no impact on the Trust, beyond explaining the above. The Auditors have confirmed they will not be issuing a further “Section 19” letter for 2014/15.
Liquidity - working capital and cash in 2013/14 The Annual Report has, for each of the last few years, provided a description of the weakness of the Trust’s balance sheet and tried to explain the technicalities of what that means. Liquidity has sat resolutely on the Board Assurance Framework as one of our main strategic risks for many years. The problem is the liquidity of the statement of financial position (as the balance sheet is correctly called). We have done pretty well to keep the Trust operating with such a weak balance sheet for the last 6 years. In 2011/12
we needed an injection of cash, but the Trust has managed without the need for that, or to take out any other permanent loan in 2014/15. The fragility of the position has meant, in 2014/15, that with our cash flow interrupted by late payments from commissioners we did have to temporarily borrow cash (which we have repaid already).
What is liquidity? Liquidity has various meanings - in this instance it provides an indication of how far away an organisation is from running out of cash and being unable to pay its bills. The statement of financial position describes the Trust’s accumulated financial strength or, and in our case, weakness. The statement of financial position (the balance sheet) was not particularly strong when the Trust was created and the substantial deficits up to 2006/07 drained its working capital to the point where the only way to keep payments going was to take out the £56.0m loan. Although this was the largest loan allowed for any NHS Trust, it did not cover the full extent of the liquidity problem. Since December 2007 the Trust has been reporting its liquidity position in its monthly Board reports in terms of the number of days the Trust’s working capital would cover the cost of average running costs. Because the Trust has negative working capital (its payables (creditors) are far greater than receivables (debtors)/cash) this measure has fluctuated around minus 20 days for the last 7 years. The solution is a significant injection of cash, either from a new working capital loan, a working capital facility (an “overdraft” allowing cash to be drawn when needed) or a straight forward payment of “equity” (for NHS Trusts that would be public dividend capital). To get to a sustainable position the value of this cash injection is estimated to be about £18.0m for this Trust.
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Annual Report 2014-2015
Trust financial plan
Transitional Support provided
13/14
14/15
15/16
Future State
SaSH in Transition (Stabler less NEL more EL)
SaSH manages NEL impact (with small deficit)
SaSH right sized and transition to recurrent surplus
Sustainable FT
£3.5m*
Small defecit
Surplus
Performance and productivity Improvement Partnership Opportunities * Note: £3.5m paid - agreement was £8.5m
The Department of Health and Trust Development Authority, who have advised that Surrey and Sussex Healthcare is one of several NHS Trusts in this historic position, will be discussing how we manage this as we progress our Foundation Trust application. Just to note, in 2014/15 the Monitor liquid ratio calculation changed and this forms part of the “continuity of services” rating, taking into account capital borrowing and the ability to repay that.
Looking forward – sustainability and the Foundation Trust pipeline The Trust has now been formally recommended to Monitor for consideration as a Foundation Trust. As this is written (in May 2015,) Monitor are carrying out their detail assessment of the Trusts’ clinical and financial sustainability, about 4 months behind the timetable discussed in the previous annual report. If that assessment is positive we can be authorised as a Foundation Trust. Based on financial performance up to 2014/15, modelling shows that the Trust can be realistically positioned to achieve the financial requirements for being a Foundation Trust in 2015/16.
Recovery of the underlying deficit the Trust is carrying is key in this, and the financial plan is described as in the diagram below. This sees the Trust getting to the “right size” over a period of three years, with transitional funding supporting the process. As the Trust transitions from 2014/15 to 2015/16 it is helped by the terms of the “Enhanced Tariff Option” it opted for in March 2015. This tariff option was one of two provided after the withdrawal of the original national tariff put forward in early 2015. For this Trust this provides benefit from the increased payment for emergency activity and, noting that the Trust has a reduced clinical negligence scheme payment (CNST - the NHS clinical “insurance” policy), the full benefit of the income increase provided and the full 2.5% addition of clinical quality and innovation (CQUIN) payments. The financial plan is supported by an operational plan, as in the diagram 2 describing the activity changes that would allow the balancing of nonelective to elective activity - maximising higher contribution income. The operational plan has been disrupted in 2014/15 with the level of demand for emergency care and difficulty in delivering
Our finances
Trust Operational plan Performance and productivity Improvement in all areas
13/14 Non elective activity
Elective activity
14/15
15/16
Future State
Manage activity in non elective bed base - stop overcrowding
Manage activity growth, increase capacity, improve discharge , reduce XSBDs
Deliver LoS reduction and create capacity to manage peaks
Flexible operational position to cope with changing healthcare pathways
1) Ring fence extant elective capacity: 2) Minimal outsourcing; 3) Absorb growth
1) Ring fence and Maintain: 2) Create additional capacity; 3) Productivity changes
1) Consolidate: 2) Marketing to compete with independents and others, increase market share
Strong elective base, competitive market position and flexibility to support health system/ choice initiatives
the elective income plan. This has required revision of the operational plan which can be summarised as follows: • 2011/12: Deal with overcrowding - more capacity, infrastructure and more effective clinical pathways (modular wards, capital works to A&E/elsewhere, clinical team changes in ED, new rotas etc.); • 2012/13: Non elective activity kept within its bed-base, allowing the ring-fencing of elective and specialist beds and then reducing outsourcing – overcrowding significantly reduced; • 2013/14 to 2014/15: The plan was for length of stay reductions and reduced use of escalation through joint programmes across the health system. However, emergency demand has been very strong in 2014/15 and although actions have helped to maintain performance they have not created additional capacity. Therefore more physical emergency capacity (a new modular ward and increased hospital at home “beds”) has been created to cope .Capacity has been created from (internal processes (7 day working, physician rotas), community beds and community geriatricians);
• 2012/13 to 2015/16: significant capital programme to deal with core quality issues and improve clinical effectiveness and patient experience (theatres refurbishment, main entrance, ward refurbishment, new equipment); • 2012/13 onwards: achieve performance and CQC targets – quality improvements drive reputation and make the Trust more attractive to patients and commissioners… and more competitive – 2014/15 achieved CQC rating of “good” in all 5 domains in Chief Inspector of Hospital visit; • 2012/13 to 2014/15: deliver significant financial savings (4.5% [£10.0m] in 12/13, 4.8% in 13/14 [£11.1m] and 4.8% in 14/15 [£11.0m] before savings reduce to more manageable levels); - £8.2m is target in 15/16 (3.1%); • 2012/13 to 2014/15: establish partnerships that increase the health care provided from the East Surrey Hospital site (RSCH FT/ radiotherapy, GSTHFT/respiratory, various/ cancer services) • 2014/15 to 2018/19: specific service developments implemented for cardiology, cancer, outpatients, bowel screening, births and extensive private patient facilities.
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Annual Report 2014-2015
• 2015/16: repatriate elective activity, maintain capacity with increasing level of referrals (deliver RTT standards) and begin to increase market share – the repatriation has been put back a year to 2015/16 because non elective activity has not reduced and the scale of this has also been increased; • On-going: increased productivity, consideration of further partnership opportunities and commercial opportunities as relevant. • 2014/15 onwards: service line emphasis – specialty development not just financial SLR.
2015/16 budget To drive the delivery of the £22.0bn efficiency saving described in the Five Year Forward View and required in the next few years for the NHS to cope with demand and drive continued improvements in quality, tariff and contract rules have been strengthened for 2015/16, with some amelioration provided for this Trust by the “enhanced tariff option”. The figures that follow apply to the enhanced tariff option (ETO). The changes include reducing the tariff price of payment by results income for the fifth consecutive year, introducing a “gain share” mechanism for any growth in specialist commissioning (eg: cancer services, neo natal services and similar) that sees 70% of the additional cost paid rather than 100%, restrictions on “counting and coding” changes that affect income paid to providers and requirements that non contracted referrals must be accepted by receiving providers. As mentioned above, a favourable change in the ETO is that the marginal rate emergency tariff will be paid to providers at 70% rather than the 30% previously. In addition there are other important structural changes which were described last year and now come into full effect, changing the way money moves around and driven by specific programmes to transform services. In particular there is the Better Care Fund, which sees the transfer of funding from clinical commissioning groups to councils to drive the transfer of
care out of hospital into the community and social care. The Trust is affected by the transfer of activity away, which will help the Trust as it would wish to reduce the amount of emergency activity it sees, and which is not paid for at full tariff. The key points about the Trust’s 2015/16 budget are as follows: 1. The budget delivers a £1.6m surplus in 15/16 – this is also the planned normalised position at the end of 15/16. 2. The cost improvement plan (CIP) is £8.2m – 3% of turnover. This level of cost improvement is necessary to deliver the national efficiency target . 3. The Quality Impact Assessment (QIA) process for reviewing cost improvement plans is on going, including review of the impact of savings in-year. The output of the QIAs is reviewed by the Trust Board so that it is clearly aware of the balance between cost improvement and quality of services. 4. The income plan reflects price changes from the “enhanced tariff option” , the repatriation of elective and outpatient activity and, where agreed, the impact of CCG and NHS England QIPP plans 5. There is risk – Clinical Commissioning Groups are very short of money, emergency activity has increased in the past year and the cost improvement plan is challenging.
Analysis of financial data The key financial statements from the 2014/15 accounts are in the appendix. The table below provides a fuller summary of our income and expenditure performance since 2007/08, and the plan for 2015/16.
61
Income from patient care Other operating income Net operating income Operating expenses
153.4 17.6 171.0
172.1 15.9 188.0
174.1 20.8 194.9
179.8 16.4 196.2
189.3 20.3 209.6
197.0 29.0 226.0
210.6 21.0 231.7
225.4 18.7 244.0
15/16 plan (£m)
2014/15 (£m)
2013/14 (£m)
2012/13 (£m)
2011/12 (£m)
2010/11 (£m)
2009/10 (£m)
2008/9 (£m)
Income & Expenditure: EBITDA presentation
2007/8 (£m)
Our finances
245.6 20.3 265.9
(158.1) (171.9) (178.9) (187.2) (207.0) (215.0) (220.7) (234.7) (251.4)
EBITDA (op surplus/(deficit)
12.9
16.1
16.0
9.0
2.6
11.0
11.0
9.3
14.5
(2.3) (1.5) (0.8) (0.3) Update(5.2) with right (5.7) (4.5) (4.7) (1.4) (1.8) (2.9) (3.0) information (3.9) (0.2)
(0.4) (5.4) (3.0)
(0.3) (7.3) (3.1)
(0.3) (7.2) (3.2)
(0.3) (7.8) (3.6)
(0.5) (8.1) (4.3)
1.0
(6.1)
0.3
0.3
(2.4)
1.6
(4.8)
0.0
0.1
0.0
0.0
(3.7) (2.2)
(6.1) (13.3)
0.4 (9.2)
0.3 (4.3)
(2.4) (5.2)
1.6 1.6
(11.5) (11.2)
(0.2) (4.5)
(0.9) (3.3)
1.6
(44.2)
(43.9)
(46.3)
(44.7)
Net interest and other items Depreciation PDC dividends payable Impairments/donated assets
p57 NHS performance surplus/ (deficit) Impairments/donated assets NET SURPLUS/(DEFICIT) Underlying surplus/(deficit)
0.0
0.0 (2.6)
7.0
7.0 (2.7)
7.6
7.6 (0.2)
Normalised adjustments Normalised surplus/(deficit) B’even duty: Cumulative deficit
(54.1)
(47.0)
(39.4)
(38.4)
(44.5)
Analysis of financial data The key financial statements from the 2014/15 accounts are in the appendix. The table below provides a fuller summary of our income and expenditure performance since 2007/08, and the plan for 2015/16.
8%
2%
8%
Trust forecast income 2015/16 Income NFS contract income CSG income /Patient care SQUN (all CCGs and NHSE NHSE Sub total: contract income Other operating income Non reccurant support Total income
2015/16 Forecast (£m) 214.4 5.8 25.4 245.6 20.3 0.0 265.9
82%
NHS clinical income Comminssioning board
Other income CQUIN (all CCG’s)
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Annual Report 2014-2015
Underlying surp(def) Net surp(def)
Trust income since 2006/07 adverse
1. The transfer of Crawley Hospital and Surrey HIS caused a reduction in income between 05/06 and 07/08, with loss of clinical income from the creation of Walk in Centres’ in Crawley and Redhill. These reductions were not matched by similarly timed cost reductions until 07/08 – as a result the Trust was in deficit until this point. 2. 08/09 saw the largest step change in the Trust’s income over this period for two reasons: • a significant jump in non elective activity but also the additional activity necessary to meet the 18 week target. The income from this increase was “lost” at the time to contract challenges by PCTs but then replaced with non recurrent funding – in summary however, the income increase here is from extra activity, not non recurrent funding (the non-recurrent funding line has been adjusted). 2008/09 2010/11 • 08/09 was 2007/08 also the last year of2009/10 the phased introduction of payment by results, where the Trust was a significant “gainer” - £6.5m was added to the Trust’s market forces factor in the year.
4. 11/12 saw a steeper increase in income with increased elective activity to meet 18 weeks, some non recurrent income for that purpose, the taking back of one of the walk in centres (Redhill UTC) referred to at (a) and continued growth in outpatient income. 5. 12/13 shows2013/14 a continuation of2015/16 2011/12, 2012/13 2014/15 increased productivity and more activity, unfortunately without the reduction in none electives. The change since 2010/11 is noticeable in the chart.
2011/12
Total income from 2006/07 250.0
Total income Rec income Non rec income
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Total income
163.3
Non rec income Rec income
250
163.3
2014/15 plan
3. 09/10 saw activity income fully consolidated as contract payment (being paid for what is done, and with some increase) but suppressed by the income agreement that year (the Trust has reached agreements on overall annual Contract income with its local PCTs to settle contractual disputes through overall annual memoranda of understanding (MoU’s) in several of the last few years). The “increase” seen in 2010/11 is therefore partly a delay in seeing 09/10 benefit. There was significant loss of recharge (non contract) income in 10/11, contributing to a decline in total income compared to that from activities.
167.7
188.0
194.9
196.2
209.6
226.0
231.7
244
6.8
10.5
6.8
4.9
12.6
13.4
3.5
3.1
160.9
177.5
188.1
191.3
197.0
212.6
228.2
240.9
Our finances
6. 13/14 sees income increasing at a reduced rate with tariff deflation taking effect. 7. 14/15 – income has again increased significantly – even after £7.2m was not received due to the marginal rate for emergency tariff reduction.
Trust costs since 2006/07 Pay costs fell from 04/05 to 07/08 with the loss of Crawley Hospital, the Surrey HIS and other smaller services that were absorbed by other parts of the local NHS. Pay costs rose significantly between 2007 and 2008 (where the main hit was taken) as the Trust took back the Redwood Centre, moving a Trust forecast costs 2015-16 2015/16 Forecast (£m)
Operating costs Pay costs Non pay costs Sub total: operating costs Depreciation PDC dividend Net interest paid/received Total income
175 76.4 251.4 8.1 4.3 0.4 264.2
1.6% 3.5%
0.2%
28.1%
66.2%
Pay costs Non pay Deprec
PDC dividend Net interest
At the same time, activity increased Trust costs since 2006/07 1. Pay costs fell from 04/05 to 07/08 with the loss of Crawley Hospital, the Surrey HIS and other smaller services that were absorbed by other parts of the local NHS.
Costs in 2015/16 are forecast to total £264.2m, split as described in the table and chart below.
Costs
non pay charge to pay, but also giving a saving in non pay as the profit element of the charge was lcost.
2. Pay costs rose significantly between 2007 and 2008 (where the main hit was taken) as the Trust took back the Redwood Centre, moving a non pay charge to pay, but also giving a saving in non pay as the profit element of the charge was lost. 3. At the same time, activity increased significantly in 08/09 and 3 additional wards were opened at this time. In 2009 Surrey HIS broke up, with staff returning. The rise in pay costs from 07/08 is the main driver behind the Trust’s increasing costbase, noting that simultaneously reference costs remained at below average levels. 4. The increase in 10/11 non pay is mainly due to the £4.8m non recurrent impairment. 5. In 11/12 there was investment in staff and the increase in outsourcing, which provided an additional (partial) cost because it was on top of the fixed cost of the Surgical Division. Additionally VAT and CNST increases were substantial in year (£1.6m between them). 6. 12/13 and 13/14 sees an increase in staff costs as activity costs increase and with further investment in clinical priorities (for example midwife numbers, which were increased to match the new target ratio of midwives to births) – it should be noted that the increases in both pay and non pay costs are not as steep as the increase in income. Non pay, however, which has been a particular focus for savings, shows a decline in 13/14. 7. 14/15 sees an increase in both pay and non-pay to deliver the increased income – though to note that the income increase reflects only 30% payment for the
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Annual Report 2014-2015
250
Costs from 2006/07 240 (income for same period inset) 250 240
2013/14
2013/14
2014/15
2014/15
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Pay
106.3
102.7
116.2
125.1
131.6
140.8
147.2
155.1
163.1
Non pay
65.9
64.5
61.5
58.5
65.0
71.5
75.0
72.7
79.3
Our finances
significant activity above the marginal rate baseline – so in 14/15 the cost increase is greater than the income increase – resulting in the reported deficit for 14/15.
Capital The Trust continues to increase the amount of its capital investment. In 2013/14 we spent a total of £16.4m on capital works, IT and equipment. In 2014/15 this figure has increased to £19.3m of capital investment. The Trust structures its programme to ensure that maintenance and refurbishment is completed, that we invest in improving patient areas and support the Trust strategy to ensure patients are treated in a safe, high-quality environment, and which is welcoming and convenient for them and their families. The programme is successfully transforming the estate and has reduced the cost of maintenance as we modernise the hospital A wide-range of different projects were delivered in-year but the principle focus was investment in the Trust’s estate, and by year end the programme had delivered:
• The theatres refurbishment phase 1 was completed, giving the Trust new state of the art operating theatres – phase 2 (completing the process of replacing all of the old East Surrey Hospital theatres) will complete in April 2015; • The building of two 20-bed wards, Capel Annex and Tilgate Annex, completed in December 2014 and March 2015 respectively; • The opening of a new car park in compliance with the Trust’s Travel Plan in April 2014; In 2015/16 the Trust is planning to invest a further £16.9m across similar areas, with the principle focus being on an extensive ward refurbishment programme, enhancing diagnostic imaging and cardiology facilities and creating a new cancer information and support centre in partnership with Macmillan Cancer Support. The Trust Board has approved a five year capital investment programme of £65m which will ensure that the estate continues to develop for the future. Signed:
Michael Wilson Chief Executive
Date: 1 June 2015
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Annual Report 2014-2015
Salaries and allowances 2014-2015 Name
Title
Executive Directors Wilson, Mr. Michael Anthony Simpson, Mr. Paul Fraser Holden, Dr Desmond Philip Allsop, Mrs. Fiona Margaret Bostock, Mr. Paul Justin Bray, Dr Barbara Francis-Musanu, Mrs. Gillian Josephine Parker, Mrs. Yvonne Mackenzie, Mr. Ian Duncan
Chief Executive Chief Financial Officer Chief Medical Officer Chief Nurse Chief Operating Officer (Interim) Chief Medical Officer (31/01/2015 - 21/02/2015) Director of Corporate Affairs Director of Human Resources Director of Information and Facilities
Non-Executive Director McCarthy, Mr. Alan Roy Robbins, Ms. Yvette Anita Congdon, Mr. Richard John Shaw, Mr. Richard Oliver Durban, Mr. Richard Don Hall, Mr. Alan J Power, Mr. John Christopher Biddle, Mr. Paul Lambert, Ms. Pauline
Chairman Deputy Chairman/Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director (left 10/08/2014) Non-Executive Director Non-Executive Director
Band of Highest Paid Director’s Total Remuneration (£’000) Mid Point of the Banded Total Remuneration of Highest Paid Director (£’000) Median Total Remuneration Ratio
170-175 £172,500 £23,825 7.24
Our finances
2014-15 Salary (bands of £5,000)
170-175 125-130 135-140 110-115 110-115 15-20 80-85 100-105 100-105
30-35 5-10 0-5 5-10 5-10 5-10 0-5 0-5 0-5
Expense Performance payments pay and (taxable) total bonuses to nearest (bands of £100 £5,000)
Long term performance pay and bonuses (bands of £5,000)
1 * 25-30 1
6 2 3 4 1 2 1
Notes: * Represents clinical excellence award payments.
All pensionrelated benefits (bands of £2,500)
2.5-5 22.5-25 0-2.5 40-42.5 65-67.5 0-2.5 5-7.5 17.5-20 27.5-30
TOTAL (a to e) (bands of £5,000)
175-180 150-155 165-170 155-160 180-185 15-20 90-95 120-125 125-130
30-35 5-10 0-5 5-10 5-10 5-10 0-5 0-5 0-5
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Annual Report 2014-2015
Salaries and allowances 2013-2014 Name
Title
Executive Directors Clough, Mr. Andrew Tomlinson, Mr. Jon
(Interim) Chief Nurse (24/06/2013 - 27/09/2013) Note 1 (Interim) Chief Operating Officer (08/04/2013 - 16/08/2013) Note 2 Wilson, Mr. Michael Anthony Chief Executive Simpson, Mr. Paul Fraser Chief Financial Officer Holden, Dr Desmond Philip Chief Medical Officer Allsop, Mrs. Fiona Margaret Chief Nurse (from 01/10/2013) Bostock, Mr. Paul Justin Chief Operating Officer (from 01/08/2013) Bluhm, Mrs. Bernadette Ann Chief Operating Officer (left in 2012-13) Bray, Dr Barbara (Interim) Chief Medical Officer (01/03/2014 - 31/03/2014) Francis-Musanu, Mrs. Gillian Josephine Director of Corporate Affairs Parker, Mrs. Yvonne Director of Human Resources Mackenzie, Mr. Ian Duncan Director of Information and Facilities Aitkenhead, Mrs. Susan Margaret Director of Nursing (until 19/08/2013) Non-Executive Directors McCarthy, Mr. Alan Roy Robbins, Ms. Yvette Anita Congdon, Mr. Richard John Shaw, Mr. Richard Oliver Durban, Mr. Richard Don Hall, Mr. Alan J Power, Mr. John Christopher
Chairman Deputy Chairman/Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director
Band of Highest Paid Director’s Total Remuneration (£’000)
200-205
Mid Point of the Banded Total Remuneration of Highest Paid Director (£’000)
£202500
Median Total Remuneration
£23,825
Ratio
8.50
Our finances
2013-14 Salary (bands of £5,000)”
Expense Performance payments pay and (taxable) total bonuses to nearest (bands of £100” £5,000)”
Long term performance pay and bonuses (bands of £5,000)”
All pensionrelated benefits (bands of £2,500)”
TOTAL (a to e) (bands of £5,000)”
45-50 95-100
N/A N/A
45-50 95-100
170-175 130-135 155-160 55-60 75-80 50-55*** 10-15 85-90 100-105 95-100 40-45
125-127.5 60-62.5 52.5-55 42.5-45 110-112.5 N/A 2.5-5 87.5-90 67.5-70 72.5-75 12.5-15
300-305 190-195 250-255 100-105 190-195 50-55 15-20 175-180 170-175 170-175 50-55
30-35 5-10 5-10 5-10 5-10 5-10 5-10
45-50**
3 1
30-35 5-10 5-10 5-10 5-10 5-10 5-10
** Represents clinical excellence award payments. *** Payment in respect of loss of office in prior financial year. Equivalent to six months’ pay. Notes: 1. Payments made to agency Odgers Interim 2. Payments made to agency T4 Partners Ltd
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Annual Report 2014-2015
Pension Benefits 2014-2015 Name
Allsop, Mrs. Fiona Margaret Bostock, Mr. Paul Justin Bray, Dr. Barbara Francis-Musanu, Mrs. Gillian J Holden, Dr Desmond Philip Mackenzie, Mr. Ian Duncan Parker, Mrs. Yvonne Simpson, Mr. Paul Fraser Wilson, Mr. Michael Anthony
Title
Chief Nurse Chief Operating Officer (Interim) Chief Medical Officer Director of Corporate Affairs Chief Medical Officer Director of Information and Facilities Director of Human Resources Chief Financial Officer Chief Executive
NHSLA publication - Disclosure of Senior Managers Remuneration (Greenbury) 2015 v2
Real Increase Real in pension Increase at age 60 in pension (bands of at age 60 ÂŁ2,500 (unrounded)
ÂŁ000 2-2.5 2.5-5 0-2.5 0-2.5 0 0-2.5 0-2.5 0-2.5 0-2.5
2,073.96 2,897.06 672.58 311.18 0 1,206.49 852.88 1,085.41 217.73
1.027
102.70%
71
Our finances
Real Total Lump sum increase Accrued at age 60 in pension Pension at related to lump sum at age 60 at 31 accrued aged 60 March 2015 pension at (bands of (bands of 31 March £2,500) £5,000) 2015 (bands of £5000) £000 0 7.5-10 0-2.5 0-2.5 0 2.5-5 2.5-5 2.5-5 0-2.5
£000 10-15 25-30 60-65 30-35 0 35-40 15-20 20-25 75-80
£000 5-10 75-80 185-190 90-95 0 115-120 55-60 60-65 225-230
Cash Equivalent Transfer Value at 1 April 2014
Cash Equivalent Transfer Value at 31 March 2015
Real increase in Cash Equivalent Transfer Value
Employer's contribution to stakeholder pension
£000
£000
£000
£000
175 338 1,325 539 0 696 397 381 1,387
213 402 1,417 575 0 760 0 424 1,471
34 55 57 21 0 45 0 33 47
16 16 2 12 0 14 15 18 25
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Annual Report 2014-2015
Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.
Total remuneration includes salary, nonconsolidated performance-related pay, benefitsin-kind as well as severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions.
The banded remuneration of the highest paid director within the Trust in financial year 2014/15 was £170,000-£175,000. This approximates to 7.35 times (2013/14, 8.5 times) the median remuneration of the workforce, which was £23,825 (2013/14, £23,825).
The change in the remuneration ratio between 2014/15 and 2013/14 is as a result of the following:
In 2014-15 13 employees received remuneration in excess of the highest-paid director, (2013/14, nil). Remuneration ranged from £14,294 to £205,108 (2013/14, £14,294 to £202,062).
1. Clinical Excellence awards in 2013-14 boosted the Medical Directors total remuneration to make him the highest paid employee at the Trust at £200,000 - £205,000; in 2014-15 the Medical Director reduced the working days from 5 days a week to 4 days. 2. The number of employees based on average number of WTE (whole time equivalent including temporary staff) at the Trust rose from 3,150 in 2013/14 to 3,768 in 2014/15.
One word: amazing.
73
Our finances
Statement of Comprehensive Income for year ended 31 March 2015 2014-15 £000s
2013-14 £000s
(163,116)
(155,116)
Other operating costs
(79,326)
(72,784)
Revenue from patient care activities
225,354
210,732
18,653
20,970
Operating surplus
1,565
3,802
Investment revenue
24
23
-
21
Finance costs
(324)
(306)
Surplus for the financial year
1,265
3,540
(3,647)
(3,202)
Transfers by absorption - gains
-
-
Transfers by absorption - (losses)
-
-
-
-
(2,382)
338
2014-15
2013-14
£000s
£000s
-
(134)
Net gain on revaluation of property, plant & equipment
14,066
1,925
Total comprehensive income for the year
11,684
2,129
(2,382)
338
8
(40)
(2,374)
298
Gross employee benefits
Other operating revenue
Other gains and (losses)
Public dividend capital dividends payable
Net Gain/(loss) on transfers by absorption Retained surplus / (deficit) for the year Other Comprehensive Income
Impairments and reversals taken to the revaluation reserve
Financial performance for the year Retained deficit for the year Adjustments in respect of donated gov't grant asset reserve elimination Adjusted retained deficit
The Trust's reported NHS financial performance position is derived from its current deficit, but adjusted for the treatment of donated assets. This adjustment is not considered part of the organisation's operating position.
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Annual Report 2014-2015
Statement of Financial Position as at 31 March 2015 31 March 2015 ÂŁ000s
31 March 2014 ÂŁ000s
Non-current assets: Property, plant and equipment Intangible assets Investment property Other financial assets Trade and other receivables Total non-current assets Current assets: Inventories Trade and other receivables Other financial assets Other current assets Cash and cash equivalents Sub-total current assets Non-current assets held for sale Total current assets Total assets
144,114 2,147 3,917 150,178
117,942 2,413 3,945 124,300
3,505 17,110 2,603 23,218 23,218 173,396
3,349 14,284 2,595 20,228 20,228 144,528
Current liabilities Trade and other payables Other liabilities Provisions Borrowings Other financial liabilities DH revenue support loan DH capital loan Total current liabilities Net current assets/(liabilities) Total assets less current liabilities
(31,551) (936) (83) (216) (906) (33,692) (10,474) 139,704
(24,365) (509) (110) (216) (466) (25,666) (5,438) 118,862
Non-current liabilities Trade and other payables Other liabilities Provisions Borrowings Other financial liabilities DH revenue support loan DH capital loan Total non-current liabilities Total assets employed:
(3,543) (2,084) (3,464) (5,827) (14,918) 124,786
(3,196) (2,480) (44) (3,680) (2,554) (11,954) 106,908
Public Dividend Capital Retained earnings Revaluation reserve Total Taxpayers' Equity:
151,299 (55,783) 29,270 124,786
145,105 (53,676) 15,479 106,908
75
Our finances
Statement of Changes in Taxpayers’ Equity For the year ended 31 March 2015 Public Dividend capital
Retained earnings
Revaluation reserve
Other reserves
Total reserves
£000s
£000s
£000s
£000s
£000s
145,105
(53,676)
15,479
Retained deficit for the year
-
(2,382)
Net gain on revaluation of property, plant, equipment
-
-
Transfers between reserves
-
Balance at 1 April 2014
-
106,908
-
(2,382)
14,066
-
14,066
275
(275)
-
-
8,194
-
-
-
8,194
(2,000)
-
-
-
(2,000)
Net recognised revenue/ (expense) for the year
6,194
(2,107)
13,791
-
17,878
Balance at 31 March 2015
151,299
(55,783)
29,270
-
124,786
Balance at 1 April 2013 Changes in taxpayers’ equity for the year ended 31 March 2014 Retained surplus for the year Net gain on revaluation of property, plant, equipment Impairments and reversals Transfers between reserves Transfers under Modified Absorption Accounting PCTs & SHAs Reclassification Adjustments New temporary and permanent PDC received cash New temporary and permanent PDC repaid in year Net recognised revenue/ (expense) for the year Balance at 31 March 2014
137,510
(54,110)
13,786
-
97,186
-
338
-
-
338
-
-
1,925
-
1,925
-
98 (2)
(134) (98)
-
(134) (2)
13,095
-
-
-
13,095
(5,500)
-
-
-
(5,500)
7,595
434
1,693
-
9,722
145,105
(53,676)
15,479
-
106,908
Changes in taxpayers’ equity for 2014-15
Reclassification Adjustments New PDC Received - Cash PDC Repaid In Year
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Annual Report 2014-2015
Statement of Cash Flows for the Year ended 31 March 2015 2014-15
2013/14
£000s
£000s
Operating surplus/(deficit)
1,565
3,802
Depreciation and amortisation
7,774
7,204
Interest paid
(295)
(269)
(3,581)
(3,246)
(156)
(67)
(2,798)
(4,420)
6,368
5,330
347
(111)
(181)
(252)
130
(52)
9,173
7,919
25
23
(17,795)
(15,089)
(998)
(2,112)
(18,768)
(17,178)
(9,595)
(9,259)
8,194
13,095
(2,000)
(5,500)
Loans received from DH - New Capital Investment Loans
4,400
-
Loans repaid to DH - Capital Investment Loans Repayment of Principal
(686)
(466)
Loans repaid to DH -Revenue Support Loans Repayment of Principal
(216)
(216)
(89)
-
-
291
9,603
7,204
8
(2,055)
Cash and Cash Equivalents (and Bank Overdraft) at Beginning of the Period
2,595
4,650
Cash and Cash Equivalents at year end
2,603
2,595
Cash Flows from Operating Activities
Dividend paid Increase in Inventories Decrease/(Increase) in Trade and Other Receivables (Decrease)/Increase in Trade and Other Payables Increase in Other Current Liabilities Provisions utilised Increase/(Decrease) in movement in non cash provisions Net Cash Inflow from Operating Activities Cash Flows from Investing Activities Interest Received (Payments) for Property, Plant and Equipment (Payments) for Intangible Assets Net Cash Outflow from Investing Activities Net Cash Outflow before Financing Cash Flows from Financing Activities Gross Temporary and Permanent PDC Received Gross Temporary and Permanent PDC Repaid
Capital Element of Payments in Respect of Finance Leases and On-SoFP PFI and LIFT Capital grants and other capital receipts (excluding donated / government granted cash receipts) Net Cash Inflow/(Outflow) from Financing Activities NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS
77
Our finances
Better Payment Practice Code Measure of compliance
2014-15 Number
2014-15 £000s
2013-14 Number
2013-14 £000s
Non-NHS Payables Total Non-NHS Trade Invoices Paid in the Year Total Non-NHS Trade Invoices Paid Within Target Percentage of NHS Trade Invoices Paid Within Target
64,860 53,979 83.2%
81,932 69,650 85.0%
59,497 50,847 85.5%
71,019 61,935 87.2%
NHS Payables Total NHS Trade Invoices Paid in the Year Total NHS Trade Invoices Paid Within Target Percentage of NHS Trade Invoices Paid Within Target
2,276 1,386 60.9%
16,202 9,950 61.4%
2,207 1,689 76.5%
19,751 14,892 75.4%
The Better Payment Practice Code requires the NHS body to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. The Late Payment of Commercial Debts (Interest) Act 1998 Amounts included in finance costs from claims made under this legislation Compensation paid to cover debt recovery costs under this legislation Total
2014-15 £000s 2 0 2
2013-14 £000s 2 0 2
Capital cost absorption rate The dividend payable on public dividend capital is based on the actual (rather than forecast) absorption rate is automatically 3.5%.
External financing The Trust is given an external financing limit which it is permitted to undershoot.
External financing limit (EFL) Cash flow financing Unwinding of Discount Adjustment Finance leases taken out in the year Other capital receipts External financing requirement Under/(over) spend against EFL
2014-15 £000s 9,595 9,595 9,595 -
2013-14 £000s 9,935 9,259 35 (291) 9,003 932
2014-15 £000s 19,614 (284) 19,330 19,330 -
2013-14 £000s 16,800 (291) 16,509 17,409 900
Capital resource limit The Trust is given a capital resource limit which it is not permitted to exceed.
Gross capital expenditure Less: book value of assets disposed of Less: capital grants Less: donations towards the acquisition of non-current assets Charge against the capital resource limit Capital resource limit (Over)/underspend against the capital resource limit
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Annual Report 2014-2015
Putting people first
I am immensely proud of the people who make Surrey and Sussex Healthcare NHS Trust such a great place – who consistently strive to provide high quality care and a positive experience for the people we care for and who continue to inspire me with their enthusiasm, compassion and passion for getting it right. I know, from the regular feedback online, in letters and face-to-face that their individual and combined efforts and passion to make a difference means that we continue to put people first. I thank you all.
Michael Wilson Chief Executive Surrey and Sussex Healthcare NHS Trust
Appendices
Appendices Appendix 1 – Annual Governance Statement 2014/15 - V5.4 Note: where reference is made to the Trust website, it can be accessed at: www.surreyandsussex.nhs.uk
1. Scope of responsibility The Board is accountable for internal control. As Accountable Officer, and Chief Executive of this Board, I have responsibility for maintaining a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives. I also have responsibility for safeguarding the public funds and the organisation’s assets for which I am personally responsible as set out in the Accountable Officer Memorandum. I report to the Chair of the Trust and ensure appropriate systems exist to support the work of the Trust and the Board. I manage the executive team who have clear accountabilities and annual objectives, drawn from the annual plan for the Trust. The Trust has worked in partnership with other health and social care organisations in the area, but notably the local Clinical Commissioning Groups (CCGs). The contracts between us provides clarity on our shared priorities and officers of the Trust meet regularly with our Clinical Commissioning Groups to take forward developments and monitor the delivery of our shared healthcare plans. There has been a single co-ordinating Commissioning Group for 2014/15 who is required to intervene more strongly in performance management if the quarterly rating in the NHS performance framework requires it. This arrangement will change in 2015/16 as each county will have their own separate contracts and there will be
two co-ordinating CCGs who will represent CCGs in their counties. I also account to NHS Trust Development Authority (TDA) – This body monitors the Trust and intervenes in performance management if the quarterly rating in its performance framework requires it or there is other adverse information of sufficient importance. I, and officers of the Trust, regularly meet with officers of the TDA to discuss performance. The TDA has been involved in monthly meetings with the Trust over its performance during 2014/15. I attend the Health and Adult Social Care Overview and Scrutiny Committees in relevant Council areas to account for the performance of the Trust to the local community and oversee the work of executive officers in the work programme of the Scrutiny Committees. In preparing this statement I have ensured that it meets the requirements of the Corporate Governance Code (The HM Treasury/Cabinet Office Corporate Governance Code).
2.The governance framework of the organisation The Trust has described its corporate governance arrangements in a single document called “Rules of Procedure” (approved in January 2011, updated in November 2014), this is supported by the Corporate Governance Manual (reviewed January 2015) which pulls together and enhances aspects of the Trust’s Standing Orders, Standing Financial Instructions, Scheme of Delegation and other related policies to ensure greater clarity over individual responsibilities and how this links together. All of these documents are available on the Trust website. The Board is responsible for providing effective and proactive leadership of the Trust within
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Annual Report 2014-2015
a framework of processes, procedures and controls which enable risk to be assessed and managed.
and objectives to the wards and operational services Through this structure those with the authority can exercise it and there are clear escalation processes if they are unable to do so. The escalation processes lead to individual directors and the Trust’s Executive Committee which I chair as the Accountable Officer. It further allows staff to see where they fit in the overall strategy and how their personal objectives support the Trust to deliver its objectives.
The Board governs the Trust business, including the delivery of the strategies it sets by seeking assurance that the managerial systems that are in place deliver the desired outcomes and enable effective and timely reporting of significant issues that threaten its objectives. I have aligned and delegated accountability (see Section 1 above) and decision making authorities to the line management structures in place that deliver the day to day business. This alignment provides all staff and the Board of Directors with a simple and well understood way of
The Board of Directors has identified no departures from the Corporate Governance Code and the Head of Internal Audit has provided a rating of Significant Assurance in his formal Opinion (the details of this Opinion are referred to later).
1. ward/operational reporting to Board relevant issues
The governance framework and the escalation framework for the Trust are described in the diagrams below.
2. the Board disseminating its strategy
SASH Corporate Governance Structure / Accountability Framework for managing business
1 Audit and Assurance
Safety and Quality
Board of Directors Investment and Workforce
Corporate Management
2
Charitable Funds
Board
CEO
Executive Committee & Executive Committee for Quality & Risk
3
4 7
Nomination and Remuneration
Accountability level Management Committees/Groups
INFORMATION
Corporate
5
Clinical Divisions
6
Specialities
7
POLICIES
5 Executive Sub Committees: Safety, Effectiveness, Responsiveness, Experience and Workforce
Staff
Appendices
Overview: Governance Framework
Board
Audit and Assurance Committee
Nomination and Renumeration Committee
Finance and Workfarce Committee
Safety and Quality Committee
Charitable Funds
Executive Committee and Executive Committee for Quality and Risk
Patient Safety
Effectiveness
Access and Responsiveness
Audit and Assurance Committee
Audit and Assurance Committee
Buisness Planning (Reports to Executive Committee)
Speciality Deep Dives (Reports to ECQR)
Finance PMO's (Reports to Executive Committee)
Clinical Specialists Sub-groups (e.g. IPCAS)
Divisional Governance
Speciality Governance
Wards & Departments
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Annual Report 2014-2015
The Board of Directors
Attendance by its members has been consistently high and I am confident that the Executive Team and Board members are suitably engaged and informed in both Board and Trust management during 2014/15. The Board has reviewed its effectiveness, using external expertise – the output of that is the current Board development programme and Board Governance Assurance Framework action plan and Quality Governance Assurance Action plan. This is complimented by other actions that have been taken through the appraisal of Board members by either the Trust Chairman or I, respectively.
The Board consists of five voting executive directors, six non-executive directors (including the Chair) and one non-voting Designate nonexecutive Director. The Board meets every month in public, its minutes and papers are made freely available, including on the Trust website. The Board meets, usually bi-monthly for “Board Seminars”. The Director of Corporate Affairs & Company Secretary remains a non-voting member of the Trust Board.
July 2014
Aug 2014
Sept 2014
Oct 2014
Nov 2014
Dec 2014
Jan 2015
Feb 2015
March 2015
√
√
√
√
√
√
√
√
√
√
√
√
Michael Wilson
√
√
√
√
√
√
x
√
√
√
√
√
Paul Simpson
√
√
√
√
√
√
√
√
√
√
√
√
Paul Bostock
√
x
√
x
x
√
√
√
√
√
√
√
Des Holden
√
x
√
√
√
√
√
√
√
√
√
√
Fiona Allsop
√
√
√
√
√
√
√
√
√
√
x
√
Yvette Robbins
√
√
√
√
√
√
√
√
√
√
√
x
Richard Durban
√
√
√
√
√
√
√
√
√
√
x
√
Richard Shaw
√
√
√
√
√
√
√
√
√
√
√
√
Alan Hall
x
√
√
√
√
√
x
√
√
√
√
√
Pauline Lambert
√
√
√
√
√
√
√
√
x
Paul Biddle
√
√
√
√
√
√
√
√
√
Richard Congdon (left May 2014)
John Power (left Aug 2014)
√
x
x
x
June 2014
May 2014
(Meeting held 7 Aug)
April 2014
Alan McCarthy
Name
x
√
Appendices
Summary of Public Board Activity and points of note During the financial year the Board met regularly in public as described by the Trust “Rules of Procedure”. Its standing items include reports from the Medical Director, Chief Nurse, financial and performance reports, the Board Assurance Framework, risk management reports and my report as Chief Executive Officer. The Board received reports from its sub-committees as well as reports which are dictated by legislation or national guidance such as the annual reports for Infection Prevention and Control. The agenda regularly includes presentations or reports about patient experience and clinical work in the Trust. The Board took a great deal of assurance from the Chief Inspector of Hospitals Inspection report and associated Quality Summit. It also gained assurance from the regular updates on the Trust’s progress through the aspirant foundation Trust program cumulating in the TDA’s formal recommendation to enter the Monitor phase of the assessment. Throughout the year the Board discussed national issues and local events considering the potential impact for the Trust, of note the Board discussed the publication of the “Five year forward view”, reviews of the “Freedom to speak up” linked to the Saville review and the Trust’s involvement in the Mutuals in Health pathfinder programme. The Board regularly discussed the changing national operational picture noting the capacity issues and undertaking a winter debrief to explore and learn lessons from the Trust’s winter activity. The Board took assurance from the implementation of the “Fifteen Step Programme” which involves Non-Executive Directors (NEDs) visiting and observing clinical areas, the review of Medical Revalidation systems and management’s assessment of the Trust’s quality governance and escalation framework. The Trust’s Audit and Assurance Committee is constituted to provide the Board of Directors with an independent and objective review of its system of internal control, financial
information, and compliance with laws, guidance and regulations governing the NHS. As such throughout the financial year the AAC has gained assurance from reviews of the Trust’s internal control systems for corporate, financial and clinical governance. The AAC has scrutinised the board assurance framework and added value to the description of strategic risks, provided strong challenge to the management and recording of financial risk and identified emerging risks such as the external agreement of contracts and income plans. The AAC has gained strong assurance from External Audit relating to the completion of the final audited accounts and value for money and has received independent assurance from internal audit on a series of controls both corporate and clinical. As described in this statement the Trust Board uses the Board Assurance Framework to monitor key risks to the Trust’s strategic objectives. It also uses an internally developed system to monitor all aspects of performance and quality. This takes the form of a regular report based on the Department of Health’s TDA performance indicators, and the monthly finance report as part of the Integrated Performance Report. These reports detail the Trust’s sustained improvements in safety and the challenges that have been faced throughout the winter pressures that have affected the organisations effectiveness and performance. Board Committees The Board of Directors has authorised a number of committees to scrutinise aspects of the Trust’s business. Each committee is chaired by a Non Executive Director with a membership that has been discussed and agreed with the Board (described in the rules of procedure). The Board ensures that there is regular attendance by relevant Executive Directors as detailed below in the Trust Board attendance record for 2014/15. The terms of reference of each committee set out the remit of responsibility delegated by the Board of Directors. This in turn sets out the information requirements of the committee, how it should interact with the information it receives and use this to reach a conclusion
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Annual Report 2014-2015
about assurance. Where assurance cannot be robustly established the Chair of the Committee reports this to the Board of Directors. The Trust’s Rules of Procedure has been reviewed during the financial year to update the terms of references of all board sub committees. The Board of Directors receives a report from each chair at the following public board meeting. On receiving a report that identifies a lack of assurance in relation to an aspect of the business the Board of Directors can either hold me to account (managerial aspects) or seek independent assurance by referring the matter to its Audit and Assurance Committee. The Executive Committee The Executive Committee is the most senior managerial decision making group in the Trust. Its membership comprises the entire executive director team and the clinical Chiefs of Service for each Division. The committee has significant senior clinical membership to ensure effective clinical leadership and decision making. As Chief Executive I have directed that the Executive Committee to meet weekly to consider, on a rolling basis, managerial delivery of the Board of Directors’ strategy, quality of services provided and the effectiveness of risk management, the delivery and management of all performance and the management of each clinical division. The Executive Committee and its five sub committees have specific terms of reference for each meeting to enable it to deliver their duties. Fuller details of all of these committees, including terms of reference are set out in the Rules of Procedure. Performance Management The Trust has developed a series of performance management systems that monitor individual elements of performance and trigger actions. Financial performance management is effected through the Executive Team supported by a Programme Management Office (PMO) structure of (at least) monthly meetings with Divisions, with a separate
structure for cost improvement workstreams. For example there is a set of reports available to the Board on a regular basis which monitor performance in all key business areas of the organisation. Performance reports demonstrate that action is taken, either at the Executive Committee (and its sub committees) and at operational meetings to address variances from objectives, standards and targets. Where variance is identified, action plans are established to address them and reviews of action plans undertaken to ensure that the desired results are achieved. There is a visible process, and hierarchy, within the organisation of performance management at each level of the Trust that is coherent and amalgamated into Board level performance reports.
3. Risk assessment Risk, or change in risk is identified, evaluated and controlled as described in the Trust’s Risk Management Policy. The risk evaluation and treatment model is based on a grading matrix of likelihood and consequence. This produces a risk score to enable the risk to be prioritised against other risks. The score, in turn, is linked to a matrix of the cost and responsibility of risk treatment so that either the risk is addressed locally by the division within its resources or it feeds into the organisation wide risk register. The risks are also mapped to the strategic themes and objectives identified within the trust planning process along with the various other initiatives to confirm the score given to a risk. The Board of Directors receives details of significant risks through regular board reports. The finance report records all key financial risks, the performance and quality report records all key operational risks and performance against key clinical quality outcomes. The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives through its risk appetite.
Appendices
The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. This stance is defined by the Boards risk appetite which is reviewed annually and included in reports presented to each public board meeting. The Board of Directors will also identify risk through its review of the Board Assurance Framework at its meetings, the reports received from the Board sub-committees, the Trust significant risk register and any self assessment exercise required for regulators or commissioners of service. Clinical risks and non-clinical risks are reviewed by the Executive Committee, The Executive Committee for Quality & Risk and the Board. Capacity to handle risk The Trust’s capacity to handle risk is based around a clear Risk Management Policy, effective leadership of the risk management process and staff trained and equipped to manage risk in a way appropriate to their authority. The key elements of the Trust’s capacity to handle risk are as follows: • Effective and pro-active Leadership is provided by the Board of Directors. In my role as Chief Executive I have overall responsibility and have delegated accountability to the Chief Nurse who has responsibility for ensuring the risk policy is implemented throughout the Trust. • A body of staff under the Risk and Patient Safety Lead has Trust wide responsibility for ensuring the framework of processes, procedures and controls are in place which enables risk to be assessed and managed. • The Trust monitors its performance on all aspects of quality and risk management and undertakes investigations into any areas where an issue is identified. It works with local partner organisations to ensure risks across the health economy are managed.
• The Trust has nominated risk co-coordinators within each Division to work with Associate Directors of Operations, Clinical Chiefs of Service, Divisional Chiefs of Nursing and Heads of Corporate Departments to identify and assess risk. • Staff are trained and equipped to manage risk in a way appropriate to their authority and duties: – Staff receive a breadth of risk management information and training at mandatory corporate induction days, ongoing training as part of a mandatory programme and through distribution of relevant documents. – Managers and specialist staff (e.g. risk managers) have training from internal and external providers as determined by local needs assessment. – The Board has implemented a system of annual review of its risk appetite and Board Assurance Framework. At this review the board discusses and agrees the risk appetite and tolerances that are set for different types of strategic and operational risk. These provide the Board with an opportunity to refresh the principles of risk management and identify key issues. – Guidelines on the SaSH approach to risk management and the use of the risk register are available on the Trust intranet site and are provided to staff who have key responsibilities for risk management as set out in the accountability framework – The Risk Management Policy is reviewed regularly and promulgated throughout the Trust. The Policy describes the Risk Management training schedule which is mandatory for all staff including at Board level. • Organisational learning is communicated internally through a structure of committees (covering clinical and non-clinical risk) that penetrate throughout the organisation down to local management teams; • Learning is supported by the consistent application of root cause analysis of problems and incidents and the avoidance
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Annual Report 2014-2015
of blaming individuals for system failures as described in various Trust policies, including the Organisation-wide Policy for the Management, Reporting and Investigation of Incidents (including Serious Incidents SIs). This has been further improved during the financial year by implementing a shared learning in practice system that promulgates lessons learnt across the Trust. • The Trust has a range of problem resolution policies and procedures, including whistle blowing, harassment, capability, disciplinary and grievance, which are designed to identify and remedy problems at an early stage. • The Trust has a range of individual support mechanisms to encourage individuals to raise concerns about their own performance in ways which will not threaten their security or livelihood, e.g. appraisal, alcohol use/ abuse policies, professional counselling and occupational health services. • The Trust has in place a counter fraud contractor whose services are embedded within the Trust. More details are provided below.
4. Risk and control framework The Trust’s system of internal control is designed to manage the risks associated with achieving aims, objectives and policies to a reasonable level. The system of internal control has been in place in Surrey and Sussex Healthcare NHS Trust for the year ended 31 March 2015 and up to the date of approval of the annual report and accounts. Risk management is embedded in the activity of the organisation through: • The “Rules of Procedure” approved by the Board in January 2011 (updated November 2014) clarifying roles of Board members and defining the role and structure of Board sub-committees; • A clear accountability framework for managing risk from the Accountable Officer
outwards as set out in the Risk Management Policy; • The structure of permanent committees, including Board sub committees (see Section 2); • The Board Assurance Framework and the Significant Risk Register • The Trust’s risk management process takes into consideration the need to manage all types of risk as relevant to key stakeholders and provides one to one competent support and regular training events. The significant risk register is taken from the Trusts risk registers (All red risks) and is reviewed by the executive committee and presented at public board. • The Trust’s Performance Management Framework; • Compliance with Care Quality Commission standards and registration, Information Governance rules, health and safety requirements, and those of other regulatory bodies; • The Trust’s internal controls framework; • The work of Divisional and specialty governance meetings and specialty Deep Dive reviews; • The system of local risk coordinators and Divisional risk managers;
4.1 Board Assurance Framework The Board Assurance Framework is a key support to the Trust’s system of internal control. It is separate from the Trust’s risk register (although the Significant Risk Register is linked to it) and provides a clear methodology for the focused management of risks to the delivery of the Trust’s strategic objectives. The Executive Team oversees the maintenance of and reviews the Assurance Framework. It is then discussed and challenged at the Trust Board prior to its acceptance. The Assurance Framework and the Significant Risk Register is presented monthly to the public Board.
Appendices
The final Board Assurance Framework presented to the Board for 2014/15 described 3 “red rated areas (where Trust objectives may not be achieved and listed in Section 5 – with 2 areas listed as significant control issues).
Authority, NHS England, Local authorities, Health Education England (HEE), the General Medical Council (GMC), the Nursing and Midwifery Council, the Royal College and the local Healthwatch.
4.2 Care Quality Commission Registration
This inspection rated the Trust as “Good” overall and in all elements of quality (safe, caring, effective, responsive and well led). The inspection highlighted areas for improvement which have been agreed and actions to resolve issues are being monitored by the Executive Team. The key focus for improvement is the Trust’s outpatient services. The Board and Executive Committee review the associated action plan on a monthly basis.
The Care Quality Commission (CQC) carried out a comprehensive inspection of the Trust between 20 and 22 May 2014 and a follow up unannounced inspection visit on 6 June 2014. The team of 26 included CQC inspectors and analysts, two experts by experience as well as a variety of specialists. The CQC reviewed a range of information available publically and shared by the clinical commissioning group (CCG), community trusts, NHS Trust Development Apr 14 ED 95% in 4 hours Patients Waiting in ED for over 12 hours fo llowing DTA Cancer - TWR Cancer - TWR Breast Symtomatic Cancer - 31 Day Second or Subsequent Treatment (SURGERY) Cancer - 31 Day Second or Subsequent Treatment (DRUG) Cancer - 31 Day Diagnosis to Treatment Cancer - 62 day Referral to Treatment Standard Cancer - 62 day Referral to Treatment Screening RTT Admitted - 90% in 18 weeks RTT Non Admitted - 95% in 18 weeks RTT Incomplete Pathways % under 18 weeks RTT Patients over 52 weeks on incomplete pathways Percentage of patients waiting 6 weeks or more for diagnostic Percentage of operations cancelled on the day not treated within 28 days
May 14
June 14
July 14
96.6% 0
0
The Trust has consistently been rated as a Low Risk trust by the CQC using their intelligent monitoring (rated band 6 – the lowest risk Aug 14
Sep 14
Oct 14
96.2% 0
0
0
Nov 14
Dec 14
Jan 15
94.4% 0
0
0
Feb 15
Mar 15
92.8% 0
0
0
93.3%
93.1%
93.3%
93.1%
93.6%
93.6%
93.5%
94.5%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
99.7%
98.6%
99.4%
99.1%
88.0%
85.7%
87.0%
85.0%
100.0%
83.3%
96.2%
95.6%
0
92.9% 94.4% 94.7% 92.8% 90.4% 90.7% 88.1% 81.4% 91.1% 90.2% 82.1% 88.1% 97.4% 97.2% 96.5% 95.2% 95.8% 93.2% 93.9% 92.8% 95.0% 91.7% 91.0% 93.4% 96.4% 96.0% 95.2% 94.9% 93.9% 93.8% 93.5% 93.3% 92.2% 92.1% 94.0% 93.6% 0
0
0
0
0
0
0
0
0
0
0
0
0.0%
0.0%
0.0%
0.3%
0.1%
0.0%
0.0%
0.4%
0.1%
0.9%
0.7%
2.0%
0.0%
0.0%
0.0%
0.0%
0.0%
1.0%
1.6%
0.0%
0.0%
0.0%
0.0%
0.0%
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banding). This judgment is made based on a range of national data including mortality, activity and staffing levels.
4.3 Performance against national priorities The Trust is committed to delivery of the national priorities as set out in the TDA accountability framework and the NHS constitution. The table below sets out the Trust’s performance against the key standards. Throughout the year the Trust has been one of the top performers on the ED 4hr Standard, however performance over Q3 and Q4 was below the national standard. The Trust has plans in place to support delivery of the standard going forward into 2015/16. With regards to the 18 week referral to treatment standard, the Trust worked as part of the national drive in the second half of the year to reduce the number of patients on incomplete pathways over 18 weeks. This resulted in the Admitted and Non admitted standards not being achieved but an overall reduction in long waiters. As part of the Trust’s data quality assurance framework, Internal Audit carry out regular audits of the Trust’s RTT submissions, providing assurance on the accuracy of waiting time data. While the most recent audit has highlighted some actions, these are not significant
4.4 Quality Governance As required the Trust produces an annual “Quality Account”, which details the Trust’s performance against a series of quality indicators and details the Trusts plans to continually improve the quality of its services. This is developed internally and shared with our local health partners before publication and submission to NHS England. The Executive Team provides me with assurance and regular updates on the drafting of the account. With regards the 2013/14 Quality Account Internal Audit audited the completion of the account
providing a review of methodology to prepare quality accounts, four key quality metrics and the action plans developed to management performance. Internal audited highlighted the Trust’s performance on the timeliness of reporting serious incidents externally. External Audit gave a qualified opinion of the formation of the quality account highlighting the same issue as Internal Audit.
4.4 a The Quality Risk Structure Over the last year the Trust Board have made many significant improvements to quality governance which is evidenced in the Chief Inspector for Hospitals inspection report published in August 2014 where the Trust was awarded “Good” across all inspection domains. The Trust has developed a system that is aligned with the CQC five domains of quality (Safe, Effective, Caring, Responsive and Well led) as described in section 2. The changes to quality governance allows staff at divisional level, through the divisional governance meetings to escalate matters of concern relating to quality to the Board through the Executive Committee for Quality and Risk (ECQR) and its sub committees. Each division has a governance group which reports to and can be instructed by the five Executive sub-committees for quality and risk. Output of ECQR is a standing item on the Safety and Quality Committee (SQC) agenda as is a report from the Clinical Quality Review Meeting (CQRM). This allows the board through the SQC Chair monthly report to ask for further work or seek further clarification on issues raised or supporting agenda items such as patient stories or the Integrated Performance and Quality Report (IPQR). Divisional teams also now have a simple process for escalating issues from divisional governance thorough the relevant subcommittees of the Executive Committee for Quality, Risk and up to the SQC and public Trust Board. This is supported by the Trust’s incident reporting system and when necessary the whistleblowing policy.
Appendices
4.4.b The management of incidents and identification of clinical risk
with legally, securely, efficiently and effectively. The Department of Health provides the standards and a self-assessment tool-kit and Trusts’ compliance is measured according to the indicators in the tool-kit. The Care Quality Commission is informed of the Trust’s results.
All staff are responsible for managing risks within the scope of their role and responsibilities as employees of the Trust. There are structured processes in place for incident reporting, and the investigation of Serious Incidents and Never Events. The Trust has a positive culture of reporting incidents enhanced by accessible online reporting systems available across the Trust.
Our aim is to improve our compliance year on year and a key element in achieving this is ensuring that all staff receives annual training and regular updates relating to Information Governance.
The Trust Quality Scorecard is presented at Executive Committee Quality and Risk; it allows key threats and risks to patient safety and quality to be identified with more detail being reviewed by the relevant Trust Board sub-committee.
All Information Governance risks are added to the Trust risk register and reported in line with the Trust Risk Management Policy. The Trust has not identified any Information Governance Serious Incidents during the financial year.
The responsibility for risk management is clearly mapped to all staff, the Trust Board, NEDs and Executive Directors, department heads, managers and senior clinicians. Risks are identified reactively and proactively. All risks are assessed against one standard tool. All risks are managed through Divisional Governance meetings; oversight is maintained by the relevant Trust Board sub-committee. High level risks are reported to and reviewed by the Trust Board quarterly.
Other aspects
4.4.c Clinical Audit
Control measures are in place to ensure that all the organisation's obligations under equality, diversity and human rights legislation are complied with. As such processes are established to manage concerns when they are identified. As an employer with staff entitled to membership of the NHS Pension scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with.
The Trust has an established clinical audit program as detailed in the Trust’s Quality Account. It is recognised that the current focus of clinical audit is heavily biased towards the national program, college and CNST driven audits, which provides speciality teams assurance. The Trust has described the intention that the clinical audit program will also be used to drive continuous improvement of services and quality of care. This will heavily influence the programme of audit from 2015/16 onwards.
5. Review of effectiveness
4.4.d Information governance
• Executive Directors within the organisation who have responsibility for the development and maintenance of the system of internal control provide me with assurance.
Information governance is a framework for managing information, particularly personal information of patients and employees. It should ensure that personal information is dealt
As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review is informed in a number of ways. • The Head of Internal Audit provides me with an opinion on the overall arrangements for gaining assurance through the Assurance Framework and on the controls reviewed as part of the internal audit work.
• The Board Assurance Framework itself provides me with evidence that the
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effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. • External auditors provide me with assurances through their opinion on the financial statements, their value for money conclusion and the external auditor's report on the annual Quality Account. • Other external organisations, including the TDA, Care Quality Commission, MHRA, other agencies of the Department of Health, our commissioners and private consultancy companies commissioned by the Trust, have provided me with reports about controls, compliance with standards, financial management and performance in delivering targets. The main points from my review are as follows:
5.1 Assurance framework The Board Assurance Framework identifies 3 main strategic risks to the Trusts meeting its objectives. These are as follows: 1. Failure to maintain Emergency Department performance because of lack of capacity in health system to manage winter pressures has a significant impact on the Trust's ability to deliver high quality care. 2. Failure to deliver income plan. 3. Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquidity position.
5.2 Governance The Executive Committee which I chair reviews and manages all areas of strategic development, performance and quality on a rolling basis and is therefore supported by a series of Executive sub committees aligned with the five areas of quality described by the CQC. • The Trust was inspected by the CQC in May 2014 and received an overall ”Good” rating across all elements of quality; safe, caring, effective, responsive and well led The inspection team highlighted elements
of outstanding care in their report and the Trust maintains its position in the lowest risk banding on the CQC intelligence monitoring profile. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. The Trust developed an action plan with four key work streams to improve the quality of outpatient services; Environment, Workforce and leadership skills, Communications and Systems and processes. These actions are being monitored by the Executive Team and are reported to Public Board with satisfactory progress. • The Trust has developed an internal controls map which details the main controls (systems and processes) that the Trust uses to maintain control of its day to day business. • Internal audit reviews the existing system of internal control and the overall arrangements to gain assurances that the controls are designed to meet the objectives and are consistently applied. Action plans are developed for any areas of control which can be improved; I am satisfied with the efforts to ensure continuous improvement of the Trust’s internal controls and these actions are monitored by the Executive Committee and AAC. As mentioned earlier, the Head of Internal Audit Opinion provides “significant assurance” concerning the effectiveness of the Trust’s internal controls. • Internal Audit reports have been targeted at a broad range of areas to identify issues and the Head of Internal Audit Opinion has not identified any “Red” rated opinion reports in 2014/15. Where weaknesses have been identified management have taken action to address this.
Appendices
• The Board Assurance Framework provided the basis for monitoring the effectiveness of the management of the Trust's principal strategic risks. It was regularly reviewed and reported to the Board throughout the year with the latest version presented at the March 2015 public board. The Trust has been pro-active in its investigation of all issues raised in the year and has sought external involvement in those that required it. This has been a particular strength of the systems operating within the organisation.
5.3 Performance The Trust has developed a performance management system from which I get regular updates on relating to both day to day performance and long term trends. This system has allowed the Trust’s management team to significantly improve performance to the point where we are one of the best performing Trusts in the country. The Trusts effectiveness committee now regularly reviews long term data on performance and mortality whilst the responsiveness committee keeps a regular track of operational issues. As such there are no particular services at the Trust that is of such a concern that is significant enough to record as a governance issue.
5.4 Counter fraud The Trust achieved level 4 (the highest ranking) in the Qualitative Assessment in 2010/11. This form of assessment was suspended for 2011/12 and 2012/13 to allow for a consultation to change the assessment process. The Trust scored a green rating in 2013/14 (the highest ranking) in the new assessment ‘Self Review Toolkits’ (SRTs) and was subsequently made exempt from further assessment in 2014/15. The completion of the next SRTs are due during the early part of 2015/16.
5.5 Information governance During the financial year no data protection incidents met the criteria for external reporting (incidents with a severity rating of 3 or higher)
during 2014/15 financial year as mentioned above in Section 4.
6. Significant control issues I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Audit and Assurance Committee and the Board (described above). Those aspects that should be categorised as significant control issues are described below.
6.1 Quality and safety The Trust’s most significant issues relating to quality of services have been linked to capacity and unprecedented levels of emergency activity. This has had significant financial impact throughout the year as the Trust called on bank and agency staff to ensure that safe staffing levels were maintained throughout peak periods of activity. The sustained national activity position had a similar effect on the Trust’s Emergency Department standards and elective activity which affected the achievement of standards in the second half of the financial year. The Board was clearly sighted on this issue and took external assurance on the safety of services from the Trust’s continuing low mortality and CQC intelligence monitoring risk profile reports and internal assurance from the effectiveness of business continuity plans that mitigated against the impact of emergency activity.
6.2 Finance There are two specific financial control issues as follows: 1. Statutory breakeven duty and recurrent financial position: The Trust delivered a £2.4m deficit for the financial year 2014/15. The Trust has been in technical breach of the statutory breakeven duty (NHS Act 2006) for some time, and it will be many years before that duty is met. Section 19 of the Audit Commission Act 1998 requires the auditor to advise the Secretary of State of the breach
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(or the potential a trust may incur illegal expenditure). The Auditor issued a “Section 19 letter” when the breach first occurred in 2006/07 and in subsequent years, with the last being with the Trust’s accounts in 2013/14. The reported deficit was supported by £3.1m of non-recurrent funding in the form of resilience funding from CCGs, and one off items including settlement of CCG disputes from 2013/14 and from reducing balance sheet provisions. This provides an overall underlying (as opposed to normalised) deficit of £5.2m, which is adverse to the position originally planned. This risk position has been reported consistently throughout the year in the Trust’s finance reporting and has been driven by emergency activity above planned levels, its impact on costs and reduced income from elective activity that has been displaced. This position has been modelled as part of the Trust’s Foundation Trust assessment and the underlying position is resolved primarily through changes from the adoption of the “Enhanced Tariff Option” as the Trust moves into 2015/16. 2. Liquidity: This is described in a Board Assurance Framework indicator (BAF ref 4.1.d - “Liquidity: inability to pay creditors / staff resulting from insufficient cash due to poor liquid position”). The full liquidity issue is likely to be dealt with as part of the Foundation Trust process. The Trust’s in-year management of the position was successful and did not require any additional permanent cash borrowing in 2014/15. Cash management will continue to be an area of focus along the same lines as in the last few years, and the risk rating recording in the Board Assurance Framework has been reduced to note the success of those measures. A third item was recorded on the last 2014/15 Board Assurance Framework as “red” rated at the March Board (achievement of the income plan for 2014/15). Since that point the Trust has agreed contractual income with all CCGs thereby eliminating this risk for 2014/15.
Concluding statement With the exception of the internal control issues that I have outlined in this statement, my review confirms that Surrey and Sussex Healthcare NHS Trust has a generally sound system of internal controls that supports the achievement of its policies, aims and objectives and that those control issues have been or are being addressed.
Signed:
Michael Wilson Chief Executive
Date: 1 June 2015
How to contact us
How to contact us Surrey and Sussex Healthcare NHS Trust Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at: East Surrey Hospital Redhill Surrey RH1 5RH Telephone: 01737 768511 Surrey and Sussex Healthcare NHS Trust provides non-emergency services at Crawley Hospital which is managed by NHS Property Company. Crawley Hospital Crawley West Sussex RH11 7DH Telephone: 01293 600300 We also provide a number of services at four community sites: Caterham Dene Hospital Church Road Caterham Surrey CR3 5RA Telephone: 01883 837500 Horsham Hospital Hurst Road Horsham West Sussex RH12 2DR Telephone: 01403 227000
Oxted Health Centre 10 Gresham Road Oxted RH8 0BQ Telephone: 01883 734000 The Earlswood Centre Royal Earlswood Park 1 Anderson Court Redhill Surrey RH1 6TP 01737 768511 x 1743 Surrey and Sussex Healthcare NHS Trust Trust Headquarters Canada Avenue Redhill Surrey RH1 5RH Telephone: 01737 768511 Email: enquiries@sash.nhs.uk www.surreyandsussex.nhs.uk twitter: @sashnhs
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